Head (Skull, Scalp, Hair)

Observe the size, shape and contour of the skull.
2. Observe scalp in several areas by separating the hair at various locations; inquire about any
injuries. Note presence of lice, nits, dandruff or lesions.
3. Palpate the head by running the pads of the fingers over the entire surface of skull; inquire
about tenderness upon doing so. (wear gloves if necessary)
4. Observe and feel the hair condition.
Normal Findings:
Skull
· Generally round, with prominences in the frontal and occipital area. (Normocephalic).
· No tenderness noted upon palpation.
Scalp
· Lighter in color than the complexion.
· Can be moist or oily.
· No scars noted.
· Free from lice, nits and dandruff.
· No lesions should be noted.
· No tenderness nor masses on palpation.
Hair
· Can be black, brown or burgundy depending on the race.
· Evenly distributed covers the whole scalp (No evidences of Alopecia)
· Maybe thick or thin, coarse or smooth.
· Neither brittle nor dry.

  Face

 Observe the face for shape.

2.    Inspect for Symmetry.
a.    Inspect for the palpebral fissure (distance between the eye lids); should be equal in both
eyes.
b.    Ask the patient to smile, There should be bilateral Nasolabial fold (creases extending from
the angle of the corner of the mouth). Slight asymmetry in the fold is normal.
c.   If both are met, then the Face is symmetrical
3. Test the functioning of Cranial Nerves that innervates the facial structures
a.    CN V (Trigeminal)
1.    Sensory Function
·    Ask the client to close the eyes.
·    Run cotton wisp over the fore head, check and jaw on both sides of the face.
·    Ask the client if he/she feel it, and where she feels it.
·    Check for corneal reflex using cotton wisp.
·    The normal response in blinking.
2.    Motor function
·    Ask the client to chew or clench the jaw.
·    The client should be able to clench or chew with strength and force.
b.    CN VII (Facial)
1.    Sensory function (This nerve innervate the anterior 2/3 of the tongue).
·    Place a sweet, sour, salty, or bitter substance near the tip of the tongue.
·    Normally, the client can identify the taste.
2.    Motor function
·    Ask the client to smile, frown, raise eye brow, close eye lids, whistle, or puff the cheeks.
Normal Findings:
·    Shape maybe oval or rounded.
·    Face is symmetrical.
·    No involuntary muscle movements.
·    Can move facial muscles at will.
·    Intact cranial nerve V and VII.

  Eyebrows, Eyes and Eyelashes

All three structures are assessed using the modality of inspection.

Normal findings:
Eyebrows
·     Symmetrical and in line with each other.
·    Maybe black, brown or blond depending on race.
·    Evenly distributed.
Eyes
·     Evenly placed and inline with each other.
·    Non protruding.
·    Equal palpebral fissure.
Eyelashes
·    Color dependent on race.
·    Evenly distributed.
·    Turned outward.

All three structures are assessed using the modality of inspection.

Normal findings:
Eyebrows
·     Symmetrical and in line with each other.
·    Maybe black, brown or blond depending on race.
·    Evenly distributed.
Eyes
·     Evenly placed and inline with each other.
·    Non protruding.
·    Equal palpebral fissure.
Eyelashes
·    Color dependent on race.
·    Evenly distributed.
·    Turned outward.

ears
1. Inspect the auricles of the ears for parallelism, size position, appearance and skin color.
2. Palpate the auricles and the mastoid process for firmness of the cartilage of the auricles,
tenderness when manipulating the auricles and the mastoid process.
3. Inspect the auditory meatus or the ear canal for color, presence of cerumen, discharges, and
foreign bodies.
a. For adult pull the pinna upward and backward to straiten the canal.
b. For children pull the pinna downward and backward to straiten the canal
4. Perform otoscopic examination of the tympanic membrane, noting the color and landmarks.
Normal Findings:
· The ear lobes are bean shaped, parallel, and symmetrical.
· The upper connection of the ear lobe is parallel with the outer canthus of the eye.
· Skin is same in color as in the complexion.
· No lesions noted on inspection.
· The auricles are has a firm cartilage on palpation.
· The pinna recoils when folded.
· There is no pain or tenderness on the palpation of the auricles and mastoid process.
· The ear canal has normally some cerumen of inspection.
· No discharges or lesions noted at the ear canal.
· On otoscopic examination the tympanic membrane appears flat, translucent and pearly gray in
color.
Vestibulochoclear Nerve (cranial nerve VIII)
Examination of the cranial nerve VIII involves testing for hearing acuity and balance.
Hearing Acuity
A.    Voice test
1.    The examiner stands 2 ft. on the side of the ear to be tested.
2.    Instruct the client to occlude the ear canal of the other ear.
3.    The examiner then covers the mouth, and using a soft spoken voice, whispers non-
sequential number (e.g. 3 5 7 ) for the client to repeat.
4.    Normally the client will be able to hear and repeat the number.
5.    Repeat the procedure at the other ear.
B.    Watcher test
1.     Ask the client to close the eyes.
2.    Place a mechanical watch 1 – 2 inches away the client’s ear.
3.    Ask the client if he hears anything
4.    If the client says yes, the examiner should validate by asking at what are you hearing and at
what side.
5.    Repeat the procedure on the other ear.
6.    Normally the client can identify the sound and at what side it was heard.
Turning Fork Test
This test is useful in determining whether the client has a conductive hearing loss (problem of
external or middle ear) or a perceptive hearing loss (sensorineural). There are 2 types of tuning
fork test being conducted:
1.    Weber’s test – assesses bone conduction, this is a test of sound lateralization; vibrating
tuning fork is placed on the middle of the fore head or top of the skull.
Normal: hear sounds equally in both ears (No Lateralization of sound)
Conduction loss – Sound lateralizes to defective ear (Heard louder on defective ear) as few
extraneous sounds are carried through the external and middle ear.
Sensorineural loss – Sound lateralizes on better ear.
2. Rinne Test – Compares bone conduction with air condition.
a.    Vibrating tuning fork placed on the mastoid process
b.    Instruction client to inform the examiner when he no longer hears the tuning fork sounding.
c.    Position in the tuning fork in front of the client’s ear canal when he no longer hears it.
Normal: Sound should be heard when tuning fork is placed in front of the ear canal as air
conduction< bone conduction by 2:1 (positive rinne test)
Conduction loss: Sound is heard longer by bone conduction than by air conduction.
Sensorineural loss: Sound is heard longer by air conduction than by bone conduction

NECK

The neck is inspected for position symmetry and obvious lumps visibility of the thyroid gland and
Jugular Venous Distension.
Normal Findings:
1. The neck is straight.
2. No visible mass or lumps.
3. Symmetrical
4. No jugular venous distension (suggestive of cardiac congestion).
The neck is palpated just above the suprasternal note using the thumb and the index
finger.
The neck is palpated just above the suprasternal note using the thumb and the index
finger.
Normal Findings:
1. The trachea is palpable.
2. It is positioned in the line and straight.
 Lymph nodes are palpated using palmar tips of the fingers via systemic circular
movements. Describe lymph nodes in termsof size, regularity, consistency, tenderness and
fixation to surrounding tissues.
Normal Findings:
1. May not be palpable. Maybe normally palpable in thin clients.
2. Non tender if palpable.
3. Firm with smooth rounded surface.
4. Slightly movable.
5. About less than 1 cm in size.
6. The thyroid is initially observed by standing in front of the client and asking the client to
swallow. Palpation of the thyroid can be done either by posterior or anterior approach.
A. Posterior Approach:
1. Let the client sit on a chair while the examiner stands behind him.
2. In examining the isthmus of the thyroid, locate the cricoid cartilage and directly below that
is the isthmus.
3. Ask the client to swallow while feeling for any enlargement of the thyroid isthmus.
4. To facilitate examination of each lobe, the client is asked to turn his head slightly toward
the side to be examined to displace the sternocleidomastoid, while the other hand of the
examiner pushes the thyroid cartilage towards the side of the thyroid lobe to be examined.
5. Ask the patient to swallow as the procedure is being done.
6. The examiner may also palate for thyroid enlargement by placing the thumb deep to and
behind the sternocleidomastoid muscle, while the index and middle fingers are placed deep to
and in front of the muscle.
7. Then the procedure is repeated on the other side.
A. Anterior approach:
1. The examiner stands in front of the client and with the palmar surface of the middle and
index fingers palpates below the cricoid cartilage.
2. Ask the client to swallow while palpation is being done.
3. In palpating the lobes of the thyroid, similar procedure is done as in posterior
approach. The client is asked to turn his head slightly to one side and then the other of the
lobe to be examined.
4. Again the examiner displaces the thyroid cartilage towards the side of the lobe to be
examined.
5. Again, the examiner palpates the area and hooks thumb and fingers around
thesternocleidomastoid muscle.
Normal Findings:
1. Normally the thyroid is non palpable.
2. Isthmus maybe visible in a thin neck.
3. No nodules are palpable.
Auscultation of the Thyroid is necessary when there is thyroid enlargement. The
examiner may hear bruits, as a result of increased and turbulence in blood flow in an
enlarged thyroid.
 Check the Range of Movement of the neck.
Lung borders
In the anterior thorax, the apices of the lungs extend for approximately 3 – 4 cm above
the clavicles. The inferior borders of the lungs cross the sixth rib at the midclavigular
line.
In the posterior thorax, the apices extend of T10 on expiration to the spinous process of
T12 on inspiration.
In the Lateral Thorax, the lungs extend from the apex of the axilla to the 8th rib of the
midaxillary line.
Lung Fissures
The right oblique (diagonal) fissure extend from the area of the spinous process of the
3rdthoracic vertebra, laterally and downward unit it crosses the 5th rib at the midaxillary
line. It then continues ant medially to end at the 6th rib at the midclavicular line.
The right horizontally fissure extends from the 5th rib slightly posterior to the right
midaxillary line and runs horizontally to thee area of the 4th rib at the right sternal border.
The left oblique (diagonal) fissure extend from the spinous process of the 3rd thoracic
vertebra laterally and downward to the left mid axillary line at the 5th rib and continues
anteriorly and medially until it terminates at the 6th rib in the midclavicular line.
Borders of the Diaphragm.
Anteriorly, on expiration, the right dome of the diaphragm is located at the level of the
5th rib at the midclavicular line and he left dome is at the level of the 6th rib. Posteriorly,
on expiration, the diaphragm is at the level of the spinous process of T10; laterally it is at
the 8th rib at the midaxillary line. On inspiration the diaphragm moves approximately 1.5
cm downward.
Inspection of the Thorax
For adequate inspection of the thorax, the client should be sitting upright without support
and uncovered to the waist.
The examiner should observe:
A.
1. Shape of the thorax and its symmetry.
2. Thoracic configuration.
3. Retractions at the ICS on inspiration. (suprasternal, costal, substernal)
4. Bulging structures at the ICS during expiration.
5. position of the spine.
6. pattern of respiration.
Normal Findings:
 The shape of the thorax in a normal adult is elliptical; the anteroposterior diameter is less
than the transverse diameter at approximately a ratio of 1:2.
 Moves symmetrically on breathing with no obvious masses.
 No fail chest which is suggestive of rib fracture.
 No chest retractions must be noted as this may suggest difficulty in breathing.
 No bulging at the ICS must be noted as this may obstruction on expiration, abnormal
masses, or cardiomegaly.
 The spine should be straight, with slightly curvature in the thoracic area.
 There should be no scoliosis, kyphosis, or lordosis.
 Breathing maybe diaphragmatically of costally.
 Expiration is usually longer the inspiration.
Palpation of the Thorax
1. General palpation – The examiner should specifically palpate any areas of abnormality.
The temperature and turgor of the skin should be assessed. Palpate for lumps, masses and
areas of tenderness.
2. Palpate for thoracic expansion or lung excursion.
A. Anteriorly, the examiner’s hands are placed over the anterolateral chest with
the thumbs extended along the costal margin, pointing to the xyphoid process.
Posteriorly, the thumbs are placed at the level of the 10th rib and the palms are
placed on the posterolateral chest.
B. Instruct the client to exhale first, then to inhale deeply.
C. The examiner the amount of thoracic expansion during quiet and deep
inspiration and observe for divergence of the thumbs on expiration.
D. Normally, symmetry of respiration between the left and right hemithoraces
should be felt as the thumbs are separated are separated approximately 3 – 5
cm (1 – 2 inches) during deep inspiration.
1. Palpate for the tactile fremitus.
A. Place the palm or the ulnar aspect of the hands bilaterally symmetrical on the
chest wall starting from the top, then at then medial thoracic wall, and at the
anterolateral
B. Each time the hands move down, ask the client to say ninety-nine.
C. Repeat the procedure at the posterior thoracic wall.
D. Normally, tactile fremitus should be bilaterally symmetrical. Most intense in
the 2ndICS at the sternal border, near the area of bronchial bifurcation. Low
pitched voices of males are more readily palpated than higher pitched voices
of females.
E. Basic abnormalities like increased tactile fremitus maybe suggestive of
consolidation; decreased tactile fremitus may be suggestive of
obstructions, thickening of pleura, or collapse of lungs.
Percussion of the Thorax
Anterior thorax:
A. Patient maybe placed on a supine position.
B. Percuss systematically at about 5 cm intervals from the upper to lower chest, moving left
to right to left. (Percuss over the ICS, avoiding the ribs. Use indirect percussion starting at the
apices of the lungs.
C. The examiner notes the sound produced during each percussion.
Whispered Pectorioquy – Ask the client top whisper “1-2-3” Over normal lung tissue it
would almost be indistinguishable, over consolidated lung it would be loud and clear.

Inspection of the Heart

The chest wall and epigastrum is inspected while the client is in supine position. Observe
for pulsation and heaves or lifts
Normal Findings:
1. Pulsation of the apical impulse maybe visible. (this can give us some indication of the
cardiac size).
2. There should be no lift or heaves.
Palpation of the Heart
The entire precordium is palpated methodically using the palms and the fingers,
beginning at the apex, moving to the left sternal border, and then to the base of the heart.
Normal Findings:
1. No, palpable pulsation over the aortic, pulmonic, and mitral valves.
2. Apical pulsation can be felt on palpation.
3. There should be no noted abnormal heaves, and thrills felt over the apex.
Percussion of the Heart
The technique of percussion is of limited value in cardiac assessment. It can be used to
determine borders of cardiac dullness.
Auscultation of the Heart
Anatomic areas for auscultation of the heart:
Aortic valve – Right 2nd ICS sternal border.
Pulmonic Valve – Left 2nd ICS sternal border.
Tricuspid Valve – – Left 5th ICS sternal border.
Mitral Valve – Left 5th ICS midclavicular line
Positioning the client for auscultation:
 If the heart sounds are faint or undetectable, try listening to them with the patient seated
and learning forward, or lying on his left side, which brings the heart closer to the surface of
the chest.
 Having the client seated and learning forward s best suited for hearing high-pitched
sounds related to semilunar valves problem.
 The left lateral recumbent position is best suited low-pitched sounds, such as mitral valve
problems and extra heart sounds.
Auscultating the heart
A.
1. Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid and mitral
2. Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure of
semilunar valve). S1 sound is best heard over the mitral valve; S2 is best heard over the
aortric valve.
3. Listen for abnormal heart sounds e.g. S3, S4, and Murmurs.
4. Count heart rate at the apical pulse for one full minute.
Normal Findings:
1. S1 & S2 can be heard at all anatomic site.
2. No abnormal heart sounds is heard (e.g. Murmurs, S3 & S4).
3. Cardiac rate ranges from 60 – 100 bpm.

Inspection of the Breast

There are 4 major sitting position of the client used for clinical breast examination. Every
client should be examined in each position.
1. The client is seated with her arms on her side.
2. The client is seated with her arms abducted over the head.
3. The client is seated and is pushing her hands into her hips, simultaneously eliciting
contraction of the pectoral muscles.
4. The client is seated and is learning over while the examiner assists in supporting and
balancing her.
 While the client is performing these maneuvers, the breasts are carefully observed for
symmetry, bulging, retraction, and fixation.
 An abnormality may not be apparent in the breasts at rest a mass may cause the breasts,
through invasion of the suspensory ligaments, to fix, preventing them from upward movement
in position 2 and 4.
 Position 3 specifically assists in eliciting dimpling if a mass has infiltrated and shortened
suspensory ligaments.
Normal Findings:
1. The overlying the breast should be even.
2. May or may not be completely symmetrical at rest.
3. The areola is rounded or oval, with same color, (Color va,ies form light pink to dark brown
depending on race).
4. Nipples are rounded, everted, same size and equal in color.
5. No “orange peel” skin is noted which is present in edema.
6. The veins maybe visible but not engorge and prominent.
7. No obvious mass noted.
8. Not fixated and moves bilaterally when hands are abducted over the head, or is learning
forward.
9. No retractions or dimpling.
Palpation of the Breast
 Palpate the breast along imaginary concentric circles, following a clockwise rotary
motion, from the periphery to the center going to the nipples. Be sure that the breast is
adequately surveyed. Breast examination is best done 1 week post menses.
 Each areolar areas are carefully palpated to determine the presence of underlying
masses.
 Each nipple is gently compressed to assess for the presence of masses or discharge.
Normal Findings:
 No lumps or masses are palpable.
 No tenderness upon palpation.
 No discharges from the nipples.
NOTE: The male breasts are observed by adapting the techniques used for female clients.
However, the various sitting position used for woman is unnecessary.
abdomen

In abdominal assessment, be sure that the client has emptied the bladder for comfort.
Place the client in a supine position with the knees slightly flexed to relax abdominal
muscles.
Inspection of the abdomen
 Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus).
 Contour (flat, rounded, scapold)
 Distension
 Respiratory movement.
 Visible peristalsis.
 Pulsations
Normal Findings:
 Skin color is uniform, no lesions.
 Some clients may have striae or scar.
 No venous engorgement.
 Contour may be flat, rounded or scapoid
 Thin clients may have visible peristalsis.
 Aortic pulsation maybe visible on thin clients.
Auscultation of the Abdomen
 This method precedes percussion because bowel motility, and thus bowel sounds, may
be increased by palpation or percussion.
 The stethoscope and the hands should be warmed; if they are cold, they may initiate
contraction of the abdominal muscles.
 Light pressure on the stethoscope is sufficient to detect bowel sounds and bruits.
Intestinal sounds are relatively high-pitched, the bell may be used in exploring arterial
murmurs and venous hum.
Peristaltic sounds
These sounds are produced by the movements of air and fluids through
the gastrointestinal tract. Peristalsis can provide diagnostic clues relevant to the motility
of bowel.
Listening to the bowel sounds (borborygmi) can be facilitated by following these steps:
1. Divide the abdomen in four quadrants.
2. Listen over all auscultation sites, starting at the right lower quadrants,
following the cross pattern of the imaginary lines in creating the
abdominal quadrants. This direction ensures that we follow the
direction of bowel movement.
 3. Peristaltic sounds are quite irregular. Thus it is recommended that the
examiner listen for at least 5 minutes, especially at the periumbilical
area, before concluding that no bowel sounds are present.
4. The normal bowel sounds are high-pitched, gurgling noises that occur
approximately every 5 – 15 seconds. It is suggested that the number of
bowel sound may be as low as 3 to as high as 20 per minute, or
roughly, one bowel sound for each breath sound.
Some factors that affect bowel sound:
1. Presence of food in the GI tract.
2. State of digestion.
3. Pathologic conditions of the bowel (inflammation, Gangrene, paralytic ileus, peritonitis).
4. Bowel surgery
5. Constipation or Diarrhea.
6. Electrolyte imbalances.
7. Bowel obstruction.
Percussion of the abdomen
 Abdominal percussion is aimed at detecting fluid in the peritoneum (ascites), gaseous
distension, and masses, and in assessing solid structures within the abdomen.
 The direction of abdominal percussion follows the auscultation site at each abdominal
guardant.
 The entire abdomen should be percussed lightly or a general picture of the areas of
tympany and dullness.
 Tympany will predominate because of the presence of gas in the small and large bowel.
Solid masses will percuss as dull, such as liver in the RUQ, spleen at the 6th or 9th rib just
posterior to or at the mid axillary line on the left side.
 Percussion in the abdomen can also be used in assessing the liver span and size of the
spleen.
Percussion of the liver
The palms of the left hand is placed over the region of liver dullness.
1. The area is strucked lightly with a fisted right hand.
2. Normally tenderness should not be elicited by this method.
3. Tenderness elicited by this method is usually a result of hepatitis or cholecystitis.
Renal Percussion
1. Can be done by either indirect or direct method.
2. Percussion is done over the costovertebral junction.
3. Tenderness elicited by such method suggests renal inflammation.
Palpation of the Abdomen
Light palpation
 It is a gentle exploration performed while the client is in supine position. With the
examiner’s hands parallel to the floor.
 The fingers depress the abdominal wall, at each quadrant, by approximately 1 cm without
digging, but gently palpating with slow circular motion.
 This method is used for eliciting slight tenderness, large masses, and muscles, and
muscle guarding.
Tensing of abdominal musculature may occur because of:
1. The examiner’s hands are too cold or are pressed to vigorously or deep into
the abdomen.
2. The client is ticklish or guards involuntarily.
3. Presence of subjacent pathologic condition.
Normal Findings:
1. No tenderness noted.
2. With smooth and consistent tension.
3. No muscles guarding.
Deep Palpation
 It is the indentation of the abdomen performed by pressing the distal half of the palmar
surfaces of the fingers into the abdominal wall.
 The abdominal wall may slide back and forth while the fingers move back and forth over
the organ being examined.
 Deeper structures, like the liver, and retro peritoneal organs, like the kidneys, or masses
may be felt with this method.
 In the absence of disease, pressure produced by deep palpation may produce
tenderness over the cecum, the sigmoid colon, and the aorta.
Liver palpation:
There are two types of bi manual palpation recommended for palpation of the liver. The
first one is the superimposition of the right hand over the left hand.
1. Ask the patient to take 3 normal breaths.
2. Then ask the client to breath deeply and hold. This would push the liver down to facilitate
palpation.
3. Press hand deeply over the RUQ
The second methods:
1. The examiner’s left hand is placed beneath the client at the level of the right 11th and
12thribs.
2. Place the examiner’s right hands parallel to the costal margin or the RUQ.
3. An upward pressure is placed beneath the client to push the liver towards the examining
right hand, while the right hand is pressing into the abdominal wall.
4. Ask the client to breath deeply.
5. As the client inspires, the liver maybe felt to slip beneath the examining fingers.
Normal Findings:
 The liver usually can not be palpated in a normal adult. However, in extremely thin but
otherwise well individuals, it may be felt a the costal margins.
 When the normal liver margin is palpated, it must be smooth, regular in contour, firm and
non-tender.

Extremeties
Inspection
1. Observe for size, contour, bilateral symmetry, and involuntary movement.
2. Look for gross deformities, edema, presence of trauma such as ecchymosis or other
discoloration.
3. Always compare both extremities.
Palpation
1. Feel for evenness of temperature. Normally it should be even for all the extremities.
2. Tonicity of muscle. (Can be measured by asking client to squeeze examiner’s fingers and
noting for equality of contraction).
3. Perform range of motion.
4. Test for muscle strength. (performed against gravity and against resistance)
Table showing the Lovett scale for grading for muscle strength and functional level
Functional level Lovett Scale Grade Percentage of normal
No evidence of Zero (Z) 0 0
contractility
Evidence of slight Trace (T) 1 10
contractility
Complete ROM Poor (P) 2 25
without gravity
Complete ROM Fair (F) 3 50
with gravity
Complete range of Good (G) 4 75
motion against
gravity with some
resistance
Complete range of Normal (N) 5 100
motion against
gravity with full
resistance
Normal Findings:
 Both extremities are equal in size.
 Have the same contour with prominences of joints.
 No involuntary movements.
 No edema
 Color is even.
 Temperature is warm and even.
 Has equal contraction and even.
 Can perform complete range of motion.
 No crepitus must be noted on joints.
 Can counter act gravity and resistance on ROM.