VII - PHYSICAL ASSESSMENT OF THE FAMILY

A. Physical Assessment of Captain America

Body Parts/ System & Actual Findings Normal Findings Interpretation

Method of Assessment
Used

SKIN • Visible birthmark

• Inspect skin colour (mole) in right • Light to deep
• Inspect uniformity cheeks brown colour
of skin colour • Skin color is light • Generally,
• Pinch skin to note brown uniform in colour
Normal findings
the skin turgor except in areas
• Uniform in color
exposed to sun
• Normal skin turgor
• When pinched,
• Smooth intact skin
skin spring back
to previous state
NAILS • No clubbing • Convex curvature
• Inspect fingernail • Good cup refill • Angle 160°
plate shape • Pink in color • Intact epidermis
• Inspect fingernail • No deformities
texture
• Perform blanch test Normal findings
of capillary refill

• Normocephalic • Rounded
• No masses nodules (normocephalic)
• Symmetric facial • No masses and
movement nodules
• Uniform
HEAD consistency
• Inspect the skull for • Smooth skin
Normal Findings
size, shape, and
symmetry
• Palpate the skull for
nodule or masses and
depressions
• Note symmetry of
facial movement
EARS • No tenderness • Able to hear both
• Inspect • Color same as facial ears
the auricles skin • Symmetrical 10°
for colour, • Dry cerumen • Dry cerumen
symmetry of • Able to hear at both Mobile and firm
size, and Ears Normal findings
positions
• Inspect
the external
ear canal for
cerumen,
 skin lesions,
and blood •
Perform webers
test using tuning
fork

• Air moves freely as • Air moves freely Normal findings

the client breaths as the client
through nares breaths through
• Uniform in color nares
• Symmetric • No discharge
• No lesions and • Mucosa pink
masses • Symmetric
NOSE &
SINUSES
• Inspect
external nose for
flaring, shape, or
colour
• Inspect the
nasal septum between
the nasal chambers
• Palpate the
maxillary and frontal
sinuses for tenderness
MOUTH & • 16 Missing teeth • 32 adult teeth • 16 teeth are
THROAT • Black discoloration of • Smooth shiny missing
• Inspect the outer the enamel tooth • 6 teeth with
lips for symmetry of • Presence of caries • Smooth intact cavity
contour, colour, and • The tongue is in dentures • Dark brown
texture central position • Smooth tongue discoloration in
• Inspect the teeth • tongue moves freely base with prominent enamel
and gums while veins • Foul smell
examining the inner • No palpable (sordes)
lips and buccal mucosa nodules
• Inspect tongue
movement
• Palpate the
tongue and floor of the
mouth for any nodules,
lumps, and excoriated
areas.
 EYES • No edema or tearing • Pupils size is 3 to Normal findings
• Inspect the • No discharge 7 mm in diameter
eyebrows for hair • No lesions visible • Pupils equally
distribution • Cornea is clear and round and react
• Inspect and palpate transparent to light
the lacrimal sac and • Pupils contract when accommodation
nasolacrimal looking at near object (PERRLA)
duct • Pupils dilate when • Both eyes are
• Perform corneal looking at far object coordinated
sensitivity • No edema or
• Assess six ocular tearing
movement to • Cornea is
determine transparent
eye
alignment
and
coordination
• Assess distance
vision

NECK • Muscle equal in size • Equal strength Normal

• inspect the neck • Head centered • Equal size of Findings
muscles for abnormal • No discomfort muscle
swelling or masses • Muscle equal strength • Absence of bruits
• observe head • No spasm or tremor • Coordinated,
movement • No masses smooth
• assess muscle movement with no
strength discomfort
• palpate the entire • No spasm and
neck for stiffness
enlargement lymph
nodes
• palpate the trachea
for lateral deviation
Body Parts/ System & Actual Findings Normal Findings Interpretation
Method of Assessment
Used

• Normal breath sound • No evidence of Normal findings

• No deformities enlargement of
• Symmetric movement liver
when respiration • Flat, rounded,
convex
RESPIRATORY • No tenderness
• inspect posterior
thorax for shape and
symmetry
• Inspect the spinal
alignment for
deformities

• Inspect breathing
pattern
CARDIAC • Symmetric pulse • Symmetric heart Normal findings
• Palpate the • Normal hearth sound volume
peripheral pulse (lub dub) • Normal heart
sound
• Inspect the skin of
• Limbs not tender
the hand and feet for
• Veins are not
colour, temp, and
visible
edema
• Assess the adequate
of arterial blood flow
using capillary refill
test

ABDOMEN • Abdomen flat • Flat, rounded, Normal findings

• Inspect Abdomen convex
• Uniform of color
for skin integrity • No tenderness in
• Inspect the • Symmetric movement abdomen
abdomen for contour
and symmetry
• Percuss the
abdomen

• Percuss the liver

Body Parts/ Method of Actual Findings Normal Findings Interpretation
Assessment Used
MUSCULOSKELETAL
• Inspect the Muscle • Muscle equal
• No deformities
size size in both side Normal
of the body • No tenderness findings
• No contractures and swelling
• Inspect the Muscle • No tremors • Equal strength
and tendons for • Joint move and in each body
contractures freely and no side
swelling

• Test muscle strength

• Inspect the joints for

swelling
NEUROLOGIC
1. MENTAL STATUS
a. Orientation Normal
• Ask the Patient the • Client was able • Memory is findings
city and state of to answer the intact patient
residence question without don’t have any
difficulty difficulty in
remembering

• Ask the patient for

time of day, day of • Client was able
the week to state the time
and date correctly

• Ask the patient to

names the family • Client was able
members to state the
names
of his family
b. Memory
• Immediate
* Immediate recall
recall is intact
• Ask patient to repeat
a series of digits “9- patient don’t Normal
4-6-2-1-5” • Client was able to state have any findings
the difficulty in
• Ask patient to state number remembering
the same digits but correctly
in reverse
• Client forget one
number (11)
* Recent memory while reciting
 • Ask the Patient how Recent Memory
she got to the school is intact patient
don’t have any
• Client was able difficulty in Normal
• Provide the client to state on how remembering findings
with three facts to he goes to work
recall • Client was able
to answer the
question
correctly • Remote Memory
is intact
* Remote memory • Ask
patient don’t
patient to recall what
have any
happened during her Normal findings
difficulty in
vacation
• Client was able to remembering
recall his
vacation with
his family

2. LEVEL OF •
• 15 score 15 score
CONSCIOUSNESS
• Eye opening: 4
-using GCS
spontaneous
• Glasgow coma scale Normal findings
test • Motor response:
6 to verbal
command

• Verbal respond: 5
oriented
converses

3. 12 CRANIAL NERVES
* Olfactory
• Ask the patient to Able to identify • Intact nerve
identify different which mild • Able to identify
aroma aroma and strong aroma which smell is
mild and strong
* Optic
• Ask the patient to Not performed 20/20 vision • Not
read the snellen performed
chart
• Pupil equally
* Oculomotor rounded and • PERRLA
• Assess Pt. 6 ocular react to light
movement and pupil Normal findings
accommodation
reaction

* Pupil equally
Trochlear PERRLA
• Assess Pt. 6 ocular rounded and Normal findings
movement.
 react to light
* Trigeminal accommodation
• Inspect for blink • Able to identify
reflex. light and deep
• Patient able to sensation Normal findings
distinguish the • Intact nerve
light sensation
and deep
sensation
* Facial • No deformities
• Test the facial
movements • Symmetric
• Symmetric facial
Normal findings
movement of movement
face
* Abducens
• Assess direction of • Pupil equal
gaze • Patient able to round and react Normal findings
see in peripheral to light
gaze accommodation
Normal findings
* Glossopharyngeal
• Test the taste and • Client don’t • Gag reflex is
gag reflex have a gag present
reflex Not performed

* Auditory
• Weber’s Test using • Equal sound on
tuning fork • Not performed both ears
Normal findings

Normal findings
• Rinnes Test
• Patient able to • Equal sound on
hear on both both ears
ears • no difficulty
Normal findings
* Vagus • Client don’t when speaking
• Ask the Pt to open have difficulty
mouth and say “ ah” in speaking

* Accessories • Equal muscle

• Test the Neck strength on both
muscles strength • Muscle equally side of body
(sternocleidomastoid strength
and trapezius)

• Able to
* Hypoglossal protrude the
• Ask the patient to tongue • Gag reflex is
protrude and move it • Patient don’t • Gag reflex absent
to each side against have any present
tongue blades discomfort while
 protruding the
tongue
• Gag reflex is
absent

Body Parts/ Method of Actual Findings Normal Findings Interpretation

Assessment Used

4. REFLEXES
* Biceps
• Biceps reflex test the
spinal cord level C- • Maximal • Bicep reflex
5, C-6 activity present Normal findings
(hyperactive)

* Triceps
• Triceps reflex test the • Triceps reflex
• Maximal present
Normal findings
spinal cord level C- activity
7,C-8 (hyperactive)

* Brachioradialis
• Brachioradialis reflex • Brachioradialis
reflex is present Normal findings
test the spinal cord
level C-3,C-6
• Maximal
activity
* Patellar (hyperactive)
• Patellar reflex test the • Patellar reflex is
spinal cord level L- present Normal findings
2,L-3,L-4 • Maximal
activity
(hyperactive)

• Achilles reflex is
* Achilles present Normal findings
• Achilles reflex tests
• Maximal
the spinal cord
activity
level S-1,S-2
(hyperactive)
• Babinski reflex is
* Plantar/Babinski present
Normal findings

• Maximal
5. MOTOR FUNCTION activity • May swing
Gross: (hyperactive) slightly but it’s Normal findings
* Romberg’s Test able to maintain
upright position
 • Negative
romberge
• has upright Normal findings
* Walking Gait Test posture and
steady gait
with opposing
arm swings

• Patient has
upright posture
* Stand on One Foot and steady gait • maintains stance
with Eyes close Heel with opposing for at least 5
to toe walking arm swings seconds Normal findings

• maintains stance • able to walk

don’t have and maintain
*Heal to toe walking straight lines Normal findings
difficulties while
performing walk

• maintain straight • maintained

lines walk straight and
*Toe to heal walking steps on toes or Normal findings
heels

• able to walk
several steps on
• repeatedly and
toes or heels
rhythmically
touches the
Fine: Normal findings
nose
*Finger to nose Test
• repeatedly • repeatedly and
touches the nose rhythmically
touches the
*Finger to nose nose and the Normal findings
Nurse’s finger • don’t have any finger of the
difficulties to nurse
touch the nose
• rapidly touches
each finger to
thumb with
each hand

*Finger to thumb • rapidly touches Normal findings

each finger
• can alternately
supinate and
pronate hands at
rapidly
• no difficulty of • able to Normal findings
*Alternate supination movement discriminate
and pronation sharp and dull
 light tickling or
6. SENSATION * Pain • patient able to •
touch sensation
identify which is
sharp and dull
• able to
tickling or touch
• discriminate Normal findings
sensation
between hot and
*Light Touch cold
• able to
determine the
*Temperature hot and cold

Perception varies
• widely in
• adults over
able to identify if different parts of
7. TACTILE one or two picks Normal findings
the body.
DISCRIMINATION *One is touching him
to two point
discrimination • Recognized
common object
• Able to identify
• Easily to number or letter
when written in Normal findings
*Stereognosis recognize object palm
when closed eyes
• Both stimuli are
felt

• Able to identify
*Extinction Phenomenon where the body is Normal finding
touched or not
 B. Physical Assessment of Black Widow

Body Parts/ System & Actual Findings Normal Findings Interpretation

Method of Assessment
Used

SKIN • The patient’s skin

• Inspect color is brown • Light to deep
skin color • The parts of the skin brown colour
• Inspect that are exposed to • Generally,
uniformity of sun are darker. uniform in colour
Normal findings
skin color • Skin turgor comes except in areas
• Pinch skin back easily exposed to sun
to note the • When pinched,
skin turgor skin spring back
to previous state
NAILS • The patient’s nails are • Convex curvature
• Inspect round shaped • Angle 160°
fingernail • Fingernails’ texture is • Intact epidermis
plate shape smooth
• Inspect • Capillary refill comes
fingernail back to previous state Normal findings
texture easily.
• Perform
blanch test of
capillary refill

HEAD • The patient head is • Rounded

• Inspect the rounded, symmetric (normocephalic)
skull for size, and no presence of • No masses and
shape, and masses and nodules. nodules
symmetry • Uniform
• Palpate the consistency
skull for • Smooth skin
Normal Findings
nodule or
masses and
depressions
• Note
symmetry of
facial
movement
EARS • Able to hear both
• Inspect ears
the auricles • Auricles are the same • Symmetrical 10°
for color, color as the skin, and • Dry cerumen
symmetry of symmetrical Mobile and firm
size, and • Dry cerumen is
positions present at the Normal findings
• Inspect external ear canal
the external • Both ears can’t hear
ear canal for properly, using the
cerumen, watch tick test.
skin lesions,
and blood
 • Perform weber’s • Did not perform
test using weber’s test
tuning fork • Not performed

• The patient can • Air moves freely

• NOSE & breathe properly. as the client
SINUSES • No tenderness on breaths through
sinuses. nares
• Inspect • No discharge
external nose • Mucosa pink
for flaring,
• Symmetric
shape, or
color
• Inspect the Normal findings
nasal septum
between the
nasal
chambers
• Palpate the
maxillary and
frontal
sinuses for
tenderness
MOUTH & • Patient has • 20 baby teeth Normal findings
THROAT incomplete set of • Smooth shiny
• Inspect the outer broken teeth tooth
lips for symmetry of • Smooth intact
contour, color, and • 2 teeth with cavity dentures
texture • Smooth tongue
• Dark brown
• Inspect the teeth base with prominent
discoloration in
and gums while veins
enamel
examining the inner • No palpable
Foul smell (sordes)
lips and buccal mucosa nodules
• Inspect tongue
movement • The patient have no
• Palpate the signs of nodules,
tongue and floor of the lumps and excoriated
mouth for any nodules, areas
lumps, and excoriated
areas.
 EYES • The patients pupil is • Pupils size is 3 to Normal findings
• Inspect the equally round, both 7 mm in diameter
eyebrows for hair eyes coordinated and • Pupils equally
distribution the cornea is round and react
• Inspect and palpate transparent to light
the lacrimal sac and • Both eyes are aligned accommodation
nasolacrimal and coordination (PERRLA)
duct • Both eyes are
• Perform corneal coordinated
sensitivity • No edema or
• Assess six ocular tearing
movement to • Cornea is
determine transparent
eye
alignment
and
coordination
• Assess distance
vision

NECK
• inspect the • the patients neck • Equal strength
neck muscles have an equal • Equal size of
for abnormal strength and equal muscle
swelling or size of muscle • Absence of Normal Findings
masses bruits
• observe head • Coordinated,
movement smooth
• assess muscle • the patient have no movement with
strength sign of spasm and no discomfort
• palpate the stiffness • No spasm and
entire neck stiffness
for
enlargement
lymph nodes
• palpate the
trachea for
lateral
deviation
Body Parts/ System & Actual Findings Normal Findings Interpretation
Method of Assessment
Used

• No evidence of Normal findings

enlargement of
lungs
• The patient have no • Flat, rounden,
sign of tenderness convex
and enlargement in • No tenderness
RESPIRATORY lungs
• inspect posterior
thorax for shape and
symmetry
• Inspect the spinal • The patients posterior
alignment for thorax is flat and
deformities rounded

• Inspect breathing
pattern
CARDIAC • The patients pulse is • Symmetric heart Normal findings
• Palpate the symmetric volume
peripheral pulse • Normal heart
sound
• Inspect the skin of • The patients veins are
• Limbs not tender
the hand and feet for visible
• Veins are not
colour, temp, and
visible
edema
• The patient have a
• Assess the adequate normal heart sound
of arterial blood flow
using capillary refill
test

• The patients abdomen • Flat, rounded, Normal findings

shows no signs of convex
tenderness • No tenderness in
ABDOMEN • Abdomen is abdomen
• Inspect Abdomen symmetrical in
for skin integrity contour
• Inspect the
abdomen for contour
and symmetry
• Percuss the
abdomen
• Percuss the liver
Body Parts/ Method of Actual Findings Normal Findings Interpretation
Assessment Used
MUSCULOSKELETAL
• Inspect the Muscle
• The patient’s • No deformities Normal findings
size
muscle show no
• No tenderness
signs of
and swelling
swelling, and
• Inspect the Muscle • Equal strength
deformities
and tendons for in each body
• The patients
contractures side
muscle have an
equal strength in
each side of the
body but are
weak
• Test muscle strength

• Inspect the joints for

swelling
NEUROLOGIC 1.
MENTAL STATUS
a. Orientation Normal
• Ask the Patient the Memory is Findings
The patient
city and state of intact patient
knows the place
residence don’t have any
they live in
difficulty in
remembering

• Ask the patient for • The patient knows

time of day, day of the time of the
• Normal
the week day, and day of
Findings
the week • Immediate
recall is intact
patient don’t
have any
• Ask the patient to • The patient knows difficulty in
names the family remembering
the names of the
members family members

b. Memory Normal findings

• Recent Memory is
* Immediate recall
intact patient
• Ask patient to repeat a Normal findings
don’t have any
series of digits “94-6-2-1- • Patient can only difficulty in
5” repeat 3 remembering Normal findings
• Ask patient to state the numbers only. Normal findings
same digits but in reverse
Normal findings

• Can’t repeat • Remote Memory

* Recent memory is intact
numbers in
reverse patient don’t
have any
 • Ask the Patient how difficulty in Normal findings
he got to the school remembering
• Not performed

• Provide the client

with three facts to • Not performed
recall

* Remote memory
• Ask patient to recall • Patients abled to
what happened do without
the patient was
during her vacation discomfort
able to do the
eye opening
response but in
the motor and
verbal he is not
responding.

2. LEVEL OF
CONSCIOUSNESS
-using GCS
• Glasgow coma scale
test

• 6 score
• Eye opening: 4 • 15 score
spontaneous
•
Motor response:
1 to verbal
command
• Verbal respond: 1
oriented
converses
 3. 12 CRANIAL NERVES
* Olfactory
• Ask the patient to • Able to identify • Intact nerve Normal findings
identify different mild aroma and • Able to identify
aroma strong aroma which smell is
mild and strong
* Optic • Not performed
• Ask the patient to • 20/20 vision • Not
read the Snellen chart performed
• Pupil equally
rounded and
* Oculomotor react to light • PERRLA
• Assess Pt. 6 ocular accommodation
movement and pupil Normal findings
reaction

• Pupil equally
* Trochlear rounded and • PERRLA
• Assess Pt. 6 ocular react to light Normal findings
movement. accommodation

* Trigeminal • Patient able to • Able to identify

• Inspect for blink distinguish the light and deep
reflex. light sensation sensation
Normal findings
and deep Intact nerve
•
sensation

• No deformities
* Facial • Symmetric
• Test the facial movement of • Symmetric
movements face facial Normal findings
movement

* Abducens • Patient able to

• Assess direction of see in peripheral • Pupil equal
Normal findings
gaze round and react
gaze
to light
accommodation

* Glossopharyngeal • Client have a

• Test the taste and gag reflex • Gag reflex is
gag reflex present Normal findings

* Auditory • Not performed

• Weber’s Test using • Equal sound on
tuning fork both ears Normal findings
• Patient has
difficulties in
• Rinnes Test hearing • Equal sound on
both ears
 Client have no difficulty Normal findings
difficulty in when speaking
* Vagus speaking Normal findings
• Ask the Pt to open
mouth and say “
ah”
• Equal muscle
* Accessories • Muscle equally strength on
• Test the Neck muscles strength both side of Normal findings
strength body
(sternocleidomastoi
d and trapezius)

• Patient don’t have

any discomfort
* Hypoglossal
while protruding
• Ask the patient to • Able to
the tongue
protrude and move it protrude the
to each side against tongue
tongue blades Normal findings
• Gag reflex
present

Body Parts/ Method of Actual Findings Normal Findings Interpretation

Assessment Used

4. REFLEXES
* Biceps
• Biceps reflex test the
• weak reflexes
spinal cord level C- • Bicep reflex
5, C-6 present Normal findings

• weak reflexes
* Triceps
• Triceps reflex test the • Triceps reflex
present Normal findings
spinal cord level C-
7,C-8
• Weak reflexes

* Brachioradialis
• Brachioradialis reflex • Weak reflexes • Brachioradialis
reflex is present Normal findings
test the spinal cord
level C-3,C-6

* Patellar
 • Patellar reflex test the • Weak reflexes • Patellar reflex is
spinal cord level L- present Normal findings
2,L-3,L-4

* Achilles • Weak reflexes Normal findings

• Achilles reflex is
• Achilles reflex tests
present
the spinal cord
level S-1,S-2

* Plantar/Babinski • Not performed

• Babinski reflex is Normal findings
present

5. MOTOR FUNCTION
Gross:
• May swing
* Romberg’s Test
• Patient can slightly but it’s
• Not
maintain upright able to maintain
performed
position upright position

• has upright
* Walking Gait Test • Patient has posture and
upright posture steady gait • Not
and steady gait with opposing performed
arm swings

* Stand on One Foot • Patient can • maintains stance • Not

with Eyes close Heel to maintain stance for at least 5 performed
toe walking for at least 5 seconds
seconds

• Patient was able to

*Heal to toe walking • able to walk
walk and • Not
maintain straight and maintain
performed
lines. straight lines
walk

*Toe to heal walking • maintained

• Patient straight and • Not
maintained steps on toes or performed
straight heels

• repeatedly and • Not

Fine: • Slow
rhythmically performed
*Finger to nose Test
 touches the
nose

*Finger to nose • repeatedly and • Not

• Slow
Nurse’s finger rhythmically performed
touches the
nose and the
finger of the
nurse

• rapidly touches • Not

*Finger to thumb • Slow each finger to
performed
thumb with
each hand

• can alternately • Not

*Alternate supination
• Slow supinate and performed
and pronation
pronate hands at
rapidly
• The patient was
6. SENSATION * Pain
able to
determine pain
• able to • Normal
discriminate findings
sharp and dull

• Patient was able to • light tickling or

feel light touch sensation
*Light Touch
sensation • Not
performed

*Temperature • able to • able to

determine the discriminate Normal findings
hot and cold between hot and
cold

7. TACTILE • Perception varies

DISCRIMINATION • able to identify if widely in adults Normal findings
*One to two point one or two picks over different
discrimination is touching him parts of the
body.

• patient was able to

• Recognized
recognize
*Stereognosis common object
common objects Normal findings
 • Able to identify • Able to identify
*Extinction Phenomenon where the body number or letter Normal findings
is touched or not when written in
palm

• Both stimuli are

felt
C, Physical Assessment of Thor

Body Parts/ System & Actual Findings Normal Findings Interpretation

Method of Assessment
Used

SKIN • Uniform in colour • Light to deep

• Inspect skin colour except for those are brown colour .
• Inspect uniformity not expose to the sun. • Generally,
of skin colour • Skin spring back to uniform in colour
• Pinch skin to note previous state. except in areas
the skin turgor exposed to sun. Normal findings
• When pinched,
skin spring back
to previous state.

NAILS • Has a convex • Convex curvature

• Inspect fingernail curvature. • Angle 160°
plate shape • The nails are long and • Intact epidermis
• Inspect fingernail dirty, some have
texture hangnails.
• Perform blanch test • 2 seconds capillary Normal findings
of capillary refill refill.

HEAD • The head is round or • Rounded

• Inspect the skull for normocephalic. (normocephalic)
size, shape, and • No presence of • No masses and
symmetry masses, lumps and nodules.
• Palpate the skull for nodules. • Uniform
nodule or masses and • Facial movement are consistency
depressions symmetrical. • Smooth skin
Normal Findings
• Note symmetry of • No presence of
facial movement parasites
(pediculosis)

EARS • Small lesions • Able to hear both

• Inspect • Presence of dry ears
the auricles cerumen. • Symmetrical 10°
for colour, • No presence of • Dry cerumen
symmetry of nodules Mobile and firm.
Normal findings
size, and
positions
• Inspect
the external
ear canal for
 cerumen, skin
lesions, and blood
• Perform webers
test using tuning
fork

• Symmetrical in shape • Air moves freely Normal findings

and colour. as the client
• No presence of breaths through
discharge. nares
• Mucosa is pink. • No discharge
• No presence of • Mucosa pink
NOSE & tenderness, lumps, • Symmetric
SINUSES and nodules.
• Inspect
external nose for
flaring, shape, or
colour
• Inspect the
nasal septum between
the nasal chambers
• Palpate the
maxillary and frontal
sinuses for tenderness
• Missing teeth • 20 baby teeth • 2 teeth are
• Presence of dental • Smooth shiny missing
caries. tooth • 14 teeth with
• The tongue is in • Smooth intact cavity
central position dentures
• tongue moves freely • Smooth tongue
• No presence of base with prominent
lumps, and nodules. veins.
• No palpable
MOUTH & nodules
THROAT
• Inspect the outer
lips for symmetry of
contour, colour, and
texture
• Inspect the teeth
and gums while
examining the inner
lips and buccal mucosa
• Inspect tongue
movement
• Palpate the
tongue and floor of the
mouth for any nodules,
lumps, and excoriated
areas.
 EYES • No edema and • Pupils size is 3 to Normal findings
• Inspect the discharge. 7 mm in
eyebrows for hair • No lesions visible diameter.
distribution • Cornea appears to be • Pupils equally
• Inspect and palpate clear and transparent round and react
the lacrimal sac and • When looking at near to light
nasolacrimal object, pupils accommodation
duct contract. (PERRLA)
• Perform corneal • When looking at far • Both eyes are
sensitivity object, pupils dilate. coordinated.
• Assess six ocular • No edema or
movement to tearing.
determine • Cornea is
eye transparent.
alignment
and
coordination
• Assess distance
vision

NECK • Muscle equal in size • Equal strength Normal Findings

• inspect the neck • Head centered • Equal size of
muscles for abnormal • No discomfort muscle
swelling or masses • Muscles have equal • Absence of bruits
• observe head strength. • Coordinated,
movement • No presence of spasm smooth
• assess muscle or tremor. movement with no
strength • No presence of discomfort.
• palpate the entire masses and nodules. • No spasm and
neck for stiffness.
enlargement lymph
nodes
• palpate the trachea
for lateral deviation
Body Parts/ System & Actual Findings Normal Findings Interpretation
Method of Assessment
Used

• No enlargement of the • No evidence of Normal findings

liver felt when enlargement of
palpated. liver
• Has normal breath • Flat, rounded,
sound. convex
RESPIRATORY • No deformities • No tenderness
• inspect posterior • Symmetric movement
when respiration.
thorax for shape and
symmetry
• Inspect the spinal
alignment for
deformities

• Inspect breathing
pattern
• Symmetric pulse • Symmetric heart Normal findings
CARDIAC volume.
• Normal heart sound is
• Normal heart sound.
• Palpate the heard (lub dub) • Limbs not tender
peripheral • Veins are not visible.
pulse
• Inspect the
skin of the
hand and feet
for colour,
temp, and
edema
• Assess the
adequate of
arterial blood
flow using
capillary refill
test

ABDOMEN • The Abdomen appears • Flat, rounded, Normal findings

• Inspect Abdomen to be flat. convex
for skin integrity • Uniform in color • No tenderness in
• Inspect the abdomen.
abdomen for contour • Symmetric movement
and symmetry
• Percuss the
abdomen
• Percuss the liver
Body Parts/ Method of Actual Findings Normal Findings Interpretation
Assessment Used
MUSCULOSKELETAL
• Inspect the Muscle Muscle has an
• No deformities Normal findings
size equal size in
both side of the • No tenderness
body. and swelling.
• Inspect the Muscle No contractures • Equal strength
and tendons for and tremors in each body
contractures Joint moves side.
freely and no
• Test muscle strength
presence of
• Inspect the joints for swelling.
swelling

NEUROLOGIC 1.
MENTAL STATUS
a. Orientation
• Ask the Patient the • Client was able to • Memory is intact Normal findings
city and state of answer the patient don’t
residence question without have any
difficulty. difficulty in
remembering.
• Client was able to
• Ask the patient for the
state the time and
time of the day, and
date correctly.
day of the week

• Ask the patient to • Client was able to

state the names of state the names
family members of his family.

b. Memory
* Immediate recall
• Immediate
• Ask patient to repeat a • Client was able to recall is intact
Normal findings
series of digits “32- state the patient don’t
4-4-5-6” numbers have any
correctly. difficulty in
remembering.
• Ask patient to state
• Client forgot one • Recent Memory is
the same digits but
number (2) intact patient
in reverse
while reciting. don’t have any
difficulty in
remembering.
 * Recent memory • Ask • Client was able to • Remote Memory Normal findings
the Patient how she got to state on how is intact
the school he goes to patient don’t
school. have any
difficulty in
remembering.
• Client was able to
• Provide the client
answer the
with three facts to
question
recall
correctly

* Remote memory
• Ask patient to recall • Client was able to
Normal findings
what happened recall what he
during his school did in the
before going home. school.

2. LEVEL OF
CONSCIOUSNESS
-using GCS Normal findings
• 15 score • 15 score
• Glasgow coma scale
• Eye opening: 4
test
spontaneous

• Motor response:
6 to verbal
command
• Verbal respond:
5 oriented
converses

3. 12 CRANIAL NERVES
* Olfactory Normal findings
• Ask the patient to Able to identify • Intact nerve
identify different which is alcohol • Able to identify
aroma and which is a perfume. which smell is
mild and strong.
* Optic
• Ask the patient to Not performed 20/20 vision • Not
read the snellen performed
chart

* Oculomotor • PERRLA
• Assess Pt. 6 ocular • Pupil equally Normal findings
movement and pupil rounded and
reaction react to light
accommodation

* Trochlear
• Assess Pt. 6 ocular
• Pupil equally • PERRLA
movement. Normal findings
rounded and
 react to light
accommodation

* Trigeminal
• Inspect for blink reflex. •
Patient able to
distinguish the • Able to identify Normal findings
light and deep
light sensation
sensation.
and deep • Intact nerve
sensation

* Facial
• Test the facial • Has symmetric • No deformities Normal findings
movements facial • Symmetric
movement. facial
movement.

* Abducens •
• Assess direction of gaze Pupil equal
Patient was able
round and react
• to see in his Normal findings
to light
peripheral gaze.
accommodation.

* Glossopharyngeal
Client’s gag Gag reflex is
• Test the taste and gag • • Normal findings
reflex is present. present.
reflex

* Auditory
• Weber’s Test using • Equal sound on
tuning fork • Not performed both ears. Normal findings

• Rinnes Test • Patient able to • Equal sound on

hear on both both ears. Normal findings
ears.

* Vagus • Client don’t • No difficulty

• Ask the Pt to open have difficulty in when speaking. Normal findings
mouth and say “ ah” speaking.

* Accessories
Muscle has equal
• Test the Neck muscles • • Equal muscle Normal findings
strength.
strength strength on both
(sternocleidomastoi d side of body.
and trapezius)

• Patient don’t • Able to protrude

* Hypoglossal have any the tongue. Normal findings
 • Ask the patient to discomfort •Gag reflex is
protrude and move it while protruding present.
to each side against the tongue
tongue blades

Body Parts/ Method of Actual Findings Normal Findings Interpretation

Assessment Used

4. REFLEXES
* Biceps
• Biceps reflex test the
• Present in the
spinal cord level •Bicep reflex is
C-5, C-6 client. present. Normal findings

* Triceps
• Triceps reflex test the Normal findings
spinal cord level C- Present in the Triceps reflex is
• •
7,C-8 client. present.

* Brachioradialis
• Brachioradialis reflex Present in the •Brachioradialis
• Normal findings
test the spinal client. reflex is present.
cord level C-3,C-6

* Patellar
• Patellar reflex test the • Present in the •Patellar reflex is Normal findings
spinal cord level L- client. present.
2,L-3,L-4

• •
* Achilles
• Achilles reflex tests the Present in the Achilles reflex is
spinal cord level client. present. Normal findings
S-1,S-2
• Not Present •Babinski reflex
* Plantar/Babinski is not present.
Normal findings

• Negative •May swing

5. MOTOR FUNCTION romberg. slightly but it’s
Gross: Normal findings
 * Romberg’s Test able to maintain
upright position.

• Patient has
upright posture, • Has upright Normal findings
* Walking Gait Test and steady gait posture and
with opposing steady gait with
arm swings. opposing arm
swings.

• The client
maintains • Maintains
* Stand on One Foot stance, and stance for at Normal findings
with Eyes close don’t have least 5 seconds.
Heel to toe walking difficulties
while
performing.

• The client
maintains • Able to walk
*Heal to toe walking straight lines and maintain Normal findings
while walking. straight lines
walk.

• The client was

able to walk Maintained
*Toe to heal walking • Normal findings
several steps on straight and
toes to heels steps on toes or
test. heels.

•
Repeatedly
Fine:
touches the nose • Repeatedly and
*Finger to nose Test Normal findings
with his finger. rhythmically
touches the
nose.

• The client was

*Finger to nose Nurse’s able to touch his • Repeatedly and
finger nose and the Normal findings
rhythmically
nurse’s fingers. touches the nose
and the finger of
the nurse.
• The client was
*Finger to thumb able to touch his • Rapidly touches Normal findings
Fingers with his each finger to
thumb. thumb with each
hand.
*Alternate supination
and pronation • No difficulty of
movement. • Can alternately Normal findings
supinate and
pronate hands at
6. SENSATION rapidly.
* Pain
• The patient was
able to identify • Able to
Normal findings
which is sharp discriminate
and dull. sharp and dull.
*Light Touch

• The client felt a

tickling or touch
*Temperature sensation. • Light tickling or
• The client touch sensation. Normal findings
determined • Able to
which is hot and discriminate
cold. between hot and
cold.
• The client was
able to identify
7. TACTILE if one or two
picks is • Perception varies
DISCRIMINATION Normal findings
touching him. widely in adults
*One to two point
over different
discrimination
parts of the
body.

• Easily recognize
*Stereognosis the objects that
he holds even • Recognized Normal finding
with closed common
eyes. object.
• The client was
able to identify • Able to identify
*Extinction Phenomenon where the body Normal finding
number or letter
was touched or when written in
not. palm.
• Both stimuli are
felt.
 D. Physical Assessment of Scarlet Witch

Body Parts/ System & Actual Findings Normal Findings Interpretation

Method of Assessment
Used

SKIN • Scarlet Witch’s skin • Light to deep • Secondary skin

• Inspect skin colour colour is light brown brown colour lesions such as
• Inspect uniformity • Patient’s uniformity • Generally, Scars and Keloids
of skin colour of skin colour is uniform in colour are present
• Pinch skin to note normal except in areas
the skin turgor • Patient’s skin turgor exposed to sun
• Inspect, palpate for is normal • When pinched,
any skin lesions • Patient’s skin has a skin spring back
healed wound all to previous state
over the body • Freckles, some
birthmarks that
have not changed
since childhood

NAILS • Convex curvature • Long nails both left

• Inspect fingernail and is angle 160° and right fingers
plate shape • Smooth texture
• Inspect fingernail • The angle of the nail • Prompt return to
texture plate of scarlet witch pin or usual color
• Perform blanch test is 160 degrees’ angle (generally less
of capillary refill • Patient’s nail texture than 4 seconds)
is smooth (both
fingers and toes)
• Fingernails of the
patient return to pink
or usual color in less
than 3 seconds
• Patient’s head has a • Rounded • Asymmetric shape
normal size and (normocephalic) of head
shape of head but it’s • No masses and
not symmetric nodules
• Patient’s skull has no • Uniform
HEAD nodule or any kind of consistency
• Inspect the skull for depressions
size, shape, and • Facial movement of
symmetry the patient is also
• Palpate the skull for asymmetric
nodule or masses and
depressions
• Note symmetry of
facial movement
 EARS • Scarlet witch’s ears is • Constricted Ears
• Inspect fold both left and • Color same as both left and right
the auricles right, asymmetric; facial skin,
for colour, ear deformities and symmetrical, and
symmetry of aligned with outer auricle aligned
size, and canthus of eye about with outer
positions 10° canthus of eye,
• Inspect • The patient has a lot about 10°, from
the external of dry cerumen both vertical
ear canal for left and right ears • Distal third
cerumen, • Weber’s test was not contains hair
skin lesions, performed follicles and
and blood glands; Dry
• Perform cerumen
webers test • Sound is heard in
using tuning both ears or is
fork localized at the
center of the
head

• Scarlet Witch’s nose • Symmetric and • Discharge from

has a symmetric straight, uniform nares
shape and uniform color
color • No discharge or
• The patient has a flaring
discharge in her • Not tender; no
external nose lesions
• Patient’s nose has no
lesions nor tender
NOSE & SINUSES
• Inspect external
nose for flaring, shape,
or colour
• Inspect the nasal
septum between the
nasal chambers
• Palpate the
maxillary and frontal
sinuses for tenderness
MOUTH & • Plaque and dental
THROAT carries are
• Inspect the outer • Scarlet witch’s lip has present
lips for symmetry of a uniform pink color • Uniform pink • Tartar is also
contour, colour, and and soft, smooth color, soft, moist, visible
texture texture smooth texture • Malocclusion
• Inspect the teeth • The patient has a • Smooth, white, teeth are present
and gums while misalignment teeth shiny tooth
examining the inner on the upper and enamel, Pink
lips lower teeth, gums are gums, Moist,
pink and firm. firm texture to
Scarlet have a 20 gums. No
teeth in total retraction of
 and buccal • Scarlet witch can’t gums (pulling
mucosa open widely her away from the
• Inspect mouth teeth)
tongue • Patient tongue can’t • Moves freely;
movement move upward no tenderness
• Palpate the • Patient tongue is • Smooth
tongue and smooth with no tongue base with
floor of the palpable nodules prominent veins
mouth for any
nodules,
lumps, and
excoriated
areas.

EYES
• Inspect the • Scarlet eyebrows is • Hair evenly
eyebrows for symmetry and the distributed; skin
hair hair is black, evenly intact, Eyebrows
distribution distributed and symmetrically
• Assess each parallel to each aligned; equal
pupil’s direct other movement
and • The patient’s pupils • Illuminated Normal findings
consensual are constricted, both pupil constricts
reaction to left and right eye • No edema or
light • The patient’s tearing
• Inspect and lacrimal sac has no • Both eyes
palpate the edema or tenderness coordinated,
lacrimal sac over lacrimal gland move in unison,
and • Patient blinks when with parallel
nasolacrimal the cornea is alignment
duct touched • 20/20 vision on
• Perform • Scarlet witch cannot Snellen chart
corneal able to move her
sensitivity eyes in full range of
• Assess six motion
ocular • Distance vision is
movement to not performed
determine
eye
alignment
and
coordination
• Assess
distance
vision
 NECK
• inspect the • Scarlet neck muscle • muscles equal in
neck muscles is proportional of size and head
for abnormal the size of the body centered
swelling or and head, • coordinated, Normal Findings
masses symmetrical and smooth
• observe head straight. movement with
movement • The patient head no discomfort
• assess muscle movement is • not palpable for
strength coordinated and enlargement of
• palpate the smooth movements lymph nodes
entire neck with no discomfort • Trachea is
for • The patient able to central
enlargement resist the applied placement in
lymph nodes force midline and
• palpate the • Scarlet necks has no spaces are equal
trachea for palpable lumps, on both sides
lateral masses or areas of
deviation tenderness.
• Scarlet Witch has a
central placement
in midline of neck
and the spaces are
equal in both sides

Body Parts/ System & Actual Findings Normal Findings Interpretation

Method of Assessment
Used

• Chest symmetric Normal findings

• Spine vertically
aligned
• Scarlet witch’s chest • Quiet, rhythmic
is symmetric and effortless
RESPIRATORY • The patient’s spine is respirations
• inspect posterior vertically aligned
thorax for shape and • The patient’s
symmetry breathing pattern is
• Inspect the spinal quiet, rhythmic, and
alignment for effortless respirations
deformities
• Inspect breathing
pattern
CARDIAC Normal findings
• Palpate the • Scarlet witch’s pulse is
• Symmetric pulse
peripheral pulses palpable, has a
volumes; Full
symmetric pulse
• Inspect the skin of pulsations
volumes and full
the • Skin color is
pulsations
pink, skin
 hand and feet • The patient’s skin temperature is
for colour, color is pink, not excessively
temp, and temperature is not warm or cold,
edema excessively warm or and no edema
cold and has no
• Assess the • Capillary refill
edema
adequate of test: immediate
arterial blood • The patient’s arterial return of color
flow using blood flow is
capillary refill immediate return to
test color when the
capillary refill test is
done

ABDOMEN • Scarlet Witch’s • unblemished Normal findings

• Inspect Abdomen abdomen has skin, uniform
for skin integrity unblemished skin. colour
• Inspect the • The patient’s • abdomen is flat,
abdomen for contour abdomen is flat and rounded
and symmetry rounded
• Percuss the • Tympany over
abdomen • When patient’s the stomach and
• Percuss the liver abdomen percussed, gas- filled
tympany is heard bowels; dullness,
because of air in the especially over
stomach and intestine the liver and
spleen
• Dullness is heard over
the organs • 6 to 12 cm in the
midclavicular line; 4
to 8 cm at the
midsternal line

Body Parts/ Method of Actual Findings Normal Findings Interpretation

Assessment Used
MUSCULOSKELETAL Normal
• Inspect the Muscle size • The patient findings
muscles are
symmetrical in • equal size on both
• Inspect the Muscle and
size with no side of the body
tendons for contractures
involuntary • No contractures
movements.
• The patient has • equal strength on
no detection of the each body side
muscular • No swelling
contraction
• The patient
muscle power
 • Test muscle strength obviously
varies. Active
movement
• Inspect the joints for against gravity
swelling and some
resistance No
swelling

NEUROLOGIC 1.
MENTAL STATUS
a. Orientation
• Ask the Patient the Memory is intact Was not able
The patient was patient don’t to speak
city and state of not able to state
residence have any
the city and her difficulty in
residence remembering

• Ask the patient for • The patient was

time of day, day of not able to state the
the week date and time.

• The patient was

• Ask the patient to not able to state
names the family
her family
members members

b. Memory
* Immediate recall
• Scarlet cannot
• Ask patient to repeat a • Immediate recall is
repeat the
series of digits “94- intact patient
digits.
6-2-1-5” don’t have any
difficulty in
• Ask patient to state • Scarlet cannot
remembering
the same digits but state the same
in reverse digits in reverse

* Recent memory • Ask

• The patient • Recent Memory is
the Patient how she got to
cannot state intact patient
the school
how she got to don’t have any
the school difficulty in
• The patient remembering
• Provide the client cannot speak
with three facts to properly
recall
 * Remote memory • Ask • The patient • Remote Memory is
patient to recall what cannot speak intact patient
happened during her properly don’t have any
vacation difficulty in
remembering

2. LEVEL OF
CONSCIOUSNESS
-using GCS •
Glasgow Coma Glasgow Coma 15 score
Did not
Scale test Scale did not
performed
performed

3. 12 CRANIAL NERVES
* Olfactory
• Ask the patient to Scarlet Witch is • Intact nerve
identify different able to identify • Able to identify
aroma which mild aroma and which smell is
strong aroma mild and strong
* Optic
• Ask the patient to 20/20 vision Not
Not performed
read the snellen performed
chart

* Oculomotor • The patient

• PERRLA; Both
• Assess Pt. 6 ocular pupil is
eyes coordinated,
movement and constricts as the
move in unison,
pupil reaction light passes
through it
• The patient was
* Trochlear not able to • PERRLA
• Assess Pt. 6 ocular move her eyes • The patient
movement. in all directions cannot
• The patient understand
can’t blink • Slow
* Trigeminal • Eyelids blink blinking
more than
• Inspect for blink bilaterally
three(3) times
reflex.

• The patient
facial
• Symmetric facial
movement is
* Facial movement
symmetric
• Test the facial
movements
* Abducens • The patient can’t • Pupil equal round
performed and react to light
• Assess direction of
accommodation
gaze

• The assessment
* Glossopharyngeal • was not • Gag reflex is
Test the taste and gag performed present • Did not
reflex performed

• The assessment
was not
* Auditory performed
• Equal sound on
• Weber’s Test using • The assessment both ears
tuning fork was not
performed
• Rinnes Test • Equal sound on
both ears

• The patient
* Vagus • The patient
can’t open her • no difficulty
• Ask the Pt to open said “eh”
mouth widely. when speaking
mouth and say “ ah” instead of
So thus she said
“ah”
* Accessories only is “eh”
• The patient able
• Test the Neck
to resist the
muscles strength • Equal muscle
applied force
(sternocleidomastoi strength on
d and trapezius) both side of
body
• The patient can’t
protrude her
* Hypoglossal tongue but she
can move it • Able to protrude • The patient
• Ask the patient to
each side the tongue can’t
protrude and move it
against tongue protrude her
to each side against
blades tongue
tongue blades
Body Parts/ Method of Actual Findings Normal Findings Interpretation
Assessment Used

4. REFLEXES
* Biceps
• Biceps reflex test the • The patient has a
spinal cord level C- biceps reflex • Bicep reflex
5, C-6 present

* Triceps
• Triceps reflex test • The patient has • Triceps reflex
the spinal cord level a triceps reflex present
C-7,C-8

* Brachioradialis
• Brachioradialis reflex • The patient has a • Brachioradialis
test the spinal cord brachioradialis reflex is present
level C-3,C-6 reflex

* Patellar
• The patient has a
• Patellar reflex test the patellar reflex • Patellar reflex is
spinal cord level L- present
2,L-3,L-4

• Achilles reflex is
* Achilles • The patient has a present
• Achilles reflex tests Achilles reflex
the spinal cord
level S-1,S-2
• Babinski reflex is
* Plantar/Babinski • The patient has a present
Babinski reflex

5. MOTOR FUNCTION
Gross: • The patient • cerebellar
• May swing
* Romberg’s Test balance herself ataxia when
slightly but it’s patient can’t
only for 3
able to maintain maintain
seconds
upright position balance with
an open eyes
• Has poor
• Scarlet Witch • has upright posture and
* Walking Gait Test posture and unsteady,
can’t walk
steady gait with irregular,
straight
staggering
 opposing arm gait with
swings wide stance;
• maintains stance bends legs
The patient for at least 5 only from
* Stand on One Foot can’t stand in seconds hips; has
with Eyes close Heel to one foot • able to walk and rigid or no
toe walking maintain straight arm
lines walk movements •
Cannot maintain

The patient • maintained stance for 5

*Heal to toe walking can’t walk from straight and steps seconds
heel to toe on toes or heels

• The patient can

*Toe to heal walking
walk properly
from toe to heel

Fine:
• Scarlet Witch • repeatedly and
*Finger to nose Test can’t performed rhythmically
the finger to touches the nose
nose test
• The patient was • repeatedly and • Misses the
*Finger to nose rhythmically
able to do but finger and
Nurse’s finger touches the nose
not as fast moves
and the finger of slowly
the nurse

• rapidly touches
each finger to
• Scarlet Witch
thumb with each
*Finger to thumb can’t performed
hand
finger to thumb

• The patient can

performed the
alternate • can alternately
supination and supinate and
pronation but in pronate hands at
*Alternate supination very slow rapidly
and pronation pattern

6. SENSATION * Pain
• The patient was • able to
able to feel the discriminate
pain sharp and
dull
 • Scarlet Witch can • light tickling or
*Light Touch able to touch sensation
identify where it
touched even it
is light touched

*Temperature • Not performed •

able to
discriminate
between hot and
cold

7. TACTILE •
DISCRIMINATION *One to • Scarlet witch did Recognized
two point discrimination not speak common object
properly when
doing
assessment

*Stereognosis •

Able to identify
number or letter
when written in
palm

Both stimuli are

*Extinction Phenomenon •
felt

E. Physical Assessment of Spiderman

Body Parts/ System & Actual Findings Normal Findings Interpretation

Method of Assessment
Used

SKIN • The patients skin • Light to deep

• Inspect skin colour is light brown brown colour
colour • The patient generally • Generally,
• Inspect uniform in colour uniform in colour Normal findings
uniformity of except in areas except in areas
skin colour exposed to sun exposed to sun
 • Pinch skin to • When pinched the skin • When pinched, skin
note the skin of the patient back to spring back to
turgor previous state. previous state

NAILS • The patient have • Convex curvature

• Inspect fingernail convex curvature, • Angle 160°
plate shape intact epidermis and • Intact epidermis
• Inspect fingernail an angle of 160°
texture
• Perform blanch test Normal findings
of capillary refill

HEAD • The patient head is • Rounded

• Inspect the skull for rounded, symmetric (normocephalic)
size, shape, and and no presence of • No masses and
symmetry masses and nodules. nodules
• Palpate the skull for • The patient have • Uniform
nodule or masses and smooth skin. consistency
depressions • Smooth skin
Normal Findings
• Note symmetry of
facial movement

EARS • The patient have • Able to hear both

• Inspect Small lesions in the ears
the auricles auricle • Symmetrical 10°
for colour, • The patient was able • Dry cerumen
symmetry of to hear in both ears Mobile and firm
size, and and have a presence
positions of dry cerumen
Normal findings •
• Inspect
the external
ear canal for
cerumen,
skin lesions,
and blood • Not performed
• Perform
webers test
using tuning
fork Not performed
 • The patient was able • Air moves freely
to breath freely as the client
through his nose. breaths through
• The patient have no nares
signs of discharge • No discharge
• Mucosa pink
• Symmetric

NOSE & SINUSES

Normal findings
• Inspect external
nose for flaring, shape,
or colour
• Inspect the nasal
septum between the
nasal chambers
• Palpate the
maxillary and frontal
sinuses for tenderness
MOUTH & • The patient have 20 • 20 baby teeth • 2 teeth with
THROAT teeth and 2 have a • Smooth shiny cavity
• Inspect the outer cavity. tooth • Dark brown
lips for symmetry of • Smooth intact discoloration in
contour, colour, and dentures enamel
texture • The patients dentures • Smooth tongue • Foul smell
• Inspect the teeth was intact and have base with prominent (sordes)
and gums while smooth tongue base. veins
examining the inner • No palpable
lips and buccal mucosa • The patient have no nodules
• Inspect tongue signs of nodules
movement
• Palpate the
tongue and floor of the
mouth for any nodules,
lumps, and excoriated
areas.
 EYES • The patients pupil is • Pupils size is 3 to Normal findings
• Inspect the equally round, both 7 mm in diameter
eyebrows for hair eyes coordinated and • Pupils equally
distribution the cornea is round and react
• Inspect and palpate transparent to light
the lacrimal sac and • The patient have no accommodation
nasolacrimal sign of edema (PERRLA)
duct • Both eyes are
• Perform corneal coordinated
sensitivity • No edema or
• Assess six ocular tearing
movement to • Cornea is
determine transparent
eye
alignment
and
coordination
• Assess distance
vision

NECK
• inspect the • the patients neck • Equal strength
neck muscles have an equal • Equal size of
for abnormal strength and equal muscle
swelling or size of muscle • Absence of Normal Findings
masses bruits
• observe head • Coordinated,
movement smooth
• assess muscle • the patient have no movement with
strength sign of spasm and no discomfort
• palpate the stiffness • No spasm and
entire neck stiffness
for
enlargement
lymph nodes
• palpate the
trachea for
lateral
deviation
Body Parts/ System & Actual Findings Normal Findings Interpretation
Method of Assessment
Used

• No evidence of Normal findings

enlargement of
liver
• The patient have no • Flat, rounden,
sign of tenderness convex
and enlargement in • No tenderness
RESPIRATORY liver.
• inspect posterior
thorax for shape and
symmetry
• Inspect the spinal • The patients posterior
alignment for thorax is flat and
deformities rounded

• Inspect breathing
pattern
CARDIAC • The patients pulse is • Symmetric heart Normal findings
• Palpate the symmetric volume
peripheral pulse • Normal heart
sound
• Inspect the skin of • The patients veins are
• Limbs not tender
the hand and feet for not visible, limbs are
• Veins are not
colour, temp, and tender
visible
edema
• Assess the adequate • The patient have a
of arterial blood flow normal heart sound
using capillary refill
test

• The patients abdomen • Flat, rounded, Normal findings

is distended convex
• The patients • No tenderness in
anbdomen show no abdomen
ABDOMEN
sign of tenderness
• Inspect Abdomen
for skin integrity
• Inspect the
abdomen for contour
and symmetry
• Percuss the
abdomen

• Percuss the liver

Body Parts/ Method of Actual Findings Normal Findings Interpretation
Assessment Used
MUSCULOSKELETAL
• Inspect the Muscle
• The patients • No deformities Normal findings
size
muscle show no
• No tenderness
signs of
and swelling
swelling, and
• Inspect the Muscle • Equal strength
deformities
and tendons for in each body
• The patients
contractures side
muscle have an
equal strength in
each side of the
body

• Test muscle strength

• Inspect the joints for

swelling
NEUROLOGIC 1.
MENTAL STATUS
a. Orientation
• Ask the Patient the Not performed Memory is Not
city and state of intact patient performed
residence don’t have any
difficulty in
remembering

• Ask the patient for

time of day, day of • Not performed
the week
• Not
performed

• Ask the patient to

names the family • The patient does
members not response

b. Memory
• Immediate
* Immediate recall recall is intact • Not
• Ask patient to repeat patient don’t performed
• Not performed have any
a series of digits 94-6-2-1-5” difficulty in
• Ask patient to state remembering
• Not
the same digits but • Not performed
performed
in reverse

Normal finding
• The patient does
* Recent memory
not response
 • Ask the Patient how • Not performed he got to • Recent Memory is • Not
the school intact patient performed
don’t have any
difficulty in
• Provide the client • Not performed remembering • Not
with three facts to recall performed

• Remote Memory
is intact
* Remote memory • Not performed • Not
patient don’t
• Ask patient to recall performed
have any
what happened
difficulty in
during her vacation
remembering

2. LEVEL OF
CONSCIOUSNESS
-using GCS
• Glasgow coma scale • 6 score
• 15score the patient
test • Eye opening: 4
was able to do
spontaneous
the eye
opening
• Motor response:
response but
1 to verbal
in the motor
command
and verbal he
• Verbal respond: is not
1 oriented responding.
converses
 3. 12 CRANIAL NERVES
* Olfactory
• Ask the patient to • Able to identify • Intact nerve Normal findings
identify different which mild • Able to identify
aroma aroma and which smell is
strong aroma mild and strong
* Optic
• Ask the patient to • Not performed • 20/20 vision • Not
read the snellen chart performed

• Pupil equally
* Oculomotor rounded and • PERRLA
• Assess Pt. 6 ocular react to light
movement and pupil accommodation Normal findings
reaction

* Trochlear • Pupil equally • PERRLA

• Assess Pt. 6 ocular rounded and Normal findings
movement. react to light
accommodation
* Trigeminal • Able to identify
• Inspect for blink • Patient able to light and deep
reflex. distinguish the sensation
Normal findings
light sensation
Intact nerve
and deep
sensation

• No deformities
* Facial
• Test the facial • Symmetric • Symmetric
movements movement of facial Normal findings
face movement

* Abducens
• Patient able to • Pupil equal
Normal findings
• Assess direction of gaze see in peripheral round and react
gaze to light
accommodation

* Glossopharyngeal
• Test the taste and • Client have a • Gag reflex is
gag reflex gag reflex present Normal findings

* Auditory
• Weber’s Test using • Not performed • Equal sound on
tuning fork both ears
Normal findings

• Rinnes Test • Equal sound on

both ears
 Patient able to • no difficulty Normal findings
hear on both when speaking
* Vagus ears Normal findings
• Ask the Pt to open Client have difficulty in
mouth and say “ speaking
ah”
Equal muscle
* Accessories strength on both
• Test the Neck muscles side of body Normal findings
strength
(sternocleidomastoi Muscle equally
d and trapezius) strength

* Hypoglossal
• Ask the patient to • Able to
• Patient don’t have
protrude and move it protrude the
any discomfort
to each side against tongue
while protruding Normal findings
tongue blades
the tongue • Gag reflex
present

Body Parts/ Method of Actual Findings Normal Findings Interpretation

Assessment Used

4. REFLEXES
* Biceps
• Biceps reflex test the
spinal cord level C- • Maximal • Bicep reflex
5, C-6 activity present Normal findings
(hyperactive)

* Triceps
• Triceps reflex test the • Triceps reflex
• Maximal present Normal findings
spinal cord level C- activity
7,C-8 (hyperactive)

* Brachioradialis
• Brachioradialis reflex • Brachioradialis
• Maximal reflex is present Normal findings
test the spinal cord
level C-3,C-6 activity
(hyperactive)

* Patellar
 • Patellar reflex test the • Patellar reflex is
spinal cord level L- present Normal findings
• Maximal
2,L-3,L-4
activity
(hyperactive)

* Achilles Normal findings

• Achilles reflex is
• Achilles reflex tests • Maximal
present
the spinal cord activity
level S-1,S-2 (hyperactive)

* Plantar/Babinski
• Maximal • Babinski reflex is Normal findings
activity present
(hyperactive)
5. MOTOR FUNCTION
Gross:
• Not performed • May swing
* Romberg’s Test
slightly but it’s
• Not
able to maintain
performed
upright position

• has upright
* Walking Gait Test • Not performed posture and
steady gait • Not
with opposing performed
arm swings

* Stand on One Foot

• Not performed • maintains stance • Not
with Eyes close Heel to for at least 5 performed
toe walking seconds

*Heal to toe walking • able to walk

• Not performed • Not
and maintain
performed
straight lines
walk

*Toe to heal walking • maintained

• Not performed straight and • Not
steps on toes or performed
heels

• repeatedly and • Not

Fine: • Not performed
rhythmically performed
*Finger to nose Test
 touches the
*Finger to nose nose
Nurse’s finger • Not performed • • Not
repeatedly and performed
rhythmically
touches the nose
and the finger of
the
nurse
*Finger to thumb • Not performed • •

rapidly touches
each finger to Not
thumb with each performed
hand

*Alternate supination and

pronation
can alternately Not
• Not performed • supinate and • performed
6. SENSATION * Pain pronate hands at
rapidly

• The patient was

able to • able to • Normal
determine pain discriminate findings
sharp and dull
*Light Touch

light tickling or
• Not performed •
touch sensation
Not
• performed
*Temperature

• able to • able to
determine the discriminate Normal findings
hot and cold between hot and
cold
7. TACTILE
DISCRIMINATION
*One to two point • Perception varies
discrimination • able to identify if widely in adults Normal findings
one or two over different
picks is touching parts of the body.
him

*Stereognosis • Recognized
• the patient does common object
not respond Normal findings
*Extinction Phenomenon
• Able to identify • Able to identify
where the body number or letter Normal findings
is touched or not when written in
palm

• Both stimuli are

felt