1. 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.

1.    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.

1. Inspect the eyelids for position and symmetry.

2. Palpate the eyelids for the lacrimal glands.
a. To examine the lacrimal gland, the examiner, lightly slide the pad of the index finger against
the client’s upper orbital rim.
b. Inquire for any pain or tenderness.
3. Palpate for the nasolacrimal duct to check for obstruction.
a. To assess the nasolacrimal duct, the examiner presses with the index finger against the client’s
lower inner orbital rim, at the lacrimal sac, NOT AGAINST THE NOSE.
b. In the presence of blockage, this will cause regurgitation of fluid in the puncta

Normal Findings:

Eyelids

· Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open.
· No PTOSIS noted. (drooping of upper eyelids).
· Meets completely when eyes are closed.
· Symmetrical.

Lacrimal Apparatus

· Lacrimal gland is normally non palpable.

· No tenderness on palpation.
· No regurgitation from the nasolacrimal duct.

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.

The bulbar and palpebral conjunctivae are examined by separating the eyelids widely and having
the client look up, down and to each side. When separating the lids, the examiner should exert no
NO PRESSURE against the eyeball; rather, the examiner should hold the lids against the ridges
of the bony orbit surrounding the eye.

In examining the palpebral conjunctiva, everting the upper eyelid in necessary and is done as
follow:

1.          Ask the client to look down but keep his eyes slightly open. This relaxes the levator
muscles, whereas closing the eyes contracts the orbicularis muscle, preventing lid eversion.
2.    Gently grasp the upper eyelashes and pull gently downward. Do not pull the lashes outward
or upward; this, too, causes muscles contraction.
3.    Place a cotton tip application about I can above the lid margin and push gently downward
with the applicator while still holding the lashes. This everts the lid.
4.    Hold the lashes of the everted lid against the upper ridge of the bony orbit, just beneath the
eyebrow, never pushing against the eyebrow.
5.    Examine the lid for swelling, infection, and presence of foreign objects.
6.    To return the lid to its normal position, move the lid slightly forward and ask the client to
look up and to blink. The lid returns easily to its normal position.

Normal Findings:

·    Both conjunctivae are pinkish or red in color.

·    With presence of many minutes capillaries.
·    Moist
·    No ulcers
·    No foreign objects

The sclerae is easily inspected during the assessment of the conjunctivae.

Normal Findings:

·    Sclerae is white in color (anicteric sclera)

·    No yellowish discoloration (icteric sclera).
·    Some capillaries maybe visible.
·    Some people may have pigmented positions.

The cornea is best inspected by directing penlight obliquely from several positions.

Normal findings:

·    There should be no irregularities on the surface.

·    Looks smooth.
·    The cornea is clear or transparent. The features of the iris should be fully visible through the
cornea.
·    There is a positive corneal reflex.

The anterior chamber and the iris are easily inspected in conjunction with the cornea. The
technique of oblique illumination is also useful in assessing the anterior chamber.

Normal Findings:

·    The anterior chamber is transparent.

·    No noted any visible materials.
·    Color of the iris depends on the person’s race (black, blue, brown or green).
·    From the side view, the iris should appear flat and should not be bulging forward. There
should be NO crescent shadow casted on the other side when illuminated from one side.

Examination of the pupils involves several inspections, including assessment of the size, shape
reaction to light is directed is observed for direct response of constriction. Simultaneously, the
other eye is observed for consensual response of constriction.

The test for papillary accommodation is the examination for the change in papillary size as the is
switched from a distant to a near object.

1.    Ask the client to stare at the objects across room.

2.    Then ask the client to fix his gaze on the examiner’s index fingers, which is placed 5 – 5
inches from the client’s nose.
3.    Visualization of distant objects normally causes papillary dilation and visualization of nearer
objects causes papillary constriction and convergence of the eye.

Normal Findings:

·    Pupillary size ranges from 3 – 7 mm, and are equal in size.
·    Equally round.
·    Constrict briskly/sluggishly when light is directed to the eye, both directly and consensual.
·    Pupils dilate when looking at distant objects, and constrict when looking at nearer objects.

If all of which are met, we document the findings using the notation PERRLA, pupils equally
round, reactive to light, and accommodate

. 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.

The external portion of the nose is inspected for the following:

1.     Placement and symmetry.

2.    Patency of nares (done by occluding nosetril one at a time, and noting for difficulty in
breathing)
3.    Flaring of alaenasi
4.    Discharge

The external nares are palpated for:

1.    Displacement of bone and cartilage.

2.    For tenderness and masses
The internal nares are inspected by heperextending the neck of the client, the ulnar aspect of the
examiner’s hard over the fore head of the client, and using the thumb to push the tip of the nose
upward while shining a light into the naris.

Inspect for the following:

1.     Position of the septum.

2.    Check septum for perforation. (can also be checked by directing the lighted penlight on the
side of the nose, illumination at the other side suggests perforation).
3.    The nasal mucosa (turbinates) for swelling, exudates and change in color.
Paranasal Sinuses

Examination of the paranasal sinuses is indirectly. Information about their condition is gained by
inspection and palpation of the overlying tissues. Only frontal and maxillary sinuses are
accessible for examination.

By palpating both cheeks simultaneously, one can determine tenderness of the maxillary
sinusitis, and pressing the thumb just below the eyebrows, we can determine tenderness of the
frontal sinuses.

Normal Findings:

1.    Nose in the midline

2.    No Discharges.
3.    No flaring alae nasi.
4.    Both nares are patent.
5.    No bone and cartilage deviation noted on palpation.
6.    No tenderness noted on palpation.
7.    Nasal septum in the mid line and not perforated.
8.    The nasal mucosa is pinkish to red in color. (Increased redness turbinates are typical of
allergy).
9.    No tenderness noted on palpation of the paranasal sinuses.

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.

 <!--[if !supportLists]--><!--[endif]-->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. <!--[if !supportLists]-->May not be palpable. Maybe normally palpable in thin clients.

2. <!--[if !supportLists]-->Non tender if palpable.
3. <!--[if !supportLists]-->Firm with smooth rounded surface.
4. <!--[if !supportLists]-->Slightly movable.
5. <!--[if !supportLists]-->About less than 1 cm in size.
6. <!--[if !supportLists]-->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 the
sternocleidomastoid 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 3rd
thoracic 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.

<!--[if !supportLists]-->A. <!--[endif]-->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.

<!--[if !supportLists]-->B. <!--[endif]-->Instruct the client to exhale first, then to inhale

deeply.

<!--[if !supportLists]-->C. <!--[endif]-->The examiner the amount of thoracic expansion

during quiet and deep inspiration and observe for divergence of the thumbs on
expiration.
 <!--[if !supportLists]-->D. <!--[endif]-->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.

<!--[if !supportLists]-->A. <!--[endif]-->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

<!--[if !supportLists]-->B. <!--[endif]-->Each time the hands move down, ask the client
to say ninety-nine.

<!--[if !supportLists]-->C. <!--[endif]-->Repeat the procedure at the posterior thoracic

wall.

<!--[if !supportLists]-->D. <!--[endif]-->Normally, tactile fremitus should be bilaterally

symmetrical. Most intense in the 2nd ICS 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.

<!--[if !supportLists]-->E. <!--[endif]-->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.

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

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)