Body Part Actual Finding Normal Finding Clinical

Examined Significance
HEAD .
Skull and Face The head is
I: size, shape , composed of the
symmetry  The skull is normal  The head is skull bones,
cephalic, atraumatic normocephalic and muscles, arteries
: facial features
(NC/AT). Hair with atraumatic without and veins,
: eyes for tenderness, visible lymphatic nodes,
edema average texture. No head,
or palpable and facial
and sinus, or TMJ tenderness.
masses, structures. It
hollowness  Head symmetrically depressions, or contains the
P: nodules, round, hard, and smooth scarring. Hair is of pathways for
masses, without lesions or normal texture and examining the
Depressions bumps. evenly distributed. remaining
structures of the
HEENT system.
The skull
possesses a
unique
responsibility of
protecting the
inner
components of
the head,
including the
brain (Jarvis,
2016).
Eyes and
Vision  Eyebrows
 Eyebrows are thick should be
I: eyebrows for and evenly equally
distribution & distributed, with distributed,
alignment, normal alignment. aligned with the
quality & Were able to move up iris and can
movement and down without move from up
difficulties and down w/out
problem.

The eyes
uphold an
important task
by producing
sight and are
protected by
 Distributed
: eyelashes for  Eyelashes are slightly varying
equally. Should
evenness of thin and equally be span structures to
distribution & distributed. Eyelashes upwards. maintain
direction of are span upwards integrity.

John Lloyd B. Agasang

BSN 2-3
curl Bilateral
 Superior eyelid eyelids function
covers a portion of
as mobile
iris when open.
shields and
protect the
eyes from
injury and
powerful light
sources.
Continuous
lubrication is
provided by the
lacrimal
apparatus to
sustain
moisture of the
 The lids should
 Upon inspection, fit smoothly cornea and
: eyelids for eyelids is not flaky against the conjunctiva
surface and not swelling. eyeball. No pus (Jarvis, 2016).
characteristics, There is also nno discharge, The bony orbits
position in indication of hordeola. scales, or are cavities
relation to lumps. which
cornea, ability encompass the
to blink & eyeballs and
frequency provide durable
: bulbar & protection from
palpebral outside
sources.

conjunctiva for  Conjunctiva and  Conjunctivae

color, texture, sclera appear moist clear and
and lesion and smooth. Sclera inapparent.
I/P: lacrimal white with no lesions Sclerae white
gland sac, or redness. No and visible
nasolacrimal swelling or redness above irides
over lacrimal gland. only when
duct for
 Cornea is eyelids are wide
edema, open.
transparent, smooth,
tenderness /
and moist with no
tearing
opacities, lens is free
I: cornea for
of opacities.
clarity, texture  Pupils are equal in
& sensitivity size and reactive to
I: pupils for light and
color, shape, accommodation.
symmetry of Pupils converge
size, direct and evenly.

John Lloyd B. Agasang

BSN 2-3
 consensual
reaction to
light, &
accommodatio  Acuity by Snellen  Distant vision
n chart O.D. 20/20, 20/20 by
* Visual Acuity O.S. 20/20. Visual Snellen. Visual
(near & far fields full by fields full by
confrontation. confrontation.
vision test)
Extraocular Extraocular
* Visual Field movements smooth movements
Test and symmetric with intact and full,
* EOM Test no nystagmus. no nystagmus.

Ears and  Ears are equal in

Hearing size bilaterally.  Familial
I: auricles for  Auricles are aligned variations.
with the corner of Auricles of
color, equal size and
symmetry and each eye. Skin
similar
position smooth, no lumps,
appearance.
: external lesions, nodules. No
Darwin
canal for discharge. tubercle.
Nontender on  Top of auricle
cerumen,
palpation. Small touching or
lesions, pus or
amount of moist above
blood
yellow cerumen in horizontal line.
P: auricles for external canal. Vertical
texture,  Whisper test : patient position.
elasticity and repeats 2 syllable  Patient repeats
areas of word. numbers and
tenderness letters correctly
* Gross Hearing more than 50%
Acuity Tests: of time.
normal voice
tone and Jarvis (2016)
whispered signifies the
voice importance of
* Watch Tick  Sound heard the nose as it
Test  Acuity good to
equally in both provides
* Tunning Fork whispered voice.
ears moisture,
Tests: Weber midline. AC > (unoccluded). filtration, and
- Weber for BC (Rinne) in both Sound heard inhalation of
bone ears. better in
oxygen. It is
conduction occluded ear.

the beginning
- Rinne’s to Air conduction
heard longer of the
compare air than bone respiratory

John Lloyd B. Agasang

BSN 2-3
 and bone conduction by system and
conductions 2 : 1 ratio permits
(Rinne positive) patency
through both
 Nose slightly large nostrils for
Nose and but smooth and adequate
symmetric. Able to
 The septum is
Sinuses delivery of air
sniff through each in the middle
I: nose deviation into the lungs.
nostril. and the
in shape size, Hair receptors
 Nasal mucosa pink, turbinates
color, flaring, exist within the
septum midline. project into the
discharge; nasal cavity
Nares patent nasal
: nasal mucosa and allow for
bilaterally. Olfaction passages.
for redness, the sense of
intact.  There is
swelling, smell to be
sufficient room
growth or interpreted by
for the nasal
discharge the temporal
passages.
Pa: tenderness, lobe of the
masses,  The mucous brain (Jarvis,
 Frontal and maxillary membrane is
displacements; sinuses are non- 2016).
: nasal patency red and Communicatio
tender to palpation compact over
: maxillary and and percussion. n between the
frontal the turbinates. sinuses within
sinuses for the skull allows
tenderness for protective
Pe: the above mechanisms,
sinuses for such as mucus
tenderness production, in
Transilluminatio times of illness.
n Test The nose plays
Mouth /  Lips pink, smooth, an important
and moist without
Oropharynx  The lips role in
lesions. Buccal
I: lips for mucosa pink, moist,
are normally preventing the
symmetry of symmetrical, invasion of
and without exudates.
contour, color, pink, smooth, foreign bodies
texture, and moist. and bacteria
 dentition good
moisture, There should be into the body.
no growths,
lesion
lumps, or
: teeth for discoloration of
alignment, the tissue.
loss, dental Abnormal
filings and  Gums is pink no findings are
caries; inspected bleeding, asymmetricality,
lesions and no signs
: gums for cyanosis, a
of swelling. cherry-red or
bleeding,
color, pale color or
retraction, dryness.
 Ventral surface of

John Lloyd B. Agasang

BSN 2-3
 lesions, tongue smooth and
swelling shiny pink with small
: tongue for visible veins present.
position, color Frenulum in midline.
& texture;
movement, as
well as the
base of the
tongue, mouth
floor and
frenulum  Soft palate smooth
: salivary and pink.
gland ducts
for swelling,
redness
: palates for
color, shape,  Uvula is in midline, no
swelling.
texture,
presence of  The
bony neck supports
prominences the weight of
: uvula for the head
position & and protects
mobility  Tonsillar pillars pink the
: oropharynx and symmetric. nerves that
for color & carry
texture sensory and
: tonsils for ‘ motor
information
color,
from the
discharge, and brain down
size to the rest of
Test for Gag the body. In
Reflex addition, the
P: nodules, lump neck is
and excoriated highly
areas flexible and
allows the
 Neck is with full range head to turn
NECK of motion and is and flex in
 Neck should be all
Neck Muscles symmetrical. There is
no visible neck vain
symmetrical with directions.
upon inspection. full range of motion.
I: abnormal  No neck vein
 Both the uvula and
swelling or tongue and also the distension should
masses, head trachea are in midline. be visible.
movement,  There is no inspected  Inspect and palpate
and muscle problem with cervical vertebrae

John Lloyd B. Agasang

BSN 2-3
 strength swallowing .  Uvula and tongue
are midline.
Lymph Nodes  Patient is able to
P: enlargement swallow their own
secretions.
Trachea  Trachea is midline.
P: lateral
deviation

John Lloyd B. Agasang

BSN 2-3