ASSESSING EARS

Equipment use ● Watch with second hand for Romberg test

● Tuning fork (512 Hz or 1,024 Hz)
● Otoscope

Normal Findings 1. Ears equal in size bilaterally (normally 4-10cm). Auricle aligns with
corner of each eye and 10-degree angle vertical position
2. Ear skin is smooth, with no lesions, lumps, or nodules. Color is
consistent with facial color.
3. Auricle, tragus, and mastoid process are not tender.
4. External auditory canal has small amount of odorless cerumen with
color of yellow, orange, red, brown, gray or black. Consistency may be
soft, moist dry, flaky or even hard.
5. Canal walls should be pink and smooth without nodules
6. Tympanic membrane should be pealry gray, shiny, and translucent,
with no bulging or retraction. Slightly conclave, smooth and intact.
7. Healthy membrane flutter when bulb is inflated and returns to resting
position once air released.
8. Whisper test- able to correctly repeat two-syllable words as whispered.
9. Weber test (conduction of sound tru bone help distinguish between
conductive hearing loss or sensorineural hearing loss) vibration heard
equally in both ears, no lateralization of sound to either ear.
10. Rinne test ( compares air and bone conduction sounds) – air
conduction sound is normally heard longer than bone conduction
sound.
11. Romberg test (test equilibrium) – clients maintain position for 20
seconds without swaying or with minimal swaying.

Abnormal Findings 1. Ears smaller than 4cm or larger than 10cm. Mal-aligned or low-set
ears.
● Microtia- congenital deformity in external ears and ear canal
are jot fully developed.
● Macrotia- excessive enlargement of external ear.
2. Ear preaurical and postaurical lymph nodes are enlarged, tophi,
blocked sebaceous glands, ulcerated, crusted nodules that bleed,
redness, swelling, scaling, or itching; pale blue ear color.
3. Painful auricle or tragus, tenderness over mastoid process and behind
ears.
4. External auditory canal has/with otits externa/ impacted foreign body,
otitis media with ruptured tympanic membrane, blood or watery
drainage, conductive hearing loss.
5. Ear canal has/with otitis externa, exostoses, polyps
6. Tympanic membrane has/with acute otits media, serous otits media,
blood behind eardrum from skull trauma, white spots, perforation,
prominent landmarks, obscured or absent of landmark
7. With otits media, the membrane does not move or flutter.
8. Whisper test- unable to repeat two syllables word after two tries
indicates hearing loss
9. Weber test- with conductive hearing loss and poor ear receives most
of the sound conducted by bone vibration; sensorineural hearing loss
10. Rinne test- sensorineural: AC>BC, conductive: BC heard longer than
or equally as long as AC (BC≥AC)
11. Romberg test- clients moves feet apart to prevent falls or start to fall
from loss of balance.

Abnormalities of Externa ear and 1. Malignant lesions

Ear canal 2. Otitis externa
3. Buildup of cerumen in ear canal
4. Polyp
5. Exostosis
6. Microtia
7. Tophi- hard external ear nodules associated with deposits pf
uric acid crystals in advanced gout.

Abnormalities of Tympanic 1. Acute otitis media- red, bulging membrane; decreased or absent light
Membrane reflex
2. Serous otitis media- yellowish, bulging membrane with bubbles behind
it.
 3. Blue/Dark Red Tympanic Membrane- indicates blood behind eardrum
due to trauma
4. Scarred tympanic membrane- white spots and streaks indicates
scarring from infection.
5. Perforated tympanic membrane- perforation results from rupture
caused by increased pressure, usually from untreated infection or
trauma
6. Retracted tympanic membrane- prominent landmarks are caused by
negative ear pressure due to obstructed eustachiantube or chronic
otitis media.

Assessing Mouth, Throat, Nose, and Sinuses

Equipment use ● Nonlatex gloves (wear gloves when examining any
mucous membrane)
● 4 x 4 inches gauze pad
● Penlight
● Short, wide-tipped speculum attached to the head of an
otoscope
● Tongue depressor
● Nasal speculum

Abnormalities of the mouth
and throat
1. Herpes simplex type 1 (cold sore) – clear vesicles
surrounded by red indurated base
2. Cheilosis of lips- scaling painful fissures at corners of lips
3. Carcinoma of lips- round, indurated lesion becomes
crusted and ulcerated with border
4. Leukoplakia (ventral surface)- thick raised patch does not
scrape off; seen in heavy tobacco or alcohol use
5. Hairy leukoplakia (lateral surface)
6. Candida albicans infection (thrush)- Curdlike patches
easily scrape off, leaving a reddened area
7. Smooth, reddish, shiny tongue without papillae due to
vitamin B12 deficiency
8. Black hairy tongue- Not hair, but elongated filiform papillae
seen with use of antibiotics that inhibit normal bacteria
9. Carcinoma of tongue- Round indurated lesion becomes
crusty and ulcerated with elevated border
10. Canker sore- Painful small ulcers inside mouth; do not
occur on lip surface; non-contagious
11. Gingivitis Red swollen gums that easily bleed
12. Receding gums- Gum tissue surrounding tooth pulls back,
exposing more of tooth or root of tooth
13. Kaposi’s sarcoma lesions- Advanced lesions seen in HIV
(human immunodeficiency virus)
14. Acute tonsillitis- Acute tonsillitis secondary to infectious
mononucleosis. Note the marked tonsillar enlargement
with erythema and the large white-gray
15. Streptococcal pharyngitis- Characterized by an
erythematous posterior pharynx (A), palatal petechiae (B),
and a white strawberry tongue (C).

Tonsillitis (Detecting and
Grading)
In a client who has both tonsils and a sore throat, tonsillitis can be
identified and ranked with a grading scale from 1-4 as follows:
● 1+ Tonsils are visible
● 2+ Tonsils are midway between tonsillar pillars and uvula.
● 3+ Tonsils touch the uvula.
● 4+ Tonsils touch each other.

Common abnormalities of 1. Nasal polyp

nose 2. Perforated septum
 Assessing Thorax and Lungs
Equipment use ● Examination gown and drape
● Gloves
● Stethoscope
● Light source
● Mask
● Skin marker
● Metric ruler
Thoracic Deformities and
Configurations
Deviation:
Normal:
1. Normal chest configuration
1. Barrel chest
2. Pectus excavatum (funnel chest)
3. Pectus carinatum (Pigeon chest)
4. Scoliosis
5. Kyphosis- an exaggerated increased rounding of the
thoracic spine, often seen with osteoporosis in older
women
6. Athletes (swimmers) – use arms in overhead position
often have forwarded-translated head, pronounced
thoracic kyphosis, lumbar lordosis and internally
rotated shoulders

Assessing Breasts and Lymphatic system

Equipment use ● Centimetre ruler
● Small pillow
● Gloves
● Client handout for BSE
● Slide for specimen

3 different patterns of breast 1. Circular or clockwise

palation 2. Wedge

Levels of pressure for breast
palpation
Note: Use bimanual technique of clients has large breast
Abnormalities noted on
inspection pf the breast
Abnormalities noted on
Palpation pf Breasts
Assessing peripheral Vascular System
Equipment use
Types of Peripheral Edema
3. Vertical strip
● Light- superficial
● Medium- mid-level tissue
● Firm- to the ribs
1. PEAU D’ORANGE- Resting from edema, an orange peel
appearance of the breast is associated with cancer
2. PAGET DISEASE-Redness and flaking of the nipple may
be seen early in Paget disease and then disappear.
However, further assessment is needed as this does not
mean the disease is gone. Tingling, itching, increased
sensitivity, burning, discharge, and pain in the nipple are
late signs of Paget disease. It may occur in both breasts,
but is rare
3. RETRACTED NIPPLE- A retracted nipple suggests
malignancy
4. DIMPLING- Dimpling suggests malignancy
5. RETRACTED BREAST TISSUE- Retracted breast tissue
suggests malignancy.
6. MASTITIS- Reddened painful area on breast warm to
palpation.
7. MASTECTOMY- (A)Radical mastectomy (B) Modified
radical mastectomy.
1. CANCEROUS TUMORS- These are irregular, firm, hard,
not defined masses that may be fixed or mobile. They are
not usually tender and usually occur after age 50.
2. FIBROADENOMS- These lesions are lobular, ovoid, or
round. They are firm, well defined, seldom tender, and
usually singular and mobile. They occur more commonly
between puberty and menopause.
3. BENIGN BREAST DISEASE- Also called fibrocystic breast
disease. Benign breast disease is marked by round,
elastic, defined, tender, and mobile cysts. The condition is
most common from age 30 to menopause, after which it
decreases.
● Stethoscope
● Doppler ultrasound device
● Centimetre tape
● Conductivity gel
● Tourniquet
● Gauze or tissue
● Waterproof pen
● Blood pressure cuff
1. EDEMA ASSOCIATED WITH LYMPHEDEMA
● Caused by abnormal or blocked lymph vessel
● Nonpitting
● Usually bilateral; may be unilateral
● No skin Ulceration or pigmentation
2. EDEMA ASSOCIATED WITH CHRONIC VENOUS
INSUFFICIENCY
● Caused by obstruction or insufficiency of deep veins
 ● Pitting, documented as:
✔ 1+= slight pitting
✔ 2+ deeper than
✔ 1+ 3+ = noticeably deep pit; extremity looks
larger
✔ 4+= very deep pit; gross edema in extremity
● Usually unilateral; may be bilateral
● Skin ulceration and pigmentation may be present

Abnormal Arterial Finding 1. Necrotic great toe with blister on toes and foot
2. Raynaud disease
3. Superficial thrombophlebitis
4. Lymphedema
5. Varicose

Assessing Abdomen
Equipment Use ● Small pillow or rolled blanket
● Centimetre ruler
● Stethoscope (warm the diaphragm and bell)
● Marking pen

Examination position ● Supine position examine tru IAPePa

● Examination start from LRQ→ URQ→ULQ→LLQ

Abnormal Distention 1. PREGNANCY (NORMAL FINDING)- It causes a

generalized protuber- ant abdomen, protuberant umbilicus,
a fetal heart beat that can be heard on auscultation,
percussible tympany over the intestines, and dullness over
the uterus.
2. FAT- Obesity accounts for most uniformly protuberant
abdomens. The abdominal wall is thick, and tympany is the
percussion tone elicited. The umbilicus usually appears
sunken.
3. FECES- Hard stools in the colon appear as a localized
distention. Percussion over the area discloses dullness.
4. FIBROIDS AND OTHER MASSES- A large ovarian cyst or
fibroid tumor appears as generalized distention in the
lower abdomen. The mass displaces bowel, thus the
percussion tone over the distended area is dullness, with
tympany at the periphery. The umbilicus may be everted.
5. FLATUS- The abdomen distended with gas may appear as
a generalized protuberance (as shown), or it may appear
more localized. Tympany is the percussion tone over the
area.
6. ASCITIC FLUID- Fluid in the abdomen causes generalized
protuberance, bulging flanks, and an everted umbilicus.
Percussion reveals dullness over fluid (bottom of abdomen
and flanks) and tympany over intestines (top of abdomen).

Abdominal Bulges 1. Umbilical hernia- results from the bowel protruding through
a weakness in the umbilical ring. This condition occurs
more frequently in infants, but also occurs in adults.
2. Epigastric hernia- occurs when the bowel protrudes
through a weakness in the linea alba. The small bulge
appears midline between the xiphoid process and the
umbilicus. It may be discovered only on palpation.
3. Diastasis recti- occurs when the bowel protrudes through a
separation between the two rectus abdominis muscles. It
 appears as a midline ridge. The bulge may appear only
when the client raises the head or coughs. The condition is
of little significance.
4. Incisional hernia- occurs when the bowel protrudes
through a defect or weakness resulting from a surgical
incision. It appears as a bulge near a surgical scar on the
abdomen.

Enlarged abdominal organs 1. Enlarged liver (hepatomegaly)- is defined as a span

and other abnormalities greater than 12 cm at the middlavicular line (MCL) and
greater than 8 cm at the midsternal line (MSL). An
enlarged nontender liver suggests cirrhosis. An enlarged
tender liver suggests congestive heart failure, acute
hepatitis, or abscess.
2. Enlarged nodular liver- An enlarged firm, hard, nodular
liver suggests cancer. Other causes may be late cirrhosis
or syphilis.
3. Liver higher than normal- A liver that is in a higher position
than normal span may be caused by an abdominal mass,
ascites, or a paralyzed diaphragm.
4. Liver lower than normal- A liver in a lower position than
normal with a normal span may be caused by emphysema
because the diaphragm is low.
5. Enlarged spleen (splenomegaly)- is defined by an area of
dullness exceeding 7 cm. When enlarged, the spleen
progresses downward and toward the midline.
6. Aortic aneurysm- prominent, laterally pulsating mass
above the umbilicus strongly suggests an aortic aneurysm.
It is accompanied by a bruit and a wide bounding pulse.
7. Enlarged kidney- may be due to a cyst, tumor, or
hydronephrosis. It may be differentiated from an enlarged
spleen by its smooth rather than sharp edge, the absence
of a notch, and tympany on percussion.
8. Enlarged Gallbladder- An extremely tender, enlarged gall-
bladder suggests acute cholecystitis. A positive finding is
Murphy sign (sharp pain that causes the client to hold the
breath).
 Assessing Musculoskeletal System
Equipment use ● Tape measure
● Goniometer (optional)
● Skin marking pen (optional)

Abnormal Spinal Curvatures 1. THORACIC KYPHOSIS, LORDOSIS, AND SCOLIOSIS

2. FLATTENING OF THE LUMBAR CURVATURE- Flattening
of the lumbar curvature may be seen with a herniated
lumbar disc or ankylosing spondylitis.
3. LUMBAR HYPERLORDOSIS- Hip flexion contracture and
hip extensor weakness drive the lumbar spine into
increasing lordosis to balance head over pelvis. Note the
use of the hands for stability.
4. KYPHOSIS- A rounded thoracic convexity (kyphosis).
5. SCOLIOSIS- A lateral curvature of the spine with an
increase in convexity on the side that is curved is seen in
scoliosis.

Abnormalities affecting the 1. ACUTE RHEUMATOID ARTHRITIS Tender, painful,

wrists, hands, and fingers swollen, stiff joints are seen in acute rheumatoid arthritis.
2. CHRONIC RHEUMATOID ARTHRITIS- Chronic swelling
and thickening of the metacarpophalangeal and proximal
interphalangeal joints, limited range of motion, and finger
deviation toward the ulnar side are seen in chronic
rheumatoid arthritis
3. BOUTONNIÈRE AND SWAN-NECK DEFORMITIES-
Flexion of the proximal Interphalangeal joint and hyper-
extension of the distal interphalangeal joint (boutonnière
deformity) and hyperextension of the proximal
interphalangeal joint with flexion of the distal
interphalangeal joint (swan-neck deformity) are also
common in chronic rheumatoid arthritis
4. GANGLION- nontender, round, enlarged, swollen,
fluid-filled cyst (ganglion) is commonly seen at the dorsum
of the wrist.
5. OSTEOARTHRITIS Osteoarthritis (degenerative joint
disease) nodules on the dorsolateral aspects of the distal
interphalangeal joins (Heberden nodes) are due to the
bony overgrowth of Osteoarthritis. Usually hard and
painless, they may affect middle-aged or older adults and
often, although not always, are associated with arthritic
changes in other joints Flexion and deviation deformities
may develop.
6. TENOSYNOVITIS Painful extension of a finger may be
seen in acute tenosynovitis (infection of the flexor tendon
sheaths).
7. THENAR ATROPHY Atrophy of the thenar prominence
due to pressure on the median nerve is seen in carpal
tunnel syndrome.

Abnormalities of the feet and 1. ACUTE GOUTY ARTHRITIS In gouty arthritis, the
toes metatarsophalangeal joint of the great toe is tender,
painful, reddened, hot, and swollen.
2. FLAT FEET A flat foot (pes planus) has no arch and may
cause pain and swelling of the foot surface.

Equipment use
Abnormal motor and sensory
findings in spinal cord injury
3. CALLUS- Calluses are nonpainful, thickened skin that
occurs at pressure points.
4. HALLUX VALGUS- Hallux valgus is an abnormality in
which the great toe is deviated laterally and may overlap
the second toe. An enlarged, painful, inflamed bursa
(bunion) may form on the medial side.
5. CORN- Corns are painful thickenings of the skin that occur
over bony prominences and at pressure points. The
circular, central, translucent core resembles a kernel of
corn.
6. HAMMER TOE- Hyperextension at the
metatarsophalangeal joint with flex- ion at the proximal
interphalangeal joint (hammer toe) commonly occurs with
the second toe.
7. PLANTAR WART- Plantar warts are painful warts (verruca
vulgaris) that often occur under a callus, appearing as tiny
dark spots,
Assessing Neurologic System
General:
● Examination gloves
Cranial Nerve Examination
● Cotton-tipped applicators
● Newsprint to read
● Ophthalmoscope
● Paper clip Penlight
● Snellen chart
● Sterile cotton ball
● Substances to smell or taste such as soap, coffee, vanilla,
salt, sugar, lemon juice
● Tongue depressor
● Tuning fork
Motor and Cerebellar Examination
● Tape measure
Sensory Examination
● Cotton ball
● Objects to feel such as a quarter or key
● Paper clip
● Test tubes containing hot and cold water
● Tuning fork (low-pitched)
Reflex Examination
● Cotton-tipped applicator
● Reflex (percussion) hammer
1. Cross-section of the spinal cord demonstrating the major
tracts of the spinal cord.
2. Brown-Séquard syndrome. A hemisection of the spinal
cord resulting in ipsilateral loss of strength and
proprioception and contralateral loss of pain and
temperature.
3. Central cord syndrome. Injury results in sacral sparing and
preferentially upper- more than lower- extremity weakness.
 4. Anterior cord syndrome. Injury results in variable loss of
motor function as well as pain and temperature.
Proprioception is preserved.
5. Posterior cord syndrome. Injury results in loss of
proprioception and variable preservation of motor function
and pain and temperature sensation.

Abnormal muscle 1. Atrophy and fasciculation of the tongue in a patient with

movements amyotrophic lateral sclerosis.
2. Pathway of tremor impulse down the arm of a male figure.
3. Eye tic. Tics are brief, repetitive, stereotyped, coordinated
movements occurring at irregular intervals. Examples
include repetitive winking, grimacing, and shoulder
shrugging. Causes include Tourette syndrome and drugs
such as phenothiazines and amphetamines.
4. Chorea choreiform movements of the hand- are brief,
rapid, jerky, irregular, and unpredictable. They occur at rest
or interrupt normal coordinated movements. Unlike tics,
they seldom repeat themselves. The face, head, lower
arms, and hands are often involved. Causes include
Sydenham chorea (with rheumatic fever) and Huntington
disease.
5. Resting (static) tremors. These tremors are most
prominent at rest, and may decrease or disappear with
voluntary movement. Illustrated is the common, relatively
slow, fine, pill- rolling tremor of parkinsonism, about 5 per
second.
6. Postural tremor. These tremors appear when the affected
part is actively maintaining a posture. Examples include
the fine, rapid tremor of hyperthyroidism, the tremors of
anxiety and fatigue, and benign essential (and sometimes
familial) tremor. Tremor may worsen somewhat with
intention.
7. Intention tremor of a pointed finger. Intention tremors,
absent at rest, appear with activity and often get worse as
the target is neared. Causes include disorders of
cerebellar pathways, as in multiple sclerosis.
8. Athetosis. Athetoid movements are slower and more
twisting and writhing than choreiform movements, and
have a larger amplitude. They most commonly involve the
face and the distal extremities. Athetosis is often
associated with spasticity. Causes include cerebral palsy.

Abnormal Gaits 1. CEREBELLAR ATAXIA

● Wide-based, staggering, unsteady gait.
● Romberg test results are positive (client cannot
stand with feet together).
● Seen with cerebellar diseases or alcohol or drug
intoxication.
2. PARKINSONIAN GAIT
● Shuffling gait, turns accomplished in very stiff
manner.
● Stooped-over posture with flexed hips and knees.
● Typically seen in Parkinson disease and
drug-induced parkinsonian because of effects on
the basal ganglia.
3. SCISSORS GAIT
● Stiff, short gait, thighs overlap each other with each
step.
 ● Seen with partial paralysis of the legs.
4. SPASTIC HEMIPARESIS
● Flexed arm held close to body while client drags toe
of leg or circles it stiffly outward and forward.
● Seen with lesions of the upper motor neurons in the
cortical spinal tract, such as occurs in stroke.
5. FOOTDROP
● Client lifts foot and knee high with each step, then
slaps the foot down hard on the ground.
● Client cannot walk on heels.
● Characteristic of diseases of the lower motor
neurons.