Body Part Assessed
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Transcript of Body Part Assessed
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BODY PART
ASSESSED
TECHNIQUE USED
NORMALFINDING
S
ABNORMAL
FINDINGS
INTERPRETATION
ANALYSIS
Head Inspection andPalpation
Small, roundhead,normocephalic, no wounds,no rashespresent;
Palpabletemporalpulse, soft,no evidenceof abnormalmass, noprotrusionsand pond feltuponpalpation
None Normal
Hair Inspection -Hair is short,black incolor, evenlydistributed,no scales,has a finehair
none Normal
Face Inspection andpalpation
-Symmetrical,check bonesare slightlyprominent,no presenceof scars
No lesions,notenderness
none Normal
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Eyes Inspection Symmetrical,round, alignwith the ears,fewdischarges
seen
None Normal
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no pain feltuponpalpation of pinna
Skin Inspectionand
palpation
Brown incolor, nodryness,slightlywarm andwith goodturgor
NoneNormal
Lungs Palpationand
auscultation
No nodulesor bulges,no
adventitioussoundheardv
None Normal
Heart Palpationand
auscultation
Apical pulseis palpable,
HR = 93bpm
No murmurs
None Normal
Abdomen Inspection,palpation
andauscultation
Flat, soft,unblemished skin, nolesions, nolumps
palpated intheabdomen,audiblebowelsounds of 18 from the
None Normal
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normalrange of 5-35 bowelsound. Dullsound at
upperquadrant
Spine Inspectionand
palpation
Has normalcurvature,notendernessnoted
None Normal
Upperextremitie
s
Inspection,palpation
andpercussion
Capillaryrefill time is
2 seconds,sizes of fingers areall normal;
Radial pulse: 90bpm
Brachialpulse ispalpable, no
tenderness;Biceps andtricepsreflexpresent
None Normal
Musclestrength
Inspectionand
palpation
Able toperformROMexercises,slightlywarm, dryto touch,with painuponpalpation
None Normal
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Lowerextremitie
s
Inspection Brown,equal insize,coveredwith cloth,
limitedmovementon lowerextremities;
Patellarreflexpresent;
Capillaryrefill time is
2 seconds
swellingnoted onright leg
Abnormal
Musclestrength
Inspection Left leg-Normal
Right legcan only dolimited ROM
exercises
Normal
Muscletone
Inspection Ability toovercomeresistance:low.
None Normal
