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