HEAD TO TOE PHYSICAL ASSESSMENT

Body Part Measurement Normal Actual Analysis

Findings Findings
Skull Inspection Rounded Proportional to The patient’s
(normocephalic the body and skull is Normal
and face. Round upon
symmetrical, and Inspection and
with frontal, symmetrical in there’s no
parietal, and all planes. presence of
occipital excessive
prominences); growth
smooth skull hormone or
contour. increased bone
thickness.

Palpation Smooth, Smooth, Normal upon

uniform uniform palpation and
consistency; consistency of there’s no
Free from the skull is sebaceous
nodules or present and cysts and local
masses. absence of deformities
nodules or from trauma
masses. was present.

Scalp Inspection White, free White, no Normal scalp

from masses, masses, lumps features.
lumps, scars, and lesions but
nits, dandruffs, w/ some
and lesions dandruffs.

Hair Inspection Black evenly With some Presence of

distributed Hair white strands white strands
and covers the in the hair. in the hair.
whole scalp,
thick, & shiny.

Face Inspection Symmetric or Symmetric Normal

slightly facial features, symmetry of
asymmetric palpebral face and
facial features. fissures equal evenly
in size. distributed
facial hair.
 Eyes Inspection Free from Eyes are Intact Absence of
periorbital and non- periorbital
edema and exophthalmia. edema.
non-
exopthalmia.

Eyebrows Inspection Black, thick, Black, slightly Normal

evenly thin and evenly Eyebrows, loss
distributed. distributed of hair,scaling
eybrow. and flakiness
of skin are not
present.

Ears Inspection Color same as The same Normal ears,

facial skin, color with acyanotic
symmetrical. facial skin, earlobes and
symmetrical, absence of
and auricle inflammation.
aligned
w/outer cantus
of the eye.

Nose Inspection Symmetric and Symmetric, no Normal.

straight. No nasoaural Equally divided
discharge or discharges nares and
flaring and coming from absence of
uniform color. the nares and lesions.
absence of
lesions.

Throat Palpation Un-inflamed, Absence of Normal.

absence of nodules or
masses, difficulty when
nodules or any swallowing.
bulky sensation
upon palpation.

Skin Inspection Varies from No Jaundice, Normal & intact

light to deep there is no skin formation
brown; from hyper and and absence of
ruddy pink to hypo lesions on
light pink; from pigmentation surfaces of the
yellow of the skin as skin.
overtones to well as edema.
olive. (+) Tattoo on
left shoulder.
Chest & Inspection Chest wall Symmetric Chest
Lungs Palpation intact; no chest symmetric,
Percussion tenderness; no expansion, chest wall
Auscultation masses. (-) retractions, intact; no
Full and clear breath tenderness; no
symmetric sounds. Lungs masses.
chest are normal and
expansion. no evidence of Lungs are clear
RR =12-20cpm spots upon and no
chest evidence of
X-ray. adventitious
RR= 15cpm breath sounds.

Heart Auscultation Normal Sinus BP = 130/90 Normal Heart

and rhythm. PR= 89bpm sounds, BP,
BP= 120/80 ECG = PR , no
PR = 80- Findings of evidence of
120bpm Left ventricular cardiomegaly
ECG=normal hypertrophy. but abnormal
PQRST wave. ECG results.
There is an
thickness of
muscle in the
heart that
results to
increased
electrical
voltage that
manifested by
the patient

Abdomen Inspection Flat, rounded Flat, Normal

Auscultation (convex), or Normoactive abdominal
Palpation scaphoid Bowel sounds, contour and
Percussion (concave), Soft non- Bowel sounds.
symmetric tender.
contour, Good
audible bowel Peristaltic
sounds, movement was
absence of present.
arterial bruits,
absence of
friction rub.
Genital Inspection Penile should Had a purulent Abnormal
and palpation be in the yellowish
middle with no discharge.
deviation. The
scrotum was
not at the same
level and no
penile
discharge.

Shoulder Inspection No Fracture Normal

Palpation and proportion
to the body. No fracture
and can
perform on
Arms Inspection No Fracture ease.
Palpation and can flex Normal
towards the Can perform
trunk. on ease
through flex.
Elbows Inspection No Fracture
Palpation Normal
No fracture

Hands & Inspection No Fracture

wrists Palpation and can
perform fine Can perform Normal
and gross fine and gross
motor skills. motor skills on
ease.
Legs Inspection No Fracture,
Palpation proportion to Normal
the body and No fracture
can perform and can
walking easily. perform on
ease.
 NEUROLOGIC EXAMINATION

CRANIAL NERVES NORMAL FINDINGS ACTUAL FINDINGS

I – OLFACTORY Ability to / Sense of Smell Can Smell

II – OPTIC Vision and visual fields Can See within 20ft,

are normal 20/20 Vision. 2-3mm pupil ERTL.

EOM; movement of Intact extra- ocular

III- OCULOMOTOR sphincter of pupil; muscles.
movement of ciliary
muscles of lens are
normal.

IV – TROCHLEAR EOM; specifically, moves

Can move eyes
eyeball downward and
according to six gaze
laterally.
direction.

V- TRIGEMINAL Sensation of cornea, skin

Elicits Blink reflex, intact
of face, and nasal
extra ocular muscles.
mucosa.

VI – ABDUCENS EOM; moves eyeball Normal. Can move eyes

laterally. according to six gaze
 direction.

Facial expression; taste

VII – FACIAL (anterior two-thirds of Can Smile, raise
tongue) eyebrows, frown, puff out
cheeks, close eyes, and
can identify various
tastes placed on tip of
tongue.

Equilibrium & Hearing No problem with his

VIII – AUDITORY
balance and hearing
ability.

Swallowing ability,
IX- Can move the tongue
tongue movement, taste
GLOSSOPHARYNGEAL side to side and can
(post. Tongue)
identify tastes through
post. Portion of his
tongue. Gag reflex is
present.

Client can move tongue

Sensation of pharynx and side to side and tastes
X – VAGUS larynx; swallowing; vocal anything. Gag reflex is
cord movement. present.

Head movement; Can shrug his shoulders

XI – ACCESSORY Shrugging of shoulders. and perform activities
using accessory muscle.

Protrusion of tongue; Protrusion of tongue and

XII - HYPOGLOSSAL moves tongue up and moving side to side was
down and side to side. present. Normal.