PA FINDINGS

Body Part Examined Actual Findings Normal

Findings
Interpretation/
Analysis
Scalp
a. Color of Scalp
b. Presence of
dandruff
infection
c. Odor
d. Lesions

Hair
a. Color of hair
b. Distribution
c. Thickness/
thinness
d. Texture
e. Oiliness
f. Presence of
lice, nits


- White scalp
- no dandruff
or infection
- odorless
scalp
- no presence
of lesions

- hair is black
- evenly
distributed
hair
- thin hair
- oily
- no lice, nits


Hair Evenly
Distributed,
Thick hair,
silky and
resilient, no
infection or
manifesta-
tions

Normal
Nails - Convex
curvature
160
0

- Smooth, no
furrows and
pinkish in
color
- No
hangnails, no
inflamed
surrounding
tissues
- returns to its
original form
after the nail
is pinched
(2sec)
Nail
Curvature at
160
0
angle,
Smooth
Texture,
pink in color,
intact
epidermis,
capillary
refill after
blanch test
(generally
<4sec)
Normal
Skull
a. Size
b. Shape
c. symmetry

- skull is
rounded
- symmetrical,
smooth
contour
Rounded,
smooth
uniform in
consistency,
absence of
nodules and
masses
Normal
Face
a. Color of skin
b. Symmetry
c. Texture
d. Shape/
contour
e. Facial
movements





- Skin
a. Color
b. Texture
c. Presence of
lesions



- Skin is
brown,
evenly
distributed
color
- Symmetrical
- Smooth and
rounded
- Facial
movement
symmetry


- Evenly
distributed
color on the
body

- Dry in
texture

- Presence of
scars and
lesion on the
R elbow 5
cm in
diameter,
callus on the
L thumb

Symmetrical
facial
movements,
symmetric/sl
ightly
asymmetric
facial
features.





Skin intact,
generally
uniform skin
color,
smooth and
moisture on
skinfolds
Normal














Abnormal
Skin is not intact
due to presence
of lesions which
permits entry of
microorganisms
causing infection.
Dryness of skin is
an indicative sign
of dehydration.
Ears
- Auricles
a. Color
b. Symmetry of
size
c. position











- Color is
consistent
with the
facial color
- equal and
symmetric in
size and
- positioned in
a 10 angle.







Symmetrical

The auricle
aligns with
the outer
canthus of
each eye
about 10
vertical.

Color is
same with
facial skin.










Normal


















External ear canal
a. Cerumen
b. Skin, lesions,
pus, blood








- Hearing
a. Hearing normal
voice
b. Watch tick test











Dry cerumen
is present
- Absence of
skin lesions,
pus, or
blood.








a. can hear normal
voice

b. Watch tick test
-- can hear and
recognize the
sound of the watch
symmetrically on
both ears.



Mobile, firm,
and not
tender;
pinna recoils
after it is
folded.




Dry
cerumen,
grayish-tan
color; or
sticky, wet
cerumen in
various
shades of
brown.Abse
nce of skin
lesions, pus
and blood.


Normal
voice tones
audible

Able to hear
ticking in
both ears













Normal













Normal
Nose and Sinuses
External Nose
a. Shape
b. Size
c. Color
d. Flaring
e. Discharges




- Nose is
symmetric
and straight
- no
discharge or
flaring, and
- is uniform in
color
there are no

Symmetric
and straight

No
discharge or
flaring

Uniform
color




Normal













Patency of Nasal
Cavities







Lining of Nares





Lining of Nasal Septum
a. Nares
b. Nasal septum
c. Redness swelling
Redness/ Swelling


Maxillary and Frontal
Sinus
lesions and
negative
tenderness
upon
palpation




- Patent nasal
airway with
no
obstruction.
Client
breathes with
comfort.

In the middle





Nasal
septum intact
and in the
midline

- mucosa is
pink in color
and have no
lesions

- There are no
presence of
tenderness


Not tender

No lesions




The air
moves freely
as client
breathes
through the
nares


Aligned with
the nasal
septum in
the middle


Nasal
septum
intact and in
the midline

No lesions

Mucosa Pink

Not tender









Normal








Normal





Normal





Normal
Mouth and Oropharynx
Lips and Buccal
Mucosa
a. Color
b. Moisture
c. Texture
d. Presence of
lesions




- Pink in color,
- Lips are dry
- Slightly
rough in
texture,
- there is no
presence of
lesions.


Pink in color

Soft, moist,
and smooth

No presence
of lesions.



Abnormal
Dryness of the
lips and mucosa
suggest
deficiency of body
fluid volume as in
dehydration.




Teeth and Gums
a. Condition
b. Number
c. Color
d. Presence of dental
carries
e. Odor








Tongue
a. Surface
b. Position
c. Texture
d. movement







Mouth Floor and Roof

a. Color
b. texture






Hard and Soft Palate
a. Color
b. Shape
c. texture




- 22 teeth

- presence of
dental
caries(2
teeth)

have no bad
odor







- Positioned in
the center
and is
mobile.
- Smooth
- Tongue
movements
are eligible
- There are no
presence of
nodules and
lumps



- Pink in color

- smooth in
texture

- no lesions


- Pink in color,
- smooth soft
palate
- and irregular
in texture of


32 teeth

Absence of
dental caries

No bad odor










Moves
freely;
mobile

Central
position

Absence of
nodules and
lumps





Pink color

Smooth, no
lesions




Pink Color

Smooth soft
palate



Abnormal
Dental caries can
lead to infection
and can inflict
pain.











Normal












Normal








Normal











Uvula

a. position


Tonsils and
Oropharynx
a. Color
b. Size
c. Discharge
d. Gag reflex
hard palate





- Positioned in
midline of
soft palate


- Pink and
smooth
- posterior
wall of
oropharynx,
- pink and
smooth
tonsils
Irregular in
texture hard
palate



Positioned in
midline of
soft palate


Pink and
smooth
posterior
wall of
oropharynx
Pink and
smooth
tonsils








Normal




Normal
Neck
Neck Muscles
a. Swelling or masses
b. Head movement
c. Muscle strenght







Lymph Nodes



Trachea
a. position




Thyroid Gland
a. Visible masses

Palpates thyroid gland
for
a. Smoothness
b. Areas of
enlargement,
masses,
nodule




- Muscles
equal in size,
head
centered
- Able to follow
head
movement
- Full muscle
strength

- Not palpable



- Placed on
the center




- No visible
masses


- Smooth,
- and there are
no signs of
enlargement,
masses or
nodules






Muscles
equal in size

Head
centered





Not palpable



Central
placement in
midline of
neck


No visible
masses


Smooth
Absence of
enlargement
, masses or
nodules


Normal









Normal





Normal



Normal



Normal



Eyes

Eyebrows
a. Color
b. Hair distribution
and pigments

Eyelashes
a. Distribution
b. Direction of curl



- Black in color
- Evenly
distributed in
both eyes

- Equal
distribution



Hair evenly
distributed,
skin is intact


Equally
distributed,





Normal








Eyelids
a. Surface characteristics
b. Position in relation to
corner
c. Ability to blink and
frequency
d. Lower lids when eyes
is closed
















Conjunctiva
a. Color
b. Texture
c. Lesions
d. Foreign bodies




Cornea
a. Clarity
b. Texture
c. Transparenc
y
d. Depth




- Curl outward



- Smooth
- Symmetrical
- 17
involuntary
blinks per
minute
- Bilaterally
blinking
- Sunken eyes















- Color is
transparent
- Smooth in
texture
- No presence
of lesions or
foreign
bodies


- Appears
clear
- Smooth in
texture
- Transparent


curled
slightly
outward


Skin is intact
no
discoloration
, lids close
symmetricall
y
Blinks
approximatel
y 15-20
minutes,
when lids
open, no
visible sclera
above
corneas,
upper and
lower
borders of
cornea are
slowly
covered



Transparent,
capillaries
sometimes
evident,
sclera
appears
white



Transparent,
shiny and
smooth,
details of iris
are visible











Abnormal
Sunken eyes is
an indicative sign
of dehydration.

















Normal









Normal





Lacrimand, sac and
nasolacrimal
a. Edema
b. Evidence of
tearing

Pupil
a. Color
b. Shape
c. Symmetry of
size
d. Direct and
consensual
reaction to
light
e. Reaction and
accommodat
ion to light














Peripheral Vision
a. Temporal
b. Central
c. Nasal

- No edema or
tearing




- black in color
- round
- symmetrical
of size
- illuminated
pupil

- non
illuminated

- pupils
constricts
when looking
at near
objects,
dilate when
looking at far
object







- the client can
see all areas
of periphery





Transparent,
shiny details
of iris are
visible


Black in
color, equal
in size,
normally 3-
7 in
diameter
Round,
smooth and
smooth
border and
the iris is flat
and
rounded.
Illuminated
pupil (direct
response)
Non
illuminated
pupil
constricts(
consensual
response )



When
looking
straight
ahead, client
can see
objects in
the
periphery.














Normal





















Normal




Abdomen
Shape
Tenderness
Bowel sounds






Anterior Thorax
Breathing pattern

Temperature and
Integrity of the skin
Areas of tenderness,
bulges, abnormal
movement.
Chest excursion

























- Flat
- No
tenderness
- hyperactive






- Quite, rhythmic
and effortless
respirations.
- Skin is intact and
uniform in
temperature.
- No presence of
tenderness, bulges
and abnormal
movements.
- Full and
symmetric chest
excursion;





















- flat,
rounded
(convex) or
scaphoid
(concave)
- No
tenderness
- normo
active

- Quite,
rhythmic and
effortless
respirations.
- Skin is
intact and
uniform in
temperature.
- No
presence of
tenderness,
bulges and
abnormal
movements.
- Full and
symmetric
chest
excursion
when client
takes a deep
breath, your
thumbs
should move
apart an
equal
distance and
at the same
time;
normally the
thumbs
separate
about 3-5cm
approximatel
y in women
Normal



Normal

Normal



Normal




























Normal




Body Part Examined Actual Findings Normal
Findings
Interpretation/
Analysis





Tactile fremitus










Breath sounds






- Same as posterior
vocal fremitus;









- Bronchial and
tubular breath
sounds over the
trachea.
Bronchovesicular
and vesicular
breath sounds over
the anterior chest
and 5-6cm
in men
during deep
inspiration.

- Same as
posterior
vocal
fremitus;
fremitus is
normally
decreased
over heart
and breast
tissue.

- Bronchial
and tubular
breath
sounds over
the
trachea.
Bronchovesi
cular and
vesicular
breath
sounds over
the anterior
chest.






Normal


Body Part Examined Actual Findings Normal Findings Interpretation/
Analysis
Upper Extremities
Shoulder
Bone structure
Areas of edema or
tenderness
Muscle coordination


Symmetry
Range of Motion
a. Flexion


- no deformities
-no tenderness or
swelling
-smooth
coordinated
muscle
-symmetric

- flexion is 180
- hyperextension


- no deformities
- no tenderness or
swelling
- smooth
coordinated
muscle
-symmetric

- flexion is 180
- hyperextension


Normal
Normal

Normal

Normal


Normal
Normal
b. Hyperextension

c. Rotation (internal
and external)



Muscle size

Joint structure


Strength

Temperature
Muscle tremors


Elbow
Bone structure
Areas of edema or
tenderness
Muscle coordination
Symmetry



Range of Motion
a. Flexion
b. Extension
c. Supination
d. Pronation


Muscle size

Joint structure



Strength

Temperature
Muscle tremors

Wrist
is 50
- external rotation
is 90
- internal rotation
is 90

-equal size on
both sides of body
-no tenderness,
swelling,
crepitation, or
nodules
-equal strength on
each body
-even temperature
-no tremors



-no deformities
-no tenderness or
swelling
-smooth
coordinated
muscle
-symmetric


- flexion is 160
- extension is 180
- supination and -
pronation is 90


equal size on both
sides of body
-no tenderness,
swelling,
crepitation, or
nodules
-equal strength on
each body
-even temperature
-no tremors


is 50
- external rotation
is 90
- internal rotation
is 90

- equal size on
both sides of body
- no tenderness,
swelling,
crepitation, or
nodules
- equal strength on
each body
- even
temperature
- no tremors


-no deformities
-no tenderness or
swelling
-smooth
coordinated
muscle
-symmetric


- flexion is 160
- extension is 180
- supination and -
pronation is 90


equal size on both
sides of body
-no tenderness,
swelling,
crepitation, or
nodules
-equal strength on
each body
-even temperature
-no tremors



Normal

Normal


Normal

Normal



Normal

Normal



Normal
Normal

Normal

Normal


Normal
Normal
Normal

Normal

Normal



Normal

Normal
Normal


Normal
Bone structure
Areas of edema or
tenderness
Muscle coordination
Symmetry


Range of Motion
a. Flexion
b. Extension
c. Radial movement
d. Ulnar movement




Muscle size

Joint structure


Strength

Temperature
Muscle tremors


Hands
Bone structure
Areas of edema or
tenderness
Muscle coordination


Symmetry
Muscle size

Joint structure


Strength

Temperature
Muscle tremors

-no deformities
-no tenderness or
swelling
-smooth
coordinated
muscle
-symmetric


- flexion is 90
- extension is 70
- radial movement
is 20
- ulnar movement
is 55

-equal size on
both sides of body
-no tenderness,
swelling,
crepitation, or
nodules
-equal strength on
each body
-even temperature
-no tremors



-no deformities
-no tenderness or
swelling
-smooth
coordinated
muscle
-symmetric
-equal size on
both sides of body
-no tenderness,
swelling,
crepitation, or
nodules
-equal strength on
each body
-even temperature
-no tremors
-no deformities
-no tenderness or
swelling
-smooth
coordinated
muscle
-symmetric


- flexion is 90
- extension is 70
- radial movement
is 20
- ulnar movement
is 55

-equal size on
both sides of body
-no tenderness,
swelling,
crepitation, or
nodules
-equal strength on
each body
-even temperature
-no tremors



-no deformities
-no tenderness or
swelling
-smooth
coordinated
muscle
-symmetric
-equal size on
both sides of body
-no tenderness,
swelling,
crepitation, or
nodules
-equal strength on
each body
-even temperature
-no tremors
Normal

Normal


Normal


Normal
Normal
Normal

Normal


Normal

Normal



Normal

Normal
Normal



Normal
Normal


Normal


Normal
Normal

Normal



Normal

Normal


Fingers
Bone structure
Areas of edema or
tenderness
Muscle coordination
Symmetry



Range of Motion
a. Flexion
b. Hyperextension
c. Abduction
d. Adduction
e. Thumb flexion



Muscle size

Joint structure



Strength

Temperature
Muscle tremors


Arm (biceps)
Muscle strength

Tone
Areas of edema or
tenderness

Arm (triceps)
Muscle strength

Tone
Areas of edema or
tenderness




-no deformities
-no tenderness or
swelling
-smooth
coordinated
muscle
-symmetric


-flexion is 90
-hyperextension is
30
-abduction is 20
-adduction is full
- thumb flexion is
50

-equal size on
both sides of body
-no tenderness,
swelling,
crepitation, or
nodules
-equal strength on
each body
-even temperature
-no tremors



-equal strength on
each body
-normally firm
-no tenderness or
swelling


-equal strength on
-each body
-normally firm
-no tenderness or
swelling




-no deformities
-no tenderness or
swelling
-smooth
coordinated
muscle
-symmetric


-flexion is 90
-hyperextension is
30
-abduction is 20
-adduction is full
- thumb flexion is
50

-equal size on
both sides of body
-no tenderness,
swelling,
crepitation, or
nodules
-equal strength on
each body
-even temperature
-no tremors



-equal strength on
each body
-normally firm
-no tenderness or
swelling


-equal strength on
each body
-normally firm
-no tenderness or
swelling




Normal
Normal

Normal


Normal


Normal
Normal

Normal
Normal
Normal


Normal

Normal



Normal

Normal
Normal



Normal

Normal
Normal



Normal

Normal
Normal


Lower Extremities
Hip
Bone structure
Areas of edema or
tenderness
Joint structure


Leg length

Temperature


Range of Motion
a. Flexion



b. Rotation (internal
and external)


c. Abduction
d. Adduction



Knee
Bone structure
Areas of edema or
tenderness
Joint structure


Leg length

Temperature


Range of Motion
a. Flexion
b. Extension
c. Hyperextension


Ankle and Feet


-no deformities
-no tenderness or
swelling
-no tenderness,
swelling,
crepitation, or
nodules
-equal leg
measurement
-even temperature



-flexion with knee
straight is 90
-flexion with knee
bent is 120
- external rotation
is 45
- internal rotation
is 40
- abduction is 45-
50
-adduction is 20-
30


-no deformities
-no tenderness or
swelling
-no tenderness,
swelling,
crepitation, or
nodules
-equal leg
measurement
-even temperature


-flexion is 120-130
- extension is 0
- hyperextension
is 15



-no deformities
-no tenderness or
swelling
-no tenderness,
swelling,
crepitation, or
nodules
-equal leg
measurement
-even temperature



-flexion with knee
straight is 90
-flexion with knee
bent is 120
-external rotation
is 45
-internal rotation
is 40
-abduction is 45-
50
-adduction is 20-
30


-no deformities
-no tenderness or
swelling
-no tenderness,
swelling,
crepitation, or
nodules
-equal leg
measurement
-even temperature


-flexion is 120-130
-extension is 0
-hyperextension is
15



Normal
Normal

Normal



Normal

Normal



Normal

Normal

Normal

Normal

Normal

Normal



Normal
Normal

Normal



Normal

Normal


Normal
Normal
Normal



Bone structure
Areas of edema or
tenderness
Joint structure



Leg length
Temperature

Range of Motion
1. Eversion
2. Inversion
3. Abduction
4. Adduction


Toes
Bone structure
Areas of edema or
tenderness
Joint structure


Leg length

Temperature



Range of Motion
5. Dorsiflexion
6. Plantar flexion
7. Flexion
8. Extension

-no deformities
-no tenderness or
swelling
-no tenderness,
swelling,
crepitation, or
nodules
-equal leg
measurement
-even temperature


-eversion is 20
-inversion is 30
-abduction is 10
-adduction is 20


-no deformities
-no tenderness or
swelling
-no tenderness,
swelling,
crepitation, or
nodules
-equal leg
measurement
-even temperature




-dorsiflexion is 20
-plantar flexion is
45
-flexion is 40
-extension is 40

-no deformities
-no tenderness or
swelling
-no tenderness,
swelling,
crepitation, or
nodules
-equal leg
measurement
-even temperature


-eversion is 20
-inversion is 30
-abduction is 10
-adduction is 20


-no deformities
-no tenderness or
swelling
-no tenderness,
swelling,
crepitation, or
nodules
-equal leg
measurement
-even temperature




-dorsiflexion is 20
-plantar flexion is
45
-flexion is 40
-extension is 40

Normal
Normal

Normal



Normal

Normal

Normal
Normal
Normal
Normal


Normal
Normal

Normal



Normal

Normal