PA1 (Head to Neck)

BODY PART 1. HEAD TECHNIQUE PALPATION AND INSPECTION: Inspect the head. Inspect for size, shape and configuration. Inspect for involuntary movement. NORMAL FINDINGS Head size and shape vary, especially in accord with ethnicity. Usually the head is symmetric, round, erect, and in midline. No lesions are visible. Head should be still and upright. The temporal artery is elastic and not tender. ACTUAL ANALYSIS

Head is symmetric, round, erect and in midline. No lesions are seen.

The patients head is not moving involuntarily and it is upright. Normal.

Palpate the temporal artery, which is located between the top of the ear and the eye.

The temporal artery is elastic and is with gentle feeling or not physically painful. No swelling, enlargeme nt and tenderness were palpated.

The patient doesnt feel any tenderness when the temporal artery was palpated.

Palpate the preauricular nodes (front of the ear), postauricular nodes (behind the ears) and occipital nodes (at the posterior base of the skull). Palpate the head. Palpate for consistency.

There is no swelling or enlargement and no tenderness.

The patient has neither swelling nor tenderness when the nodes were palpated.

The head is normally hard and smooth without lesions.

Head is not easily bent. It is stiff and rigid. There are no lesions.

The patient has no lesions on the head and it is stiff and smooth.

2. NECK

INSPECTION: Inspect the neck. Observe for the clients slightly extended neck for position, symmetry, lumps or masses.

Neck is symmetric with head centered without bulging masses.

The neck is the same or proportion al with the head. There is no bulging or swelling.

The patient has neither bulging nor swelling on her neck.

3. SCALP AND HAIR

INSPECTION AND PALPATION: Inspect the scalp and hair for general condition and color.

Natural hair color, as opposed to chemically colored hair, varied among clients from paled bond to black to gray or white. The color is determined by the amount of melanin present.

The natural color of her hair is black.

The patient has natural color of hair which is black.

Inspect and palpate the hair and scalp for cleanliness, dryness or oiliness, parasites and lesions. Wear gloves is lesions are suspected or if hygiene is poor.

Scalp is clean and dry. Sparse dandruff may be visible. Hair is smooth and firm, and elastic.

Scalp is not dirty and dry. No dandruff was seen. Hair is firm, smooth and elastic. Face is oval. No abnormal movement s noted.

The patients scalp is clean. No dandruff was seen. Her hair is firm, smooth and elastic.

4. FACE

INSPECTION: Inspect the face. Inspect for symmetry, features, movement,

The face is symmetric with a round, oval, elongated, or square

No deviations.

expression and skin condition. 5. EYES INSPECTION: Inspect the eyelashes and eyelids. Note width and position of palpebral fissures. Assess ability of eyelids to close. Note the position of the eyelids in comparison with the eyeballs. Also note any unusual: Turning Color Swelling Lesions Discharge Observe for redness, swelling, discharge or lesions.

appearance. No abnormal movements noted. The upper lid margin should be between the upper margin of the iris and the upper margin of the pupil. The lower eyelid rests on the lower border of the iris. No white sclera is seen above or below the iris. The upper and lower lids close easily and meet completely when closed. The lower eyelid is upright with no inward or outward turning. Eyelashes are evenly distributed and curve outward along the lid margins. Skin on both eyelids is without redness, swelling or lesions. Eyeballs are symmetrically aligned in sockets without protruding or sinking. Eyelids and eyelashes are normal. No ptosis (drooping of the lower eyelid), entropion (inverted lower eyelid), ectropion (everted lower eyelid), seborrhea or blepharitis (redness and crusting the lid margins) was observed. No deviations.

No deviations.

Observe the position and alignment of the eyeball in the eye socket.

Eyeballs are symmetric ally aligned in sockets without protruding

or sinking. No exopthalm os (protrusion of eyeballs) was observed. 1. EARS INSPECTION: Inspect the auricle. Note size, shape and position. Ears are equal in size bilaterally (410cm). The auricle aligns with the corner of each eye and within the 10degree angle of the vertical position. Ears are 410 cm. The auricle aligns with the corner of each eye and within the 10-degree angle of the vertical position. No nodules, lesions or lumps, discharges present. Color is fair to the facial color. No deviations.

Observe for lesions, discolorations, and discharge.

Color is consistent with facial color. The skin is smooth with no lesions, lumps, or nodules. No discharge should be present. Color is the same as the rest of the face: the nasal structure is smooth and symmetric.

The patient does not have lesions nor do discharges present in the ear. Color is fair to skin tone.

2. NOSE

INSPECTION AND PALPATION: Inspect and palpate the external nose. Note nasal color, shape, consistency, and tenderness.

The patient reports no tenderness . The clients nasal structure is smooth. No sign of foreign object

The patients nose is smooth in structure and feels no tenderness.

Check the patency of air flow through the nostrils by

Client is able to sniff through each nostril

The patient has clear air ways in the nose.

occluding one nostril at a time and asking client to sniff.

while other is occluded.

obstructin g the nostrils. Client is able to sniff through each nostril while other is occluded. Lips are smooth without lesions or swelling. Has pinking lips. The patient has smooth and pinkish lips. And has no lesions.

3. MOUTH

INSPECTION: Inspect the lips. Observe lip consistency and color.

Lips are smooth and moist without lesions or swelling. Pink lips are normal in light-skinned clients as are bluish or freckled lip in some darkskinned clients. No unusual or foul odor is noted.

Note odor. While the client is speaking, or the mouth is wide open, note any unusual or foul odor.

No foul odors or halitosis was observed.

The patient has no halitosis.

BREASTS

INSPECTION: Inspect size and symmetry.

Inspect color and texture. Be sure to note clients overall skin tone when inspecting the breast skin. Note any lesions. Inspect the areolas. Note the color, size, shape, and texture of the areolas of both breasts.

Breasts can be a variety of sizes and are somewhat round and pendulous. One breast may normally be larger than the other. Color varies depending on the clients skin tone. Texture is smooth with no edema.

Breasts increase in size after pregnancy. Left breast is larger than the right. Striae albicantes is present. The skin tone of the breast and body is consistent. Areolas color is dark brown. They are both round and vary in size. Nipples are equally bilateral. Nipples are everted. No discharge present.

The patients breasts are asymmetrical which is normal.

The patients breast color is fair to the skin tone. Has striae albicantes on the breast. The patient has dark brown areolas and round in shape.

Areolas vary from dark pink to dark brown, depending on the clients skin tones. They are round and may vary in size. Nipples are nearly equally bilateral in size and are in the same location on each breast. Nipples are usually everted, but they may be inverted or flat. No discharge should be present.

Inspect the nipples. Note the size and direction of the nipples of both breasts. Also note any dryness, lesions, bleeding or discharge.

The patients nipples are equally bilateral and have no discharge present.

PA2 (Thorax to Genitalia)