Body Part Techniques Used Normal Findings Actual Findings Analysis

Head and Face Rounded and Symmetrical with Rounded and Symmetrical Normal
Frontal, Parietal, and Occipital with Frontal, Parietal, and
Cranium Inspection Prominences (Normocephalic); Occipital Prominences
Smooth Skull contour. (Normocephalic); Smooth
Absence of Nodules and Skull contour.
Masses. Absence of Nodules and
Masses.
Low cardiac ouput
Temporal Arteries Palpation Palpable temporal arteries with Weak thready pulses (CVA infarct)
full pulsations. Cerebrovascular accident: The
sudden death of some brain cells
due to lack of oxygen when the
blood flow to the brain is impaired by
blockage or rupture of an artery to
the brain.

-Aortic stenosis (based sa 2D echoi)

Normal
Face Inspection Symmetric or slightly Symmetric or slightly
asymmetric facial features; asymmetric facial features;
palpebral fissures equal in size; palpebral fissures equal in
symmetric nasolabial folds. size; symmetric nasolabial
folds.
Normal
Cranial Nerves V and VII Inspection Symmetric facial movements Symmetric facial movements
such as raising of eyebrows, such as raising of eyebrows,
puffing out of cheeks, and puffing out of cheeks, and
immediate eliciting of Blink immediate eliciting of Blink
reflex when stimulated. Able to reflex when stimulated. Able
distinguish blunt and sharp to distinguish blunt and sharp
objects correctly on both objects correctly on both
cheeks. cheeks.
Both cranial nerves are Both cranial nerves are
functional. functional.
Nose and Cranial Nerve I Inspection Symmetric and straight; no Symmetric and straight; no Normal
discharge or flaring; uniform in discharge or flaring; uniform CN-1 (n/a)
color; airway is patent. Can in color; airway is patent.
smell scents used as stimuli.
Eyes and vision Hair is evenly distributed; skin Hair is evenly distributed; skin
External Inspection is intact, eyebrows are is intact, eyebrows are Normal
symmetrically aligned and symmetrically aligned and
move equally. Eyelashes are move equally. Eyelashes are
equally distributed and are equally distributed and are
curled slightly outward. Eyelids curled slightly outward.
has no discharge and closes Eyelids has no discharge and
symmetrically. Bulbar closes symmetrically. Pale
Conjuctiva is transparent; (Anicteric) sclera;Pale
sclera appears white. Palpebral palpebral and bulbar
conjunctiva is shiny, smooth conjunctiva
and pink or red in color. (+) Opacity of lenses
Not assessed
Visual acuity Inspection Able to read small letters.
20/25 vision on Snellen’s chart
for older adults.
(www.ias.ac.in/currsci/dec1020
08/1544.pdf)
Both Eyes are coordinated, Not assessed
Extraocular Muscle Function Inspection moves in unison with parallel
(CN: III, IV and VI) alignment.
Black in color, equal in size Black in color, equal in size: 4 Normal
Pupillary Reflexes Inspection normally 3-7mm in diameter; mm in diameter; round,
round, smooth border, iris flat smooth border, iris flat and
and round. Pupils constrict round. Pupils constrict slowly
when looking at near objects; when looking at near objects;
pupils dilate when looking in pupils dilate slowly when
far objects. Pupils converge looking in far objects..
when near object is moved
 towards the client.
3.Ears and hearing Inspection and Color same as facial skin, Color same as facial skin, Normal
External Ear Palpation symmetric position, aligned symmetrical, aligned with the
with the outer canthus of the outer canthus of the eye,
eye, auricles are mobile, firm auricles are immobile, firm
and not tender, pinna recalls and not tender, pinna recalls
after folded. after folded.
Normal voice tone is audible Normal
Hearing Inspection Normal voice tone is audible. Is
able to hear ticking of stimuli in
both ears.
Normal
Ear canal and tympanic Inspection and Dry cerumen or sticky cerumen Dry yellow cerumen present
membrane Palpation could be visible. No tenderness on both ears.No tenderness
could be felt upon palpation. could be felt upon palpation.
Neck Normal
Musculoskeletal structures Inspection Muscles equal in size, head is Coordinated smooth
centered. There are movements. Head is
coordinated smooth centered.With presence of
movements with no donut ring to protect the neck
discomfort. extremity.
Lymph nodes Palpation Not palpable No palpable mass Normal
Not assessed
Thyroid gland Inspection and Lobes may not be palpated. If
Palpation palpated lobes are small,
smooth, centrally located,
painless and rise freely with
swallowing.
Musculoskeletal function and Inspection and Head flexes, hyperextends and Head flexes, hyperextends and Normal
CN XI Palpation laterally rotates. Equal muscle laterally rotates. Equal muscle
strength. strength.
Carotid arteries Inspection and Symmetric pulse volumes, full Weak Thready Pulse assessed Low cardiac ouput
Palpation pulsations thrusting quality. when the patient was (CVA infarct)
Quality remains same when positioned on a high back Cerebrovascular accident: The
 patient breathes, turns head above the level of the heart. sudden death of some brain cells
and changes position from Jugular veins are slightly due to lack of oxygen when the
blood flow to the brain is impaired by
sitting to supine. distended.
blockage or rupture of an artery to
the brain.

-Aortic stenosis (based on 21D echo)

Anterior Chest

Breast and Axillae Inspection and Breast appears saggy; skin is Skin is uniform with color, Normal
Palpation uniform with color, wrinkled wrinkled and rough. No
and rough in older adults. No tenderness, masses or nipple
tenderness, masses or nipple discharge was inspected and
discharge was inspected and palpated.
palpated.
Hooked on cardiac monitor

CR-

2D echo result

Thorax Inspection and Symmetric, there are no Bi-basal crackles noted on (+) Pneumonia
Auscultation tenderness and lesions within both fields. Increased
the area. Respiration is quiet, respiratory effort. Pkilagay po ung result ng diagnostics
rhythmic and effortless. Mild retractions noted exam na nakalagay pneumonia
Antero-posterior to lateral RR-34 bpm
diameter in ratio is 1:2, chest is
symmetric, spine is vertically XRAY result
aligned. Skin and chest wall is
intact. There is no tenderness
and masses.
No adventitious breath sounds
are heard
Precordium Inspection and Apical pulse audible muffled Low cardiac ouput
Auscultation Heart sounds are audible. and weak. (CVA infarct)
Cerebrovascular accident: The
Second intercoastal space: sudden death of some brain cells
Muffled heart sounds heard due to lack of oxygen when the
Fifth intercoastal space: blood flow to the brain is impaired
Muffled Heart sounds heard. by blockage or rupture of an artery
Apex: Abnormal cardiac rate to the brain.
and rhythym; Not clearly
audible heart sounds heard. Meron bang aortice stenosis ang
patient?kung meron isang rason pa
un kaya weak thready pulse sya

8. Posterior Chest

Musculoskeletal structure Inspection and Skin is intact, chest wall is Skin is intact, chest wall is Normal
Palpation intact. There are no tenderness intact. There are no
and masses. Full and symmetric tenderness and masses. Full
chest expansion. and symmetric chest
expansion.
Fist percussion over spine and . Spine is vertically aligned. Not assessed
kidneys There is no inflammation and
tenderness.
Posterior Thorax Symmetric, there are no Not assessed
tenderness and lesions within
the area. Respiration is quiet,
rhythmic and effortless. No
adventitious breath sounds are
heard
Abdomen
Four abdominal quadrants Unblemished skin, uniform in Unblemished skin, uniform in Is there an abdominal distention
Inspection, color. Flat, rounded (convex) or color. kaya hypoactive at tympanic?(forget
Auscultation and scaphoid (concave). No Hypoactive bowel sounds. ko ask sayo)
 Percussion evidence of enlargement of Tympanic sound upon
Liver or Spleen. Symmetric percussion.
contour.
(-) bulges or marked ridges
Symmetric movements
caused by respirations
(+) Bowel sounds
(-) Tenderness
Relaxed abdomen with
smooth consistent tension.

Specific organs Normal

Liver Inspection, Dullness heard upon Dullness heard upon
Percussion, percussion percussion
palpation May not be palpable May not be palpable
Border feels smooth Border feels smooth

Spleen No tenderness and no Not assessed

enlargement

6. Upper Extremities

a. Musculoskeletal Inspection and Generally uniformed in areas Normal skin turgor for age; Low cardiac ouput
structures, skin and Palpation exposed to the sun. Skin cold to touch (CVA infarct)
nails springs back to previous state Cerebrovascular accident: The
when pinched. Nails are Has IVF contraptions attached. sudden death of some brain cells
smooth in texture and are due to lack of oxygen when the
IVF Furosemide drip,
convex in curvature. Capillary blood flow to the brain is impaired
Furosemide 100mg + PNSS
refill time is 2-3 seconds. to make 100ml @ 2cc/hr by blockage or rupture of an artery
infusing well @ Left to the brain.
metacarpal vein with side
drip ISDN drip, 20mg ISDN Meron bang aortice stenosis ang
+ PNSS to complete 100cc patient?kung meron isang rason pa
@ 5cc/hr; With Dobutamine un kaya weak thready pulse sya
drip, Dobutamine 200mg +
PNSS 250 cc @ Impairments following brain damage
18mgtss/min, infusing well can be classified as positive (e.g.
@ Right metacarpal vein. spasticity and abnormal cutaneous
reflexes) or negative (e.g. loss of
Pale Nail Beds strength and loss of dexterity). It is
now recognized that, regardless of
Nails are rough, uncut and the presence of positive
have dirt deposits impairments, negative impairments
remain the main obstacle to
Poor capillary refill;
recovery of function following brain
Capillary refill time is 4
damage (Burke, 1988). A common
seconds.
functional problem observed after
Has tattoo on right upper stroke is that individuals are able to
arm. use their affected limbs reasonably
well at certain joint angles, but not
at others. For example, in the upper
limb, it may be possible to use the
affected arm in mid‐range, but
difficult when the affected arm is in
the last 0–20° of elbow extension
(Bohannon, 1991; Levin et al., 2000).
In the lower limb, it is common to
observe individuals after stroke
having difficulty functioning when
the affected knee is in the last 0–15°
of extension (Carr and Shepherd,
1998).
b. Musculoskeletal Inspection Could be flexed and extended,  Decreased muscle strength Impairments following brain damage
functions abducted and adducted. can be classified as positive (e.g.
4/5 4/5 spasticity and abnormal cutaneous
4/5 4/5 reflexes) or negative (e.g. loss of
 4/5- there is movement strength and loss of dexterity). It is
against resistance, but less now recognized that, regardless of
than normal the presence of positive
impairments, negative impairments
 With Motor response of 6 remain the main obstacle to
as being able to obey recovery of function following brain
commands. (Glasgow Coma damage (Burke, 1988). A common
Scale) functional problem observed after
 Has limited range of motion stroke is that individuals are able to
due to contraptions use their affected limbs reasonably
attached to the patient. well at certain joint angles, but not
at others. For example, in the upper
limb, it may be possible to use the
affected arm in mid‐range, but
difficult when the affected arm is in
the last 0–20° of elbow extension
(Bohannon, 1991; Levin et al., 2000).
In the lower limb, it is common to
observe individuals after stroke
having difficulty functioning when
the affected knee is in the last 0–15°
of extension (Carr and Shepherd,
1998).
c. Brachial and Radial Palpation Palpable and has good thrust Low cardiac ouput
Arteries quality. Symmetric pulse  Weak thready pulses (CVA infarct)
volumes with full pulsation Cerebrovascular accident: The
 Skipped beats approximately sudden death of some brain cells
10 skipped beats per minute due to lack of oxygen when the
with uncoordinated blood flow to the brain is impaired
intervals. by blockage or rupture of an artery
 to the brain.

Meron bang aortice stenosis ang

patient?kung meron isang rason pa
un kaya weak thready pulse sya
Impairments following brain damage
d. Deep tendon reflexes Inspection Normal slight flexion of elbow Upon inspection, the patient can be classified as positive (e.g.
and biceps contraction could exhibits normal slight flexion spasticity and abnormal cutaneous
be felt. Normal flexion and of elbow and biceps reflexes) or negative (e.g. loss of
supination of forearm and contraction could be felt. strength and loss of dexterity). It is
fingers of the hand may extend Normal flexion and supination now recognized that, regardless of
slightly. of forearm and fingers of the the presence of positive
hand may extend slightly. impairments, negative impairments
remain the main obstacle to
recovery of function following brain
damage (Burke, 1988). A common
functional problem observed after
stroke is that individuals are able to
use their affected limbs reasonably
well at certain joint angles, but not
at others. For example, in the upper
limb, it may be possible to use the
affected arm in mid‐range, but
difficult when the affected arm is in
the last 0–20° of elbow extension
(Bohannon, 1991; Levin et al., 2000).
In the lower limb, it is common to
observe individuals after stroke
having difficulty functioning when
the affected knee is in the last 0–15°
of extension (Carr and Shepherd,
1998).
11.Lower Extremities
Musculoskeletal Structures, Inspection and Extremities are intact and Low cardiac ouput
skin, toe and nails Palpation symmetrical. Normal skin turgor for age. (CVA infarct)
Generally uniform in color Cold to touch Cerebrovascular accident: The
Skin springs back to previous Pale Nail beds sudden death of some brain cells
due to lack of oxygen when the
state when pinched. Nails are rough.
blood flow to the brain is impaired by
Nails are convex in curvature, Poor capillary refill; Capillary blockage or rupture of an artery to
smooth in texture and highly refill time is 4 seconds. the brain.
vascular.
Capillary refill time is 2-3 secs. Meron bang aortice stenosis ang
patient?kung meron isang rason pa
un kaya weak thready pulse sya

Musculoskeletal function Inspection (+) Extension, flexion, Impairments following brain damage
dorsiflexion, plantar flexion and Decreased muscle strength can be classified as positive (e.g.
rotation without any 4/5 4/5 spasticity and abnormal cutaneous
complaints 4/5 4/5 reflexes) or negative (e.g. loss of
4/5- there is movement strength and loss of dexterity). It is
against resistance, but less now recognized that, regardless of
than normal the presence of positive
With Motor response of 6 as impairments, negative impairments
being able to obey commands. remain the main obstacle to
(Glasgow Coma Scale) recovery of function following brain
Has limited range of motion damage (Burke, 1988). A common
on Right. functional problem observed after
Decreased sensation on Right. stroke is that individuals are able to
use their affected limbs reasonably
well at certain joint angles, but not
at others. For example, in the upper
limb, it may be possible to use the
affected arm in mid‐range, but
difficult when the affected arm is in
the last 0–20° of elbow extension
(Bohannon, 1991; Levin et al., 2000).
In the lower limb, it is common to
 observe individuals after stroke
having difficulty functioning when
the affected knee is in the last 0–15°
of extension (Carr and Shepherd,
1998).
Popliteal, Posterior Tibial and Palpation Symmetric pulse volumes with Low cardiac ouput
Pedal arteries full pulsations Absent pulses on both lower (CVA infarct)
extremities. Cerebrovascular accident: The
sudden death of some brain cells
due to lack of oxygen when the
blood flow to the brain is impaired
by blockage or rupture of an artery
to the brain.

Meron bang aortice stenosis ang

patient?kung meron isang rason pa
un kaya weak thready pulse sya
Deep Tendon Reflex Percussion Normal extension or kicking Upon inspection, the patient Normal
out of leg as the quadriceps exhibits normal extension or
muscle contracts. kicking out of leg as the
+2 quadriceps muscle contracts.
Deep tendon reflex is +2 =
normal
Percussion on the patient was
not done to assess deep
tendon reflexes due to the
contraptions present.
Genitals and Pelvis Inspection Pubic hair is in triangular Pubic hair is in triangular Normal
distribution, often spreads up distribution, often spreads up
in abdomen. in abdomen. Normal
Urethral Meatus is pink and slit Urethral Meatus is pale and
like appearance. slit like appearance. Has
indwelling foley catheter
intact.
Rectum Inspection Intact peri-anal skin. Usually Intact peri-anal skin. Usually Normal
slightly more pigmented than slightly more pigmented than
the skin of the buttocks. Anal the skin of the buttocks. Anal
skin is normally more skin is normally more
pigmented, coarser and pigmented, coarser and
moister than peri-anal skin and moister than peri-anal skin
is usually hairless. and is usually hairless.