Physical Assessment

Head:
Skull: proportion to the body, symmetrical
Scalp: no scaliness, no lumps, no lesions
Hair: good distribution, shiny, smooth, oily

Face:
Facial skin: brown, same color with body complexion, with pigmentations, dry, no lesion
Facial expression: looks weak, no edema, no masses or lumps

Eyes:
Conjunctiva: pale, no nodules, no swelling
Eyelids: not symmetrical, drooping at left eyelid
Pupil: black, round, equal, no discoloration, no cloudiness
Iris: no inflammation, no irregularity

Ear:
No tinnitus, symmetrical, no discharge, no vertigo
Auricle: no deformities, no lumps, no skin lesions
Hearing: good

Nose: normal bone alignment, no epistaxis, no abnormal skin marking, no discharge, no flaring
of nares

Throat:
Lips: pale pink, dry, no cracking, no lumps or no ulcer
Buccal mucosa: no white patches, no nodule, no ulcers

Teeth: 3 (up), 11 (down)

Neurological:
Conscious-alert, awake of herself and environment

Pupillary Reaction:
Symmetrical, with accommodation, round, constrict with increasing light

Gastrointestinal:
Abdomen; no rashes, no dilated veins

Musculoskeletal:
Muscle bones: symmetrical, no pain
Muscle tone: relaxed

Integument:
Brown complexion, no jaundice, with few freckles
Skin texture: coarse
Temperature: warm
Consistency: firm
Nail: yellowish, long, smoothe, no bitted edges