Client has a frame body built, with slightly stooped posture. He is appropriately dressed. Client has no body odor.

No obvious deformities. His height is 56 and his weight is 60kg. Vital signs: BP: 140/80 RR: 26 PR: 96 T: 36

My client is well-oriented to time, place and person. He use simple words in communicating. He is also cooperative.

The skin is in normal racial tone which is brown, has warm temperature. Clients skin is smooth. Theres a birthmark in right arm. Hair is evenly distributed.

The client nail plate is convex 160. it has a smooth texture, pinkish nail bed. Capillary refills at 3 seconds. No presence of Beaus line.

Skull and face are symmetrical, equal distribution of fine hair. No tenderness on the scalp, no lesion, no lice, and no deformities.

Pinna is in normal racial tone, shape size is proportional to the size of the head, color is fair, external canal. Theres a presence of ceraminous wax.

He has a straight normal eye condition w/thick eyebrows,eyelids are symmetrical, blink response are present, symmetrical eyeballs. Bulbar conjunctiva is clear, palpebral conjunctiva is pink, sclera is white. Pupils are equally round. Reactive to light and accomodation. Lacrimal apparatus has no excess tearing.

Nose is good with minimal speculum. Nasal cavity airways are both patent. Sinuses are non-tender.

His lips are slightly pale pink, dry and symmetrical. Mucosa is pink, tongue is in midline. Gums are pink.

Uvula is in midline, mucosa is pink, tonsils are not inflamed, posterior pharynx is not inflamed. Gag reflex is present.

Breast contour is flat. Ratio is 1:2, lung expansion to anterior and posterior chest are symmetrical, breathing pattern is regular. Costal angle is 45 degree, heart sound have equal rate and equal rhythm heard at apical region.

Abdomen is flat and has a racial tone of brown. Free from lesion, liver not palpable.

Motor strength is 3/5. no lesion and deformities seen. Peripheral pulses are bounding.

He refused it during the assessment.