SKIN

CHARACTERISTICS NORMAL ACTUAL FINDINGS INTERPRETATION

FINDINGS
Inspection PreOp IntraOp PostOp PreOp IntraOp PostOp
GENERAL COLOR
Normal (-) Pallor
(-) Jaundice
Pallor (-) Redness
Jaundice
Redness
MOISTURE
Moist (-) Dryness
(-) Clammy
Dry skin
(-) Oily Skin
Wet/Clammy
Oily

TEXTURE
Smooth (-) Scaly
Skin
Scaly (-) Rough
Skin
Rough

Palpation
TEMPERATURE (-) Coolness
Warm

Cool

TURGOR
Good (-) Poor
Skin Turgor
Fair

Poor

EDEMA
No edema
(-) Edema
Pitting
Non pitting
Pedal R/L
OTHERS
Petechiae (-)Petechiae
(-)
Ecchymosis Ecchymosis
(-) Lesion/
Lesion/Rashes Rashes
 HEAD
CHARACTERISTICS NORMAL ACTUAL FINDINGS INTERPRETATION
FINDINGS
Inspection PreOp IntraOp PostOp PreOp IntraOp PostOp
SCALP (-) Dandruff
Clean (-) Lice
Dandruff (-) Wounds
(-) Scars
Lice
(-) Lesion
Wounds/Scars/
Lesions
HAIR (-) Dryness
Normal/Even (-)
distribution Coarseness
Fine (-) Alopecia
Coarse (-) Hair
Thinning
Dry
Palpation
CONFIGURATION (-) Masses
Normocephalic
Masses
FONTANELS
Close (-) Open
Fontanels
Open (-) Sunken
Fontanels
Sunken
(-) Bulging
Bulging Fontanels

EYES
CHARACTERISTICS NORMAL ACTUAL FINDINGS INTERPRETATION
FINDINGS
Inspection
LIDS (-) Edema/
Symmetrical Swelling
Edema/ Swelling
PERIORBITAL (-) Edema
REGION (-) Sunken
Normal Periorbital
Edema Area
Sunken (-)
Discoloratio
Discoloration
n
CONJUNCTIVA
Pinkish (-) Paleness
Pale (-) Lesion
Lesion (-)Discharge
Discharge
SCLERA (-)Subicteric
Anicteric (-)Icteric
Subicteric (-)
Hemorrhage
Icteric
Hemorrhages
 CORNEA (-) Lesion
Smooth (-) Opacity
Clear (-)
Lesions ArcusSenilis
Opacity
ArcusSenilis
PUPILS
Equal (-) Unequal
Unequal Diameter
Diameter (R) __
mm
Diameter (L) __
mm
REACTION TO
ACCOMMODATION (-) Unequal
Uniform Constriction
Constriction
Unequal
Constriction
CONVERGENCE
Uniform (-) Unequal
Convergence Convergence
Unequal
Convergence
VISUAL ACQUITY
Gross normal
Wears eye-
glasses
Other Findings

EARS
CHARACTERISTICS NORMAL ACTUAL FINDINGS INTERPRETATION
FINDINGS
Inspection PreOp IntraOp PostOp PreOp IntraOp PostOp
EAR PINNAE
Symmetrical
Gross
Abnormalities
EAR CANAL
Normal
Impacted (-) Impacted
Cerumen Cerumen
Discharge (-)Discharge
(-) Foul
Foul Smell
smell
Mucoid
Serous
Purulent
GROSS HEARING (-) Deafness
Symmetrical on either
side
Deafness on L/R
 NOSE
CHARACTERISTICS NORMAL ACTUAL FINDINGS INTERPRETATION
FINDINGS
Inspection PreOp IntraOp PostOp PreOp IntraOp PostOp
NASOLABIAL Symmetrical
Symmetrical Nasolabial
Shallow Fold
Nasolabial Fold
L/R
SEPTUM Nasal
Midline Septum at
midline, (-)
Deviated to L/R Deviation
on either
Perforated side,(-)
Perforation
MUCOSA
Pinkish (-) Paleness
Pale (-) Redness
Reddish on mucosa
DISCHARGE
No Discharge (-)
Serous Discharge
Mucoid
Purulent
Bloody
PATENCY (-)
Both Patent Obstruction
Obstructed L/R (-) Masses,
Masses/Lesions (-) Lesions
GROSS SMELL (-) Olfactory
Symmetrical Deficiency
Olfactory on either
Deficiency R/L side
SINUSES (-)
Non- tender Tenderness
Tender on Sinuses
MOUTH
CHARACTERISTICS NORMAL ACTUAL FINDINGS INTERPRETATION
FINDINGS
Inspection
LIPS (-) Pallor
Normal (-) Cyanosis
Pallor (-) Dryness/
Cracks
Cyanosis
(-) Lesion
Dryness/ Crack (-) Swelling
Lesions
Swelling
TONGUE Tongue is at
Midline Midline
(-) Deviation
Deviation to L/R on either
 Atrophy side (-)
Fasciculation Atrophy
(-)
Lesions Fasciculation
(-) Lesions
TEETH
Complete Complete
Missing Teeth set of teeth
___ (-) Carries
Caries (-)Dentures
(-) Braces/
Dentures
Retainers
Braces/
Retainers
GUMS (-) Paleness
Pinkish (-) Bleeding
Pale (-)
Bleeding Tenderness
Tenderness
BUCCAL MUCOSA
Pinkish (-) Paleness
Pale (-) Cyanosis
Cyanotic Stenson’s
Duct visible
Stenson’s Duct
SPEECH Speech is
Intact intact, (-)
Slurred Slurred
Aphasia
PHARYNX
CHARACTERICS NORMAL ACTUAL FINDINGS INTERPRETATION
FINDINGS
Inspection (-) Deviation PreOp IntraOp PostOp PreOp IntraOp PostOp
UVULA on either
Midline side
Deviation to L/R
MUCOSA
Pinkish (-)Paleness,
Pale (-) Redness
Reddish
TONSILS Not
Not inflamed inflamed
Slightly inflamed (-) Exudates
Exudate
NECK
CHARACTERISTICS NORMAL ACTUAL FINDINGS INTERPRETATION
FINDINGS
Inspection PreOp IntraOp PostOp PreOp IntraOp PostOp
TRACHEA (-) Deviation
Midline on either
sides
Deviated to the
R/L
 Palpation
CERVICAL LYMPH Lymph
NODES nodes are
Non-palpable non-
Palpables palpable
Tender
THYROID GLAND
Non-palpable Thyroid
Neck rigidity glands are
Others non-
palpable
Masses
Neck vein
engorgement
BREAST AND AXILLAE
CHARACTERISTICS NORMAL ACTUAL FINDINGS INTERPRETATION
FINDINGS
Inspection PreOp IntraOp PostOp PreOp IntraOp PostOp
SIZE & SYMMETRY Equal in
Equal size and
Unequal symmetrical
SKIN (-) Redness
Normal (-) Venous
Redness Prominence
Venous (-) Edema
Prominence
Edema
CONTOUR (-) Masses
Normal (-) Dimpling
Masses
Dimpling
NIPPLE & AREOLA (-) Inversion
Normal (-) Flattening
Inversion (-) Retraction
Flattening or (-) Edema
retraction (-) Deviation
Edema on either
Discharge side
Deviation (-) Deviation
LUNGS
CHARACTERISTICS NORMAL ACTUAL FINDINGS INTERPRETATION
FINDINGS
Inspection PreOp IntraOp PostOp PreOp IntraOp PostOp
BREATHING (-)
PATTERN Hyperventilat
Effortless ion
(-) Use of
Hyperventilation Accessory
Muscle
Use of
Accessory
Muscle
 SHAPE OF CHEST
Anterior- (-) Barrel
Posterior- Chest
Lateral Ratio (-) Funnel
AP__ Chest
L__ (-) Pigeon
Barrel Chest Chest.
Funnel
Pigeon
Other
CHEST EXPANSION Symmetrical
Symmetrical Lung
Decreased L/R Expansion
PERCUSSION (-) Dullness,
Resonant (-) Hyper
Dullness resonance,
Hyper-resonant (-) Tympani
at __ (-) Flatness
Tympani
Flatness
VOCAL TACTILE
Symmetric Symmetrical
Decreased/Incre Tactile
ased at __ lung Fremitus
field
BREATH SOUNDS
Normal
Abnormal Breath
Sound
Broncho-
vesicular
Vesicular
Bronchial
Wheezes
Ronchi
Rales
Pleural Friction
HEART
CHARACTERICS NORMAL ACTUAL FINDINGS INTERPRETATION
FINDINGS
Inspection PreOP IntraOp PostOp PreOp IntraOp PostOp
PERICORDIAL (-)
AREA Hyperdyna
Flat mic
Normodynamic Precordium
pre-cordium (-) Bulging
Hyperdynamic
precordium
Bulging
Tenderness
Heave
Thrill
 Point of (-)
Maximal Tenderness
Impulse at__ (-) Heave
Apical Beat at__ (-) Thrill
Auscultation
HEART SOUNDS Distinct
Distinct heart sound
Faint (-) faint
heart sound
S1__S2__ at
the base
S1__S2__ at
the apex
EXTRA SOUND
S3
S4
Murmur, grade
Best heard at
______
ABDOMEN
CHARACTERICS NORMAL ACTUAL FINDINGS INTERPRETATION
FINDINGS
Inspection PreOp IntraOp PostOp PreOp IntraOp PostOp
SKIN (-) Dilated
Normal Vein
Dilated Vein (-)Scars
(-) Rashes
Scars
(-) Striae
Rashes (-) Lesion
Striae
Lesion
CONFIGURATION
Flat Flat
Globular Abdomen
Protuberant
Scaphoid
UMBILICUS Umbilicus is
Sunken/Normal sunken
(-) Bulging
Bulging (-)
Hernia Herniation
PALPATION
Normal (-) Muscle
Muscle guarding grunting
Direct (-) Direct
tenderness tenderness,
(-) Rebound
Rebound
tenderness
tenderness
PERCUSSION (-)
Resonant Hypertympa
nic
Tympanic
(-) Fluid wave
Hyper tympanic Test,
 Fluid wave (-) Shifting
Shifting dullness Dullness
AUSCULTATION
BRUITS
Present Bruits are
Absent absent
BOWEL SOUND
Normoactive
Hyperactive
Hypoactive
Absent
GENITO-URINARY
CHARACTERISTICS NORMAL ACTUAL FINDINGS INTERPRETATION
FINDINGS
Inspection PreOp IntraOp PostOp PreOp IntraOp PostOp
LABIA (-) Lesion
Normal (-)
Symmetrical Discoloratio
n
Asymmetrical
(-) Redness
Lesion (-)
Pinkish Asymmetry
Discoloration (-) Edema
Edema
BLOOD (-) Purulent
Normal discharge,
Discharge (-) Bloody
Purulent discharge,
(-) Foul
Bloody
smell
Foul smelling
INGUINAL (-)
Normal size Enlargemen
Enlarged t
BARTHOLIN’S (-) Swelling
GLAND (-)
Normal Tenderness
Swelling (-)
Discharge Discharge
Tenderness
BACK AND EXTREMITIES
CHARACTERISTICS NORMAL ACTUAL FINDINGS INTERPRETATION
FINDINGS
Inspection Peripheral PreOP IntraOp PostOp PreOp IntraOp PostOp
PEROPHERAL pulses are
PULSE present
and are
Symmetrical
symmetrical
Absent
Palpation (-) Warmth,
Normal (-) Bounding
Warm Pulses
Bounding
NAILS & NAIL BEDS
Inspection
Normal (-) Redness,
Redness (-) Swelling,
Swelling (-) Pain
Pain
Palpation (-)
Normal Tenderness
Tenderness
Auscultation (-)
Normal Crepitation
Crepitation
JOINTS
Inspection
Normal (-) Redness,
Redness (-) Swelling,
Swelling (-) Pain
Pain
Palpation (-)
Normal Tenderness
Tenderness
Auscultation (-)
Normal Crepitation
Crepitation
MUSCLE TONE &
STRENGTH
Inspection
Symmetrical (-) Tics
Tone Normal (-) Tremors
Tics
Tremors
Palpation (-)
Normal Fasciculatio
Fasciculation n
SPINE
Midline (-) kyphosis,
Kyphosis (-) Lordosis,
Lordosis/ (-) Scoliosis
Scoliosis
KIDNEY
Palpate: (-)
(Costovertebral Angle Costoverteb
Tenderness) ral Angle
Normal Tenderness

Costovertebral
Angle
Tenderness
Summary: