Date

Patient name: Patient X

General survey:

Vital sign

Body temperature:

Blood pressure:

Respiratory rate:

Pulse rate:

BODY METHODS USED FINDINGS INTERPRETATION

Skin  Inspection  dry  normal
Skin turgor  palpation  brown in color  normal
 the skin go back to  normal
its normal state
after pinching
Head  Inspection  round in shape  normal
 scalp  Inspection  no presence of  normal
 hair  inspection dandruff, no lice
 no nodules or  normal
masses
 black/long hair  normal
 hair is smooth and
thin  normal

Eyes  inspection  symmetrical  normal

 conjunctiva  inspection  transparent  normal
 eyebrows  inspection  pinkish in color  normal
 pupils using penlight  black in color  normal
 eyelashes  inspection  symmetrically  normal
 eyelids  inspection aligned
 iris  inspection  equally round  normal
and react to
light and
accommodation
 black in color  normal
 equally  normal
distributed
 skin intact  normal
 ability to blink
 light brown in  normal
color
External ears  inspection  symmetrical  normal
 same color with  normal
face
 without lesions  normal
 the upper point of
attachment is  normal
leveled to the
outer cantus
Internal ears  palpation  pinna recoil  normal
 inspection using  dry discharge are  normal
penlight seen
Nose  inspection  same color as the  normal
face
 peeling of the skin  normal
Mouth
 lips  inspection  Moist  Normal
 teeth  inspection  Clean, no dental  Normal
 tongue  inspection caries
 gums  inspection  Pink in color  Normal
 Moist
 More freely  Normal
 Pink in color
Neck
 Trachea  Inspection  flexed normally
 Palpation  trachea is in the
 Thyroid middle Cause of lymp.
 Inspection and  presence of mass
palpation 5 cm
Chest
 thorax  inspection  symmetrical  normal
 auscultation  no presence of  normal
 abdomen  inspection crackles
 auscultation  no presence of  normal
mumur
 no lesions  normal
 no pain during  normal
palpitation
 bowel sound:3bpm  normal
Upper Extremities
 shoulder  inspection  moves freely  Normal
 symmetrical to  Normal
both left and right
 arm  inspection  moves freely  Normal
 right and left arm  Normal
are symmetrical
 no lesions  Normal
 hands  inspection  symmetrical both  Normal
 left and right
 fingernails  inspection  no presence of  Normal
edema
 short nails  Normal
 capillary  3 seconds  Normal
nailbed
 pulse  palpation  Pulse rate-  Normal
Lower extremities
 Legs  inspection  less hair  normal
 symmetrical to  normal
both left and right
 able to flexed and  normal
extend
 no presence of  normal
edema
 feet  palpation  no mass or lumps  normal
 inspection  short nails  normal
 palpation  no pain during  normal
palpation