BODY PARTS ACTUAL FINDINGS

HEAD Ÿ Normocephalic
Ÿ Black hair and evenly distributed
Ÿ (-) nits, (-) lice
Ÿ (-) alopecia
Ÿ (-) masses, (-) lesions

EYES Ÿ icteric sclera both eyes

Ÿ pale conjunctiva
Ÿ (-) lacrimation
Ÿ pupils 3mm/3mm
Ÿ equally round reacted to light and accommodation

EARS Ÿ Normal shape

Ÿ (-) wound
Ÿ (-) bleeding
Ÿ (-) secretion or cerumen

NOSE Ÿ Normal shape

Ÿ Midline septum
Ÿ (-) secretion
Ÿ (-) lesions, (-) polyps

MOUTH Ÿ Lips: Moist

Ÿ Teeth: (-) dental caries
Ÿ Mucous: Moist
Ÿ Tongue: not dirt
Ÿ Tonsils: not enlarged
Ÿ Uvula: midline

NECK Ÿ (-) Lymph node enlargement

Ÿ (-) scrofuloderma
Ÿ (-) masses

ABDOMEN Ÿ (-) widening of the veins, (-) spider nevi,

Ÿ (+) gurading behavior when touched
Ÿ Pain scale of 6/10
Ÿ Liver palpable slightly enlarged confirm in ULTZ
Ÿ Spleen not palpable
Ÿ (-) Fluid wave, (-) abdominal mass
Ÿ Upon percussion: the entire field of tympanic abdomen,
(-) shifting dullness
Ÿ Upon auscultation: normal bowel sound, (-) bruit
VERTEBRAE Ÿ (-) deformities , (-) masses along the line of the vertebral

EXTREMITIES Ÿ Warm
 Ÿ Capilliary refill time < 2 seconds
Ÿ (-) edema
SKIN Ÿ Good turgor
Ÿ Slightly dry
Ÿ Jaundice prominent on the eyes and body
Ÿ Itchiness