Assessment

Personal Data

Chief Complaint

Present Illness & present health

Past History

Family History

Social history

Physical Assessment

 GENERAL SURVEY

BP: 120/80; PR: 91; RR: 20; TEMP: 360 C; O2 Sat: 94%. Patient is alert and awake.
Speech is not clear with slur. She cannot express well ideas and feelings concisely.
She maintains eye contact often during a conversation. Lying on the bed and looks
weak.

 SKIN, HAIR & NAILS

SKIN: Brown, warm and dry. Turgor intact, over the clavicle. No scars and lesions.
No rashes and no signs of redness or pallor.

HAIR: Black with few white hairs, short and no scalp lesions.

NAILS:

 HEAD & NECK

 EYES
 EARS
 MOUTH, THROAT, NOSE & SINUSES
 THORAX & LUNGS
 BREASTS
 HEART & NEC VESSELS
  PERIPHERAL VASCULAR
 UPPER EXTREMITIES
 LOWER EXTREMITIES
 ABDOMEN
 MUSCUSKELETAL
 NEUROLOGIC
 MENTAL STATUS EXAMINATION
 CRANIAL NERVE EXAMINATION
 MOTOR & CEREBELLAR EXAMINATION
 SENSORY STATUS EXAMINATION
 GENITALIA
 ANUS/ RECTUM

Small macule on the left temporal.