III.2.

Internal Status

System Physical Findings Impression

Within
Skin: light-colored, no hair loss, no rash, slight dry skin,
Integument normal limit
no hyperpigmentation, normal temperature
(Wnl)
Nail: no yellowish, no sign of anemic/cyanotic, capillary
Wnl
refill time less than 2 seconds
Head
No mass/tumor, no hematoma, no edema, no
Wnl
lesion/trauma sign.
No deformity, no mass, trachea in the midline,
Neck symmetrical, no enlargement of lymph nodes, carotid Wnl
pulsation normal
No anemic conjunctiva, no icteric sclera, pupil isochors φ
Eyes 3 mm /3 mm, direct light reflexes positive/positive, Wnl
indirect light reflexes positive/positive
No septum deviation, no nasal discharge, no conchae
Nose Wnl
hypertrophy
Ear No edema, no tenderness, no lesion sign Wnl
Chest Heart : Wnl
Inspection: ictus cordis not visible
Palpation: ictus cordis not palpable
Percussion:
nd
- Upper border on the 2 intercostal space II along the
left midclavicular line
th
- Right border on the 4 ICS along the midsternal line

th
- Left border on the 5 ICS space along the left
midclavicular line
Auscultation:
S1-S2 normal and regular, no murmur, no gallop
Chest expansion : 4-4-3 cm