REVIEW OF SYSTEMS

AREA/SYSTEMS FINDINGS
General Health The patient’s level of understanding has been good. Awake,
Survey aware, and focused. There was no immediate danger/risk.
Well-developed, well-hydrated, and well-nourished. Age
appears to be indicated.

Carotid Artery and

Jugular Vein

Posterior Chest

Anterior Chest

PHYSICAL EXAMINATION

Documenting the Physical Assessment Findings

AREA/SYSTEM FINDINGS
Charmel Dame S. Tumarong, 22
years old, female, seems to be age-
appropriate.
The patient’s vital signs are normal
with a temperature of 37.3 degree
Centigrade, pulse rate of 77 beats per
minute, respiration rate of 16 cycles
per minute and blood pressure of
 General Health Survey 110/80 mmHg.
Upon receiving the patient, the patient
was looking good with no complaints
of pain at all.
The patient has no obvious physical
deformities or abnormalities.
The patient showed no sign or
potential signs of distress.
The patient is relaxed, has an erect or
upright posture and coordinated by
body movements, can freely move,
doesn’t use any assistive device and
can voluntarily move.
The patient has a good facial
expression without grimacing or pain.
The patient’s mood is appropriate to
the situation, has appropriate
response, comfortable and calm.
The patient is understandable, and
moderate in pace.
The patient physically looks clean and
neat.
Skin:
Inspection
color of Filipino ethnicity specifically,
the tanned brunette color or the
Morena color
fine/normal odor
lesion specifically pustule, pt. is
suffering from facial acne
No presence of edema
Palpation
INTEGUMENTARY SYSTEM temperature of being warm
little moisture
texture of firmness
instantly rebounding based on its
turgor-mobility.
Nails
Inspection
color of transparent light brown
fair toe-finger nail plates
varied shapes
slightly symmetrical
Palpation
firm and smooth
capillary refill goes back instantly
 when pinch.
HEAD, SKULL, AND HAIR Head/Skull:
Inspection
Normocephalic
Erected or upright
Normal symmetry
No presence of scales
Palpation
No lumps, deformities, and lesions.
Hair:
Inspection
Black
Well-distributed
Medium
Coarse and dry
Palpation
Lumps, deformities, and lesions are
none

FACE Inspection
The face noted to be symmetrical and
has round shape/contour
Palpation
No masses and lesions existing
Temporal arteries not seen but
palpable.
Temporomandibular joint is normal as
evidently depicted of clicking
sensations or there’s cracking sound.
EYES Inspection
Visual Acuity:
The pt. manifested 20/20 vision in line
11 of Near Visual Acuity, 20/20 in line
8 for both left and right eyes utilizing
cover and uncover approach of Far
Visual Acuity through Snellen’s chart.

Palpation
Upon palpation, bulbar conjunctiva
appears to be mainly white,
semitransparent and/or colorless, and
no lesions found.
Upon palpation, palpebral conjunctiva
has color of pink, opaque, and no
lesions or foreign bodies found.
Upon palpation, cornea & lens, have
 normal clarity, the texture is clear or
transparent, and has sensitivity to an
object making the pt. manifested blink
movement.
The pupils found out to be round,
equal, responsive or reacted to light,
and is accommodated, in terms of
consensual reaction.
The peripheral visual field noted as
normal and for extraocular
movements, there’s no presence of
any obscurity.
Eyelids are also equal, Morena-toned
color, and no edema or masses

EYEBROWS Inspection
Upon inspection, eyebrows are
medium and well-distributed.
Palpation
Noted to have no scales and masses
EARS Inspection
Upon inspection, external ears are
tanned light brown, symmetrical,
aligned, no deformities, smooth and
firm. The internal ears noted to be
translucent white, has hair and
cerumen, and none for discharges

Palpation
Upon palpation, there was elasticity
and no tenderness felt

Whispered Voice Test:

Kitchen fork utilized as assumably the
tuning fork, pt. was responsive to this
test and thus, normal.

Weber Test:
Kitchen fork utilized as assumably the
tuning fork, pt. can be able to localize
sounds within the head for both ears.

Rinne Test:
Kitchen fork utilized as assumably the
tuning fork, pt. can hear the sound for
a few seconds.
 NOSE Inspection
The external nose noted to be normal
in size and shape, symmetrical, no
deformities, flaring, discharges, or
nodules. As for internal nose, it has
hair, few dried nasal mucus, and no
lesions or deformities.

Palpation
Upon palpation, no tenderness
depicted and can be able to exhale in
both nares of external nose.
SINUSES Palpation
There was no presence of tenderness
in frontal and maxillary sinuses.
MOUTH Lips:
(External)
Inspection
Pink
Slightly symmetrical
Intact
No lesions
Odor was normal

(Internal)
Palpation
Pink
Smooth
Has moistures
No lesions or discharges

Gums/Buccal Mucosa:
(Upper and Lower)
Inspection
Pink
No bleeding, discoloration, and growth
Has moisture

Teeth:
Inspection
Misalignment of upper canine teeth
Varied shape
Has cavities on the lower molar part

Roof of Mouth/ Hard Palate:

 Inspection
Pink
Ridged
No deformities

Tongue:
Inspection
Dorsum-color was pink
Papillae was whitish pink
Texture was shiny but rough
Size was small
Frenulum appears to be normal

PHARYNX Inspection
Soft palate is normal
Pink
Symmetrical
No discharges and ulcerations seen
No enlargement of tonsils
Uvula is in the midline
Has gag reflex
NECK Inspection
Symmetrical
No scars or growths
Parotid glands are normal
Neck muscles are normal and pt.
exhibited movements.
Palpation
All lymph nodes (Occipital, Post-
auricular, Pre-auricular, Tonsilar,
Submandibular, Submentum,
Cervical’s superficial and deep, and
Supraclavicular) were not swelling,
therefore, normal.
TRACHEA Inspection
Trachea noted to be aligned and has
deviation
THYROID GLAND Palpation
Upon palpation, thyroid noted to be
not visible or feel and pt. has no
difficulty when swallowing.