|General Survey Body built: [J Endormorph i Mesomorph O Ectomorph Height_icm)Weight_(kg) | Posture/Gait: DLowdosis | (CKyphosis. (Scoliosis Shutting 1 Physical defects LOc:(jatert-drowsy-jOttunded Clatupsrous [1 comatose Verbal Response: Llorented Ci confused Dinapprepriate incomprehensible none Grooming:LWwell-groomed disheveled Orientation? JOrionted Fi pisoriented Mood] appropriate 5 inappropriate Vital Signs: Temp. HR PR RR BP. |__Pain(PaRsT) [i Skin Gonora! Color! uniform! Patior (laundicel- Flushed Kyanotic Srenzng/tanning Texture: Smooth Rough Turgor. UGoocl rai] Poor ‘Temperature: Llwarm(] Cool Moisture Ory ICiemmyC Oily CO Lesions: Ci Primary CiSecondery | (Vascular [Becema:O Pitting C1 Non-ptting utzorstion Buuidate Tyoe) noneC serous 1 serosanguinous [purulent fou puruient Surrounding Shin: C) plakiskin tone Ci redeiehibianchabie [1 whitefpallor 1 purple Ciblack | Nails well trimmedC jagged edges CG Paronychia kollonychia NOTES til, Head ‘Configuration: CiNormocephatic Oitasses Fontanelles: (Closed LI Open 1 Sunken Bulging skutt-"Isymmatrical!IDstomitios 1 Depression I umes Tenderness Scalp:(ICleen() Dandruff] Lice Ctesions Hair) Normal distribution open (Final) Coase Cory Dolly Clinfestation Hirsutism Face:_] symmetrical movements ‘asymmetrical movements involuntary movements paralysis D edema Ci masses | Muscve strenath of Jaw: normal W. Eyes ‘Strucwure: Eyebrows: Cl aignes scaly symmetrical movements Clasymmetrical movements Lids Asymmetrical EdemalIPtcsis | Lashes: Cjeuried inward (jeuies outwars Lacrimal Duct normal Cl sweling Llexcossive tearing aty Goren & Lara TSnonth Ciciear Lesions (]Opaciiy Arcus Seniis Gonjunctiva: lPinileh Li Pale Ci Lesion Periorbital region:=] Edema sunken - LIDiscooration Seleray} Anicterc icteric. Bloodshet PupitClisecone L1 arisocose easton to ight: ‘OD: Brisk C)Slusgish Fixed | 0:51 Brisk (1 Slugaish(7 Fixed | Reaction fo accommodation norm Urea ome EH normal () nystagmus Convergence:!duntform Ciunequat Visual Acuity:CIGrossiy normal [With Correctivelanses Funetional Vision jcouniing fingers Biriand movement ilight percostion Visual fields "Ihomonymcus hemiancpsia [1biemperal hnemianopsia Hguacrarticcticcts | V. Ears: Pinna: LJ Normoset Cisymmetrical CiTendemess External Canal{_Jimpacted oerumen Cobischarge: C] Foul smeling CF Serous D Puruient Mucsic Tympanie membrane: (optional peary-aray [1 pinkish, Hearing acuity:CInormal C Deaf Vi.Nose Nasolabial Fal |Symmatrical saymmeteel Septum: maine CiSewated Perforated MucosaCJPiniish LiPaleCIRecsish Ty Blood Crusis Ljulcoreton bisctatge L} Serous Lure (Beas Goce Ci decreased | _Pateney:(1Boin Patent Obstructed Lesions 1] Sinuses:ClNon-tender ClTende: Vil. Mouth Lips: Ol Symmetrical Asymmetrical Colne Pinkish Patel Cyanotic Moisture: CIMcist C] Ory/Crack Lesions [] Tongue: 0 widtne Opeviation Datrory Cl Faseieuation hesions : Ci Compiete CI missing dentures 1 Braces LJ Caries Cbiscoleration Gums: CPirkish Cale Bleeding render Mucosa LlPinkish [Patel loyanotic Desion Palate: LJPinkish C1 Pale (Reddish Vill. Pharynx Uvula: C1 Midline CI Deviated Mucosa: C1] Pinch LI Pale CO Reddish C swelling [] uiceraton Tonsils: (Not inflamed CJ inflamed Gag Reflex: (1 Positive 1 Negative SSweting 1X. Neck ‘Trachea: (J Miaiine C] Deviated Tyinph osiens [1 sanpaipatio Paipable/entarged (I Tender TH NonpalpaslelEnirged Ctender (Brat ROM:CI Nomeal IR Sogular Vatn Dlstenton: Ciprecent(labsert Muscle Stone: normal Cdocreased Thyroi (1 Thorax ‘Shape: syinmeticat ‘Asymmetrical Cieatrai Chest [Pigeon Chast (Funnel Chest ‘Spinat alignment: C1] Normal | Abdetormed | Others: Cl. suigos L] Tendornoss Oesion Breathing Pattern: Effortless C] Bradyprea Drecnyprea C1 byspnea lyperventilation Hypoventilation Use of accessory muscies Chest skin turgor: _) poor] good Respiratory Excursion: ymmetrical | _ Casymmettigal TT increases CiDecreass Porcursion:LJResonart [Dull | Oltyperesonant Diaphragmatic excursion: RUL(cm) Breath soande[_] Bronchial Vesicular -N ( Bronchovesicular Aaventiious Breath Sounds: TO wheeces CO RalesiGractlos Crone Friction Rub | X. Heart Precordium: C] Normodynamic Tenderness Heave - Srna Heart Sound: Distinct Faint fone eS Feet Pulrone El Tess OO acl OOO Extra sounds: [] $3014 mur y Pulse: Temprrat CI thready Cl Weak © strong” C1 Absent | Carotid: Thready =D) Weak Csiong Absent ‘Apical: Regular] regular Brachial Cl Thready C) Weak Strong) Absent | Radial: 1) Thready [) Weak | Ci strong Absent Popiteal 1) Thready [) Weak i strong Absent Dorsalis Podis: CIthresdy C1 Weak C1 Sitona ‘Absent Posterior Tibie: Lithready C1] Weak Cl Strong LT Absen Calf Tenderness (Homan's Sign): Right C1 Positvel] Negative _tet C)Positive Negative XL Breast Size and Symmetry: C] Equal iunequal Contow: CI] Masses C1 Oimpling ‘Skin: OiRednoss Cledems Tender vess: _ITerder ONon-tender Nipple nd Areola Linversicn Cretraction edema Cer Discharge: serous [1Purulent Cs Citucoid O1 Bloody | Tactile Fremitus: [1 Symmetrical || | Xi. Abdomen Skin: LT inact Cisiriae C1 Scars ClLesions Contour: (Fiat CiGiobutar Cobistended Abnormalitioe: Civtasses Civisible peristaltic wave [Visible pulsations Cisiadder cistention Bowel Sounds Cl Nermoactive Dltyperactive -35/r Friction rub: C1] Absent LiPrecent Percussion: [Itympanitic Cortypertympanitic. Liver Size: MCL & MSL) Bladder C1 Paipatie ‘palpable Ascites: [Positive C] Negative Palpation: Llussle guaraing Cifendemess Female Puble Hair: Cl normat Oseanty Labi: D symmetrical Ciasymmetrical lesions Geinkish Caiscooration Dedema Vegine ischarge: Curent loody FFout-smeting Others: Dswating Dtumos/ nodules mae oo Penis] Welk-developed Cliesions Co Tencerness Cibischarge: ‘rurutent Bstocdy Drout-smeting Meatus: CMidine Clepispadia CHypospat Scrotum: 2 symmetrical ymmatreal Clesions (rendermess Enlargement © eryptercnaism | Others: LJHemia Diyérocete