The patient was seen lying in bed. Alert, relaxed, well-groomed.

Not in cardiopulmonary
GENERAL SURVEY
distress. Speaks fluently and clearly in soft, low voice.
Blood Pressure : 130/70 mmHg
Respiratory Rate : 23 breaths/minute
Pulse Rate : 66 beats/minute
VITAL SIGNS
Temperature : 36.1 degree Celsius
SO2 : 94%
Pain : 5/10
Slightly erythematous exocriation on right infraorbital rim. No bruises, pigmentations and
color change. No clubbing of fingernails. Nail beds appears as brownish in color and
SKIN
hardened in texture. No cyanosis. No ecchymoses and petechiae. Warm to touch. With
Good capillary refill.
HEENT
HEAD Rounded, atraumatic and symmetrical, smooth and has uniform consistency. Hair with
average texture. Absence of nodules or masses.
Grossly normal. No redness. Watery discharge noted bilaterally. Arcus senilis bilaterally.
EYES Eyelashes - Hair evenly distributed with skin intact.
Eyebrows - Symmetrically aligned and have equal movement.
Eyelids - Skin intact, no discolorations.
Bulbar conjunctiva – Pale.
Palpebral conjunctiva - Pale.
Sclera – Anicteric.
Pupils - Pupils are equal, round, reactive to light and accommodation constricting from
4mm to 3mm
Visual acuity test - OD 20/30 OS 20/25
No skin tags or any ear deformities. Mastoids not tender. Otoscopic finding: Tympanic
membrane intact but slightly visible with bilateral hardened cerumen; Cone of light not
EARS
seen. No bulging, effusions or bubbles. Rinne test: AD AC>BC AS AC>BC; Weber test:
No lateralization; Symmetric hearing.
No lesions or deformity noted. Symmetric and straight in shape. No swelling. No
inflammation cysts, or tumors noted. No ulceration. No flaring, uniform in color, air moves
NOSE freely as the patient’s breath through the nares. No discharge. Nostrils patent. Vestibule
unremarkable. No septal deviation, unremarkable mucosa. No hypertrophy of inferior
turbinates. No rhinorrhea. No masses. Slightly prominent vessels bilaterally.
Transillumination test unremarkable.
Teeth, gums, alveolar ridge unremarkable. Buccal, palatal, lingual mucosa and vestibule
unremarkable. Uvula in the midline. Tonsils symmetric, not enlarged and no exudates and
masses. No erythema, exudates and purulence in the posterior pharyngeal wall. Tongue
THROAT AND MOUTH
in midline, no fasciculation and atrophy with whitish plaques on the surface, no redness or
bleeding upon scraping the whitish plaques. Floor of the mouth unremarkable. No masses.
Salivary glands unremarkable. With dental carries carries.
Coordinated, smooth movement with no discomfort. No cervical lymphadenopathy.
NECK
Trachea midline. Neck supple; thyroid isthmus midline, thyroid not palpable.
Breasts symmetric and not enlarged without nodules or masses. Areola dark-brown
BREAST
Nipples without discharge and tenderness
No gross deformity. No intercostal, subcostal or rib retraction. Symmetrical chest
expansion. Platypnea noted. Chest expansion and vocal fremitus were equal anteriorly
RESPIRATORY and posteriorly at all three zones of the lung. Lower lobes dull bilaterally and resonant on
other lobes anteriorly and posteriorly. Crackles at lower lung fields bilaterally.
No tenderness. No pectoriluqoy. No egophony. No bronchophony.
Jugular Venous Pulsations at 6 cm above sternomanubrial joint while patient is lying
supine at 30-degree bed elevation. Carotid pulse is brisk, no bruits. Adynamic
CARDIOVASCULAR
precordium, PMI (1cm) at left 5th ICS, mid-clavicular line. Distinct S1 and S2, no S3 and
S4. Without heaves and thrills.