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General Survey: Patient is conscious, coherent, oriented to time, place

and person, looks appropriate for her age, well groomed, medium built, fairly nourished, no signs of cardio-respiratory distress, with the following vital signs: BP: RR: CR: Temp:

SKIN: warm to touch, brown, dry, with good skin turgor, body hair is

short and scanty, nails are pink with normal fold, with petechial rash on both lower extremeties

HEAD: Normocephalic and symmetrical, hair is black evenly distributed,

coarse and dry, no mass, no tenderness. Temporal arteries are palpable but not visible with strong and equal pulsations.

EYES: The patient has thin, black eyebrows evenly distributed, normal
palpebral fissure, no lid edema, no ptosis, negative lid lag test, normally set eye balls, thin black eyelashes, directed outward, no matting, pale palpebral conjunctiva, white sclera, transparent cornea, black iris with regular contour, pupils normal in size and shape equally reactive to light and pupils constrict and eyes adduct during accommodation, transparent lens, positive ROR reflex.

NOSE AND PARANASAL SINUSES: symmetrical, mucosa is pink,

septum in the midline and intact, nasal turbinates are flat and not congested, no tenderness over the frontal and maxillary sinuses.

EARS: Symmetrical, no tenderness, the auditory canals are patent and

with pinkish walls, with scanty brownish materials, tympanic membranes are pearly white and intact with visible cone of light. No visible mass or deformities, No discharges and no bleeding

ORAL CAVITY: Lips are dry. Buccal mucosa and gums are pink with no
signs of swelling, Tongue is normal in size, located at midline, and symmetrical. Hard and soft palates are pink, no lesions; uvula is in the midline, tonsils are not enlarged, slightly hyperemic pharyngeal wall.

NECK: Normal in size, symmetrical, no neck vein engorgement, no mass,

trachea in the midline, Lymph nodes and thyroid gland are not palpable; with fairly developed muscles and with full range of motion.

CHEST/LUNGS: Skin is lighter than the areas exposed, no lesions or

dilated blood vessels, symmetrical, elliptical, no deformities; normal muscle development, regular breathing rhythm, inspiratory phase is longer than the expiratory phase, normal respiratory effort, no tenderness, lung expansion is symmetrical anteriorly and posteriorly, normal tactile fremitus, no abnormal breath sounds heard; vesicular breath sounds over the entire lungs except beneath the manubrium, in the upper interscapular region; test for transmitted sounds was not done

HEART: External jugular veins are visible and palpable, jugular Venous

Pressure is 5 cmH20, carotid arteries are palpable, strong, regular with equal pulsations and soft consistency of walls, precordium is flat, apex beat is located on the 4th ICS 1-2cm from the LMCL, 2 cm in diameter, adynamic, no thrusts, heaves and thrills, cardiac rate is _____ with regular rhythm, no extra heart sounds, bruit and heart murmurs. Nails of extremities are pink, no deformities and lesions, popliteal, femoral, radial and brachial arteries are normal, regular with equal pulsations and soft consistency of walls.

ABDOMEN: Abdomen is flat, symmetrical, fair skin color, flank bulges on

both sides, presence of striae on the right and left lower quadrant, inverted umbilicus, no superficial blood vessels, visible peristalsis, pulsations and masses. Normoactive bowel sounds, 7 bs/min, no bruit, liver span is unable to assess, splenic dullness was not appreciated, (-) shifting dullness and fluid wave, no costovertebral angle tenderness, liver, spleen and kidneys are not palpable, no rebound or localized tenderness and palpable masses.

EXTREMITIES: no gross deformities, full and equal pulses, no cyanosis.


Cerebrum: Patient is awake, coherent, oriented to person and place,

oriented to time, follows command with GCS of 15/15 (E4V5M6)

Cerebellum: can do finger-nose test, can do supination-pronation, can do

heel to shin test, with normal gait, can walk alone and maintain balance and posture.

Cranial Nerves:
I: can identify smell of coffee II: pupils 2-3mm,equally reactive to light III, IV, VI:full and equal extra ocular muscles V: can clench teeth equally, (+) corneal reflex VII: no facial asymmetry VIII: can hear clicking of pen IX, X: (+) gag reflex XI: can turn head on both sides against resistance XII: tongue in the midline

Motor Function:
5/5 5/5 5/5 5/5

Sensory Function:
100% 100% 100% 100%

Deep Tendon Reflex:

++ ++ ++ ++

Meningeal irritation: (-) nuchal rigidity, (-) Brudzinski sign, (-) Kernig sign Pathologic Reflexes: (-) Babinski, Right (-) Babinski, Left, (-) ankle

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