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I. General Data
V. Family History
PHYSICAL EXAM
General Survey
The patient is conscious and coherent, oriented to time, place
and person. He is calm and responds to questions with an appropriate
facial expression, behavior and mood. Has develop medium body and
has no apparent gross deformities. He is clear in speech, ambulatory,
normal in gait, normal in posture, normal in grooming and is not in
cardio-pulmonary distress.
Vital Signs
Temperature: 36 BP: 129/90
PR: 68 RR: 19
Skin
Skin is brown in color, dry, warm, elastic, with areas of pigmentation or
discoloration. Hair is black in color, smooth and well distributed. Nails
are pink with capillary refill.