ASSESSTMENT FINDINGS

SKIN With dry skin, yellow discoloration of skin

from upper abdomen through toe
HAIR Evenly distributed

NAILS Capillary refill time of 4 seconds, yellowish

nails
FACE Normocephalic and symmetrical.
Absence of nodules or mass

EYEBROWS Symmetrically aligned and have equal

movement
EYELASHES Equally distributed and curled slightly
outward
EYELIDS Skin intact with no discharges and no
discoloration
BULBAR CONJUNCTIVA Transparent with capillaries slightly visible
PALPEBRAL CONJUNCTIVA Shiny, smooth
SCLERA Appears white
LACRIMAL GLAND No edema or tenderness & no tearing

CORNEA
CORNEAL SENSITIVITY Blinks when the cornea is touched through a
cotton wisp.
PUPILS Equally rounded and reactive to light
VISUAL FIELDS
VISUAL ACUITY Patent was able to read with eyeglasses

EARS AND HEARING

Auricles Color is same with face, non-tender
External ear canal Without impacted cerumen
Hearing acuity test Voice sound audible

NOSE AND SINUSES

EXTERNAL NOSE Without impacted cerumen
NASAL CAVITY Mucosa is dark in color, no lesions
MOUTH & OROPHARYNX Pale and dry lips, brown gums, able to purse
lips
TEETH Yellowish in color and missing teeths
TONGUE & FLOOR OF THE MOUTH Central position, dry
TONGUE MOVEMENT Moves when asked to move without
difficulty and without tenderness
UVULA Positioned midline of soft palate
GAG REFLEX Positive reflex
NECK Positioned at the midline without tenderness
and flexes easily. No masses palpated
HEAD MOVEMENT Coordinated with no discomfort
MUSCLE STRENGTH With equal strength
LYMPH NODES Non-palpable
THYROID GLAND Not visible on inspection

THORAX AND LUNGS

SPINAL ALIGNMENT
BREATH SOUNDS
ANTERIOR THORAX
ABDOMEN
ABDOMINAL MOVEMENTS
AUSCULTATION OF BOWEL SOUNDS
UPPER EXTREMITIES
LOWER EXTREMITIES
MUSCLES
BONES AND JOINTS
Vertically aligned
Crackles with dyspnea
Labored respiration
Symmetric contour, slightly distended
Symmetrical movements caused by
respiration
Scar at upper right shoulder
With no scars
Equal size in both sides of the body.
No swelling, slow joint movement

MENTA STATUS
LANGUAGE Can express oneself by speech
ORIENTATION Oriented to place, person, time and date
ATTENTION SPAN Able to concentrate
LOC GCS-15