EYES  Symmetrica  Eyes are symmetrical All of the findings

l  Hair evenly distributed; for the eyes are

 Equal eye skin intact found to be within
lashes distribution  Eyebrows symmetrically the normal range.
 Eyebrows are aligned
symmetrically aligned
and evenly distributed  Equal movement
 Equal movement  No discharge, no
 No discharge, no discoloration of eyelids
discoloration of eyelids  When lids are close,
 When lids are sclera is not visible
close, sclera is not  Sclera is white
visible  Pink conjunctiva
 Sclera white  No edema or tenderness
 Pink conjunctiva over the lacrimal gland
 No edema or tenderness
over the lacrimal gland
EARS  Symmetrical  Symmetrical All of the findings
 Color same as facial  Color same as for the ears are
skin facial skin found to be within
 Aligned to the inner  Auricle aligned the normal range.
canthus with other canthus of the
 No lesions eye
 Firm and  Absence of lesions
not tender  Firm and not tender
NOSE AND  Symmetrica  Symmetrical All of the findings
SINUSES l  No discharge for the nose and
 No  Absence of nasal sinuses are found
discharges flaring to be within the
 No nasal  Uniform in color normal range.
flaring  Nose is non-tender
 Uniform in color  No lesions

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  Not tender  Pink mucosa
 No lesions  Nasal septum intact and
 Pink mucosa in the midline
 Nasal septum intact  Sinuses are not tender
and in the midline
 Sinuses are
not tender
MOUTH  No tooth yet  Tooth hasn't yet All of the findings
 Lips is soft, erupted for the mouth are
moist and has smooth  Soft, moist, smooth found to be within
texture texture of lips the normal range.
 Gums is  Uniform pink color
pink of gums, tongue and
 Tongue is tonsil
pink
 Tonsil is pink at the
middle  Moist and slightly
 Moist and slightly rough tongue
rough tongue  Smooth tongue
 Smooth tongue base
base  Light pink, smooth
 Light pink, smooth soft palate
soft palate  Light pink hard
 Light pink hard palate
palate  Uvula is positioned
 Uvula is in the midline of soft
positioned in the palate
midline of soft palate
THROAT AND  Uniform in color  Generally uniform in All of the findings
NECK color for the throat and
 No palpable lymph  No palpable lymph neck are found to
nodes nodes in the be within the

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  Neck can move  Neck can move freely normal range.
freely
BREAST AND  Skin is smooth and  Skin is smooth and All of the findings
AXILLA uniform in color uniform in color for the breast and
 Symmetrical breast  Symmetrical breast and axilla are found to
 Symmetrical axilla axilla be within the
 No tenderness  No tenderness normal range.
 No secretion  No secretion
 No masses or  No palpable masses
nodules or nodules

CHEST & RES-  Skin is intact  Intact skin All of the findings
PIRATORY  Regular interval in  Regular pattern of for the chest and
breathing breathing the respiratory are
 No lesions  Absence of tenderness, found to be within
 No tenderness lesions and palpable the normal range.
 No masses masses
 Shoulder height is  Symmetrical shoulder
symmetrical height
 No observed  Absence of dyspnea and
difficulty in breathing. has regular depths of
There equal rise and respiration
fall of the chest with
regular depths of
respiration.
CARDIOVAS-  Apical pulse:110  Apical pulse is All of the findings
CULAR AND bpm palpable for the
PERIPHERAL  No cold extremities  Absence of cold cardiovascular
and discolored extremities and are found to
extremities  No discolored be within the
extremities normal range.
ABDOMEN  Uniform skin color  Uniform in color All of the findings

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 in the abdomen
 Symmetric contour 
 Rounded
 No lesions
 No tenderness
REPRODUC-  Not assessed
TIVE
MUSCULO-  Uniform in
SKELETAL skin color
 Mobile
 Equal size
on both sides of the
body
 No
deformities noted
 No fractures  Absence of swelling
and dislocations noted
 No
tenderness and swelling
 Does not
have tremors and
palpable nodules
 10 fingers
and toes
ENDOCRINE  Rapid weight gain
(gained 10.16 lbs in
four months time)
HEMATOLO-  No bleeding
GICAL  No bruises
 Type O
LYMPH  No palpable lymph
for the abdomen
Symmetric contour are found to be
 Rounded or within the normal
protuberant abdomen range.
 Absence of lesions
and tenderness
 Not assessed Not assessed
 Uniform skin color All of the findings
 Smooth coordinated for the
movements musculoskeletal
 Equal size on both sides are found to be
of the body within the normal
 Absence of deformities, range.
fractures and dislocation
 Absence of tenderness
 No tremors
 No palpable nodules
 Gradual weight gain Infant 0-6 months
old should gain 0-
2 lbs per month.
 No bleeding Normal findings.
 No bruises
 Blood Type
 No enlarged lymph Normal findings.
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NODES nodes nodes
 No tenderness  Not tender
noted

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