BLOOD TEMPERATUR HEART RESPIRATORY HEIGHT WEIGHT BMI

PRESSURE E RATE RATE

170/90 38.6 °C 120bpm 50bpm N/A N/A N/A

mmHg

AREA TO BE ASSESED NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

General Well-developed, Patient is awake The patients

appearance well-nourished, but unable to talk general
appearing stated and shows appearance
age. weakness of her indicates that
right side body. she's
Alert, oriented to
experienching left
time, place, person,
brain attack.
and situation.
Skin  Skin in warm, dry Skin is hot to Due to elevated
and intact without touch. temperature.
rashes or lesions.
Appropriate color
for ethnicity.
Nailbeds pink with
no cyanosis or
clubbing.
Head Rounded Normocephalic NORMAL
(normocephalic),
symmetric, smooth
skull contour,
uniform
consistency,
absence of masses
or nodules
Eyes The eyes are Patients have NORMAL
symmetrically spontaneous eye
aligned in sockets opening with a
without protruding GCS E-4
or sinking.

Ears Tympanic Tympanic NORMAL

 membrane is membranes intact
located in the
middle ear
that transmits
sound vibrations to
the internal ear.
Nose Nasal mucosa is Nasal septum is NORMAL
pink and moist. midline. No
The nasal septum discharge.
is midline. Nares
are patent
bilaterally. no
discharge/bleeding
, swelling,
malformations.
Lips symmetrical, pink,
smooth, and moist.
no growths, lumps,
or discoloration of
the tissue
Neck Jugular is should Jugular venous NORMAL
not be distended pulse not
and pulsation is visualized.
not visible.
Chest Normal breath Mild bilateral Due to difficulty
sounds without inspiratory in breathing.
adventitious murmur
breathing sounds
heard
Abdomen No tenderness, .
relaxed abdomen,
with smooth,
consistent tension.
Bowel sounds are
present and
normoactive in all
four quadrants. No
masses,
hepatomegaly, or
splenomegaly are
 noted.
Extremities Extremities are Weakness in the
atraumatic in right side of the
appearance without body.
tenderness and
deformity. Extremities
are without swelling or
erythema. Full range of
motion is noted to all
joints.