c
 
 

mY The patient is conscious, well-oriented of his present condition and showed interest with the interview by
answering every question instantaneously.
mY The patient͛s Vital Signs are normal with a temperature of 37.3 centigrade, pulse rate of 84 beats per minute,
respiration rate of 20 breaths per minute and blood pressure of 120/60.
mY upon receiving the patient, the patient was pale-looking and complains of pain on both lower extremities. But
at the moment, the patient is looking good with no complaints of pain at all.
mY The patient has no obvious physical deformities or abnormalities.
mY The patient showed no sign or potential signs of distress.
mY physically, the patient͛s nutritional status and body built/stature is appropriate to his age.
mY The patient is relaxed, has an erect posture and coordinated by body movements, can freely move, flex and
extend his extremities, doesn͛t use any assistive device and can voluntarily move.
mY The patient has a good facial expression without grimacing.
mY The patient͛s mood is appropriate to the situation, has appropriate response, comfortable and calm.
mY The patient is understandable, and moderate in pace.
mY The patient physically looks clean and neat.

     


mY SKIN
The patient͛s skin is uniformly brown in color except in areas exposed to the sun, has no lesions, edema or abrasions,
is not moist because of the air ventilated environment, has uniform temperature, and when pinched, the skin springs
back to the previous state. The tissues surrounding the nails of the patient are intact. And when blanched test
performed, color of the nail of the client returns into pink in less than 4 seconds.

mY Ñ AD AND FAC
The patient͛s scalp is lighter than the color of his skin and has no areas of tenderness. The hair is evenly distributed
and is thick. The patient has symmetric facial movements.

mY

The patient͛s eyebrows have evenly distributed hair, has intact skin, symmetrically aligned, and has equal movement.
The conjunctiva is transparent, capillaries sometimes evident, and sclera appears white and clear. The cornea is
transparent, shiny and smooth, details of iris are visible. The iris is brown, flat and round. The patient͛s visual acuity is
normal.

mY AR
The patient͛s external ear canal is dry, has presence of hair follicles, no pus or blood. Normal voice tones are audible
to patient. Sound is heard on both or localized at the center of the head. ar is without masses.

mY NOS
The patient has no tenderness on sinuses. The nose is in the midline, has no discharges, no nasal flaring, both nares
are patent, and no bone and cartilage deviation noted on palpation.

mY DOuTÑ AND TÑROAT

The patient͛s buccal mucosa is uniformly pink in color, moist, smooth, soft, glistening and elastic in texture, and has
no lesions. Teeth are white to yellowish in color, gums are pink, moist, firm, has no retraction and bleeding of gums.
Tongue is pink, has thin whitish color. uvula is positioned in the midline of soft palate. The tonsils are pink in color,
and have no discharges.
mY N CK
The trachea is on central placement in the midline of the neck, spaces are equal on both sides. The thyroid gland is
not visible in inspection, gland ascends during swallowing, no masses palpated.

mY CÑ ST (pOST RIOR AND LAT RAL)

posterior thorax is asymmetric, ribs are sloped downward, and muscle development is equal. Spines are slightly
aligned, are uniform in temperature, have no tenderness and masses. Chest is symmetric upon expansion.

mY CÑ ST (ANT RIOR)
Breathing pattern is quiet, rhythmic and effortless. Chest is symmetric upon expansion, has flat sound on the part
with heavy muscles and bony prominences, tympani on the stomach, dullness on the liver and spleen,
bronchovesicular and vesicular.

mY Ñ ART
The patient͛s heart has no palpable pulsation over the aortic, pulmonic, and mitral valves, no noted abnormal heaves,
and thrills felt over the apex, and no abnormal heart sounds is heard like murmurs.

mY upp R TR DITI S

Both extremities are equal in size, have the same contour with prominences of joints, no involuntary movements, no
edema, color is even, temperature is warm and even, has equal contraction and even, can perform complete range of
motion, no crepitus noted on joints, and can counter act gravity and resistance on ROD.

mY ABDOD N
The patient͛s abdomen skin color is uniform, no lesions, have scar, flat, rounded, no tenderness noted, with smooth
and consistent tension, and has no muscle guarding.

mY LOW R TR DITI S

Both extremities are equal in size, have the same contour with prominences of joints, no involuntary movements, no
edema, color is even, temperature is warm and even, has equal contraction and even, can perform complete range of
motion, no crepitus noted on joints, and can counter act gravity and resistance on ROD.

mY DuSCuLOSK L TAL
The patient͛s muscles are bilaterally symmetric, has no contractures and tremors, normal muscle tension, adequate
strength of the muscle. The bones are uniform in structure, no deformities, tenderness or edema. Joints are not
tender, has smooth movement and no nodules.

mY ANuS, R CTuD AND pROSTAT

(NOT ASS SS D)