1.

Head Normocephalic appearance, symmetrical in shape, no presence of lesion,

bruising, or swelling palpated in the scalp. Hair is thick and equally
distributed, free from lice and dandruff.
2. Eyes Normocephalic appearance, symmetrical in shape, no presence of lesion,
bruising, or swelling palpated in the scalp. Hair is thick and equally
distributed, free from lice and dandruff.
3. Ears Her ears are symmetrical and aligned with the outer canthus of her eyes upon
inspection. The pinna and external auditory canals are intact. No cerumen
discharge was detected. The patient exhibits hearing impairment, as indicated
by the necessity for significant others and the medical team to approach her
closely in order for her to perceive spoken communication.
4. Nose and sinuses Upon inspection, the nose is symmetrical and positioned in the center. We
observed no nasal flaring during respiration, and the nasal septum remains
intact, positioned at the midline without any deviations. The person does not
experience any pain, and her sense of smell is fully functional. She can
differentiate between scents such as alcohol and coffee.
5. Mouth Lips are symmetrical in shape and have a dark hue, with a red tint due to her
betel nut chewing. With missing back teeth but remaining teeth with a black
stain, gums exhibit a darkened color with no bleeding. The tongue occupies a
central position, the oral mucosa remains moist, and no lesions or sores are
visible.
6. Neck and throat The neck has an intact internal jugular catheter. Upon palpation, there are no
signs of swollen lymph nodes, palpable masses, or stiffness. The examination
revealed no signs of enlargement. Neck with full range of motion.
7. Chest The chest is symmetrical, and the chest wall is intact with no tenderness or
masses. Breathing patterns are regular.
8. Cardiac The Heart beats at a regular rhythm and a normal rate. The cardiac rate ranges
from 60 to 70 beats per minute throughout the duration of the duty.
9. Breast/Chest The breast is symmetrical in shape. There is no nipple deformity or discharge;
there is no use of accessory muscles during respiration; no palpable
tenderness or lumps are detected; and no pain or discomfort is experienced
during respiration.
10. Abdomen Scaphoid without scars. There is no abnormal tympany. Normal bowel
sounds; no bruits. Superficial and deep palpation without masses. There is no
rebound, tenderness, or rigidity. There are no visible lesions or scars noted.
11. Genitals No difficulty in controlling urine, no burning or pain during urination, and no
rashes, lesions, or discharges were observed.
12. Musculoskeletal No masses under the skin or in muscle joints. There are no lesions or edema,
but the patient needs assistance in moving or standing because of exhaustion
that results in a decreased capacity for physical and mental work. The patient
has limited bed movement and can’t ambulate.
13. Integumentary Skin color is brown, pale, and dry, with darkened areas. No rashes, lumps,
itchiness, or edema were observed. Her hair is short and black, with strands of
white hair. Capillary refill and skin turgor are at 3 seconds, with pale nail beds
and brittle nails.