Head is symmetrical, round, and erect. No indentation. Head is in the midline. Normocephalic.

No presence of lesions, scars, breaks, flaking, dandruffs, infestations, dry patches, edema,
enlarged masses, and alopecia. Scalp is pinkish in tone. No droopings in the face. Face is
symmetric. No signs of Bell’s Palsy. Visible dark spots in the face. Symmetric facial movements.
No tenderness on the temporal and masseter muscle. No elevated masses noted. No
numbness on the face. Temporal muscle is elastic and not tender. No tenderness and clicking
sound on the temporomandibular joint.

Eyes are symmetrical. No signs of thinning of eyebrows and eyelashes. Eyeballs are symmetric
and equal size. No swelling and visible lesions and redness in the eye. Outer canthus of the
eye is aligned to the ear. No pallor, redness, and inflammation in the conjunctiva. No visible
discharge. Both pupils are equally round and reactive to light and accommodation. Eyes are
able to change focus and accommodate. Passed the corneal reflex test.

No discoloration on both ears. No lesions and scars. Equal in size bilaterally. Not swelling. No
inflammation and obvious cerumen visible. Aligned from the outer canthus of the eye, 10° ,
vertical. 3 piercing holes on the right ear noted (2 lobules, 1 helix). 4 piercing holes on the left (1
conch, 1 tragus, 1 lobule, 1 helix). Not swelling and no enlarged mass at the auricle and mastoid
process. Firm and not tender. No bumps, elevated mass, excessive cerumen and foreign objects on
the auditory canal.

Nose is symmetrical. No visual discharge. Nasal septum is in the midline. Equally distributes the
nasal cavities. No dryness and bleeding. No tenderness and displacement of bones. No
discoloration and elevated mass. No tenderness in the maxillary sinuses. Olfactory nerve
functioning. No abnormalities on smelling capabilities. No signs of swelling, dryness, bleeding, and
foreign bodies in the nasal cavities. Mucosal lining is pinkish.

Lips are symmetrical and well-defined. Smooth and evenly curved. No irregularities. Pinkish. No
visible fissures and signs of swelling. No lesions around the mouth and discoloration. 28 teeth. 1
wisdom tooth on the right about to protrude. Normal bite. No dental caries. Gums, buccal mucosa,
hard and soft palates, gingival tissue are pinkish, turgid, moist, and glistening. No bleeding and
lesions. Tongue has no fissures. No elevated mass and pinkish in tone. No enlargement of the
tongue noted. Smooth palate, light pink and smooth. Hard palate, more irregular texture. No
enlargement of the tongue noted. Smooth palate, light pink and smooth. Hard palate, more irregular
texture. No enlargement of the tonsils. Grade 1+ tonsils. Uvula moves up and vibrates as the patient
talks. Uvula is in the middle. No swelling in the uvula. Vagus nerve is functioning. Involuntary
movement or contraction of the soft palate and pharynx. Glossopharyngeal nerve is functioning,
good tongue strength. Anterior and posterior tongue functioning.

Neck is symmetric, with the head centered. No lesions and discoloration. No bulging masses,
swelling, and inflammation. Has smooth, controlled, full range of motion of neck. Thyroid gland
non visible but palpable when swallowing. Trachea in midline. Lymph nodes nonpalpable. No
elevated mass and tenderness. No enlargement of the thyroid gland and tenderness. No
swishing sound on the auscultation of the carotid artery. Carotid pulse equal bilaterally, 4+,
hyperactive.
POSTERIOR THORAX
No discoloration on the posterior thorax. No nasal flaring and pursed lip breathing noted.
Scapulae are symmetrical. No protrusions. Shoulder and scapula are horizontally equal. Thorax
is oval. Spinous process appears straight and the thorax appears symmetric. No use of
accessory muscles when breathing. No tenderness and unusual sensations. Equal
temperature bilaterally. No lesions and masses. Fremitus is symmetric and easily identified in
the upper region of the lungs. Resonance tone percussed in the lung area. Flat tones in the
scapula. Dullness on the lower part, organs. Bronchovesicular sound around mid-posterior
chest in the bronchi area. Vesicular sounds in the lung area. No adventitious sounds
auscultated. Negative on bronchophony, egophony, and whispered pectoriloquy test.

ANTERIOR THORAX
Anteroposterior diameter, less than transverse diameter. Respiration 17 bpm, effortless and
even. Sternum at midline and straight. No sternal retractions noted. No retractions and bulging
of intercostal spaces. No use of accessory muscles. No tenderness upon palpation. Tactile
fremitus symmetric. Percussion tones resonant over all lung fields. Flat tones on the clavicle.
Dull tones on breast, heart and liver area. Tympany on stomach. Vesicular breath sounds
auscultated over lung fields. Bronchovesicular breath sound on mid-chest. No adventitious
sounds present. Negative on bronchophony, egophony, and whispered pectoriloquy test.

HEART AND NECK VESSELS

No distention, bulging, or protruding jugular veins. No visible pulsations. Apical heart rate
auscultated 90 beats per minute. Within normal range. S1 and S1 auscultated and clearly
heard. No splitting of heart sounds, snaps, clicks, or murmurs were noted.

ABDOMEN
Skin of abdomen is free of striae, scars, lesions, or rashes. Color of abdomen lighter than the
general skin tone. No presence of spider angioma. No signs of Jaundice, Cullen's sign, Ascites
and Grey Turner’s Sign. Umbilicus is midline and recessed with no bulging. No visible
discharge on the umbilicus. Abdomen is round and symmetric with no bulges or lumps. No
visible peristaltic wave and abdominal/aortic pulsation. Abdominal girth measures ___.
Auscultated normoactive bowel sounds. Loudest at right lower quadrant. No bruits over the
abdominal aorta, renal, and iliac arteries. No presence of an abdominal venous hum. No friction
rub. Percussed tympany sounds at the left upper quadrant. Dull tones at liver and spleen area.
Majority of sound percussed at the abdominal area, tympany. Liver size at the middle, 6 cm. Tail,
4 cm. Spleen size, 4 cm. No tenderness upon blunt percussion. Upon light palpation, no
abnormal masses, lesions and pain. Upon deep palpation, mild pain is felt. No elevated /bulging
masses. No tenderness upon palpation of liver. Spleen hard to palpate (seldom palpable).
Urinary bladder, not distended. Negative to Blumberg’s Sign, Rovsing Sign, Psoas Sign,
Obturator and Hypersensitivity test.
Extremities
Forearms and hands are fair and equal to the general skin tone. Symmetric. Warm to touch
bilaterally. Capillary refill time less than 2 seconds, radial and brachial pulses strong bilaterally.
Ulnar pulse is hard to palpate. No epitrochlear lymph nodes palpated. Palms refill within 3
seconds. Negative Phalen’s test. Full smooth ROM on shoulder, elbow, wrist,
metacarpophalangeal, hip, knee, ankle, and metatarsophalangeal joint. Popliteal pulse palpable,
3+. Upon palpating 10 cm above, no tenderness and nodules noted. Muscles are firm. Negative
to Bulge and Ballottement, and Mcmurray test. Upon palpating tibiofemoral space, no
tenderness and crepitus noted. Hips are symmetrical. Normal curves of thoracic and lumbar
spine. Hips are stable, non-tender without crepitus. Knees are symmetric, smooth, rounded, and
hollows present on both sides of patella. No visible lumps. Lower leg in alignment with the upper
leg. Patella centered. Quick involuntary extension of lower leg upon knee jerk test. Toes point
forward and lie flat. Toes and feet aligned with the lower leg. Gait smooth, rhythmic and
coordinated. Foot placement accurate. Feet free from corns and calluses. Symmetrical
bilaterally. No tenderness upon palpating ankles, feet, and toe. Posterior tibial and dorsalis pedis
both palpable. No pain and crackling sound on metatarsophalangeal joint. No tenderness on
plantar area.