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I- APPEARANCE & MENTAL STATUS Patient Diamante, years old, appears to be weak, and yellowish skin color is noticeable. (mao ra ni akong na observe ju, he3. paki add nalang
sa katong ingon ni Cyril nga mura daw way klaru ka storya. Wa ko kabalo ato. Thanks.)
II- VITAL SIGNS
III SKIN Patients skin is yellowish in color, and is slightly dry. Poor skin turgor is noted. And spots are observed in patients skin. IV HAIR Patients hair is evenly distributed, and slightly short, just above the shoulders. No infection and infestations. V NAILS Patients fingernails and toenails are yellowish in color. 180 degree angle in curvature. Capillary refill test is less than 2 seconds. VI SKULL & FACE Patients skull is round. No signs of mass upon palpation. (Ju, pls nalang ko
Patients outer lips are reddish in color, and are slightly dry and inner lips are moist. Tongue is in the central position of the tongue, moist, and no presence of nodules. Able to roll the tongue, and move from side to side. No dentures. XI NECK Patients neck muscle is equal in size and has no masses or tenderness. Coordinated movements in moving the head. Lymph nodes are not palpable. XII THORAX & LUNGS Full chest expansion was observed. No abnormal breathing sound upon auscultation. Patients spine is vertically aligned. XIII HEART & CENTRALO VESSELS Carotid artery has full pulsation. And jugular vein is not visible. XIV BREAST & AXILLAE Patients breast is yellowish in color, nipples has no discharges. No tenderness, masses, or nodules noted. XV ABDOMEN Patients abdomen is yellowish in color. Jackson Pratt is attached to the incision site in the abdomen with a bloody red-colored fluid. No masses upon palpation. XVI MUSCULOSKELETAL SYSTEM Patients muscle is equal in size in both side of the body. No muscle tendons and tremors. And no deformities. XVII NEUROLOGIC SYSTEM