Physical Examination

Skin:
Inspection: irregularly shaped, erythematous, dusky-red, purpuric macules that
coalesce progressively, morbilliform rashes ,no lumps or nodules noted
Palpation: Warm and smooth with good skin turgor. No palpable
mass, edema and tenderness noted.

Nails:
Inspection: brownish at the distal portion of fingers in both
upper and lower extremities, no clubbing noted and
trimmed fingernails and toenails.
Palpation: Normal capillary refill (< 2 seconds) on both upper
and lower extremities

Hair:
Inspection: Black and evenly distributed with no infestations.
Palpation: Smooth in texture and no infestations noted.
Head:
Inspection: Head is symmetrical, normocephalic , no facial
deformities, no involuntary movement, no visible masses,
no spasms or tics noted.
Palpation: Skull is rounded with smooth skull contour, no
maxillary and frontal sinus tenderness, no palpable
masses noted

Eyes:
Inspection: Eyelashes and eyebrows are absent, eyelids able to
close completely; anicteric sclerae
Right Eye Left Eye

Eyebrows Black color Black color

Equally distributed Equally distributed

Lids Not swollen, no lid Not swollen, no lid

lag lag

Lashes Not matted Not matted

Conjunctiva Pinkish in color Pinkish in color

Sclera Anicteric Anicteric

Cornea Hazy Hazy

Pupils 2-3mm RTL 2-3mm RTL

Palpation: No tenderness, no mass and swelling noted.

Ears:
Inspection: no deformities or lumps in both auricles, no tophi
noted on external ears.
Palpation: Auricles are firm and mobile; no masses and
tenderness noted

Nose:
Inspection: Symmetrical, septum midline and intact, no nasal
deformities, no discharges and no nasal flaring.
Palpation: No palpable masses, no sinus tenderness.

Mouth and Throat:

Inspection: Well hydrated brownish lips, no ulcers on the lips,
pinkish oral mucosa; tongue midline, presence of teeth,
no ulcerations, no dentures, uvula at midline, and
tonsils are not enlarged.
Palpation: No tenderness, masses or palpable lymph nodes
noted.

Neck:
Inspection: Neck is symmetric, no masses or tenderness and no
neck vein engorgement.
Palpation: trachea in midline, no lymphadenopathies noted on
the submental, submandibular, pre/post auricular and cervical
lymph nodes, no mass noted.

Breast:
Inspection: Symmetrical breast and presence of both nipples
noted
Palpation: No palpable masses and tenderness on breasts and
axilla.

Thorax and Lungs:

Inspection: Symmetrical chest expansion, no deformities,
lesions, cyanosis or signs of distress in breathing.
Rate and rhythm are regular.
Palpation: Tactile fremitus are normal and equal on both lung
fields.
Percussion: Resonant breath sounds on both lungs.
Auscultation: Vesicular breath sounds noted on both lung fields,
no wheezing and crackles noted.

Cardiovascular:
Inspection: No precordial bulge, adynamic precordium
Palpation: Point of maximal impulse is tapping at the 5th left
ICS midclavicular line, no palpable dullness was noted
on the 3rd to 6th ICS, no palpable mass, no thrill or
heave
Percussion: Resonance to dullness noted upon percussion from
anterior axillary line toward the sternum
Auscultation: Regular rate and rhythm; S1 is best heard on the
apex; S2 is best heard at the base, no S3 and S4, no
pericardial rubs

Abdominal:
Inspection: Flat; no vein distensions nor striae; symmetric;
scar of about 14 cm on hypogastric region
Auscultation: normoactive bowel sounds at 22 clicks per minute; no
bruit, aortic pulsations, and renal bruits

Palpation: non radiating pain with a scale of 5/10 on the left

iliac region upon deep palpation
Percussion: Tympanitic sound noted on the abdomen

Upper Extremities:
Inspection:Left and right extremities normal in size and
symmetrical. No deformities noted.
Palpation: Warm to touch; no tenderness and masses on both
arms.

Lower Extremities:
Inspection: Equal leg lengths, no fractures, no masses on both
lower extremities.
Palpation: Warm to touch; no oedema on both legs.

NEUROLOGIC:
Conscious and coherent, can speak and can hear well. Patient
was oriented as to person, time, place, and current condition,
responsive to questions and to her external
environment.Appropriate affect, mood, attitude, thinking, memory
and insight.

CRANIAL NERVES:

CN I Sense of smell intact on both nostril

CN II Pupils 2-3 mm reactive to light and accommodation with
normal consensual light reflex
CN Extra-occular movement intact
III,IV,VI
CN V Intact sensation to light touch and temperature on the
3 divisions (ophthalmic,Maxillary,Mandibular)
Able to open and close mouth
CNVII Face symmetric, No involuntary movements noted, no
weakness on the facial muscle of mastication or buccal
mucosa,
CN VIII Hearing normal to whispered voice
CN IX/X Normal gag reflex. Palate elevates symmetrically.
CN XI Intact trapezius and sternocleidomastoid. Able to
overcome resistance and symmetrical shrugging of
shoulders
CN XII No deviation of tongue. Even strength and movement.