INTEGUMENTARY SYSTEM YE

S
N
O
REMARK
S
1 Hair is properly kept
2 Scalp hair is of uniform
texture an color
! "ype of hair#
"hick$ thin$ %ne$ strai&ht$
'a(y$ curly$ coarse

) Hair is properly istri*ute
+ ,esions an excessi(e
ryness-oiliness are
present o(er the scalp
. Nails are smooth$ stron&$
roun$ partially
translucent an re&ular
/ 012 Nail eformities
3 Nails$ %rmly attache to
nail *e4 'ith 1.5 an&le
Surface is smooth an
re&ular
6niform in thickness
"ranslucent nail plate$ pink
nail *e
Nails are cut
7 Skin is 'arm
Has &oo tur&or
6niform in color
15 012 Rashes
11 012 S'ellin&
12 012 Eema
1! 012 8lu**in&
1) 012 9iaphoresis 0increase
perspiration2
1+
1.
1/
13
17
25
21
22
2!
2)
2+
2.
2/
23
27
!5
!1
!2
!!
!)
RESPIRATORY SYSTEM YE
S
N
O
REMARKS
1 E:ual an symmetric
expansion of chest
2 Spinous processes appear
GENERAL YE
S
N
O
REMARKS
1 ;t is a'ake
2
;t is fe*rile 0if yes$ inicate
;t<s "emperature2
!
=ith >?@ of 0inicate 'hat >?@
is use$ its rate an 'hat arm
it is attache2

)
RR is 0inicate RR2 0if there is
an a*normal RR reain&$
inicate 'hether it is
tachypnea$ *raynea$ or
apnea incluin& the ;t<s RR2

+
"emperature is 0if you ha(e
alreay put "emp on A2$ then
isre&ar A+2

.
;atient >s in pain 0inicate the
location an intensity2
/ ;t appears his-her a&e
3
Sexual e(elopment is
appropriate for a&e an
&ener
7
,O80,e(el of 8onsciousness2B
0inicate 'hether Alert$
lethar&ic$ stuporous or
comatose2

1
5
Skin color e(en
1
1
Skin intact
1
2
@acial features are symmetric
'ith en(ironment
1
!
012 Skin lesions
1
)
012 Acute istress 0eC&C SOD$
'heeEin&$ nasal Farin&2
present
1
+
Ht appears 'ithin normal
ran&e
1
.
=t appears 'ithin normal
ran&e
1
/
Doy parts look e:ual
*ilaterally an are in relati(e
proportion to each other
1
3
;erson stan comforta*ly
erect for a&e
1
7
;erson sits comforta*ly
2
5
Doy contour is proportion
0inclues arm span that is
approxC e:ual to hei&ht$ an$
len&th from cro'n to pu*is is
e:ual to the len&th from pu*is
to sole2
2
1
012 O*(ious physical
eformities
2
2
Gait is smooth$ e(en an 'ell
*alance
2
!
ROM full mo*ility an is
eli*erate$ accurate$ smooth
an coorinate
1
!
>n(oluntary mo(ements 0eC&C
tics$ tremors$ seiEures2
present
1
)
Maintains eye contact
1
+
8omforta*le an cooperate
1
.
Articulation is clear an
unerstana*le
1
/
9ress is appropriate to
climate$ looks clean$ an %ts
the *oy4 appropriate to the
person<s a&e an culture
HEENT YE
S
N
O
REMARKS
1
Normocephalic$ position at
miline$ erect an still
2
Hea 'ith lesions an
noules
! Hair kept properly
)
Symmetric facial
expressions
+
;resence of facial
'eakness
. Has &oo focus in o*Hects
/
012 Enlar&ement of lymph
noes
3 012 8orneal li&ht reFex
7
Eye*ro's present
*ilaterally$ mo(e
symmetrically
1
5
Eyelashes are e(enly
istri*ute alon& li
mar&ins
1
1
Eye*alls ali&ne normally
in their sockets 'ith no
protrusion or sunken
appearance
1
2
8onHuncti(a is pink
1
!
Sclera is 'hite an clear
1
)
,acrimal apparatus has no
response
1
+
Ears e:ual in siEe
*ilaterally
1
.
Ears< skin color is
consistent 'ith facial skin
color
;resence of tenerness
an has pain 'hen
touche
Reness$ s'ellin&$ lesions$
ischar&e is present
1
/
Nose is symmetric$ in the
miline$ an in proportion
to other facial features
1
3
Nostrils are patent 0no
o*structions2
1
7
Sinus areas are %rm an
no pain
2
5
"rachea at miline
2
1
"hyroi not palpa*le
2
2
2
!
2
)
2
+
EASY G6>9E @OR "HE ASSESSMEN" O@ SYS"EMS ,EGEN9# I isre&ar
checkin&
EASY G6>9E @OR "HE ASSESSMEN" O@ SYS"EMS ,EGEN9# I isre&ar
checkin&
EASY G6>9E @OR "HE ASSESSMEN" O@ SYS"EMS ,EGEN9# I isre&ar
checkin&
EASY G6>9E @OR "HE ASSESSMEN" O@ SYS"EMS ,EGEN9# I isre&ar
checkin&
EASY G6>9E @OR "HE ASSESSMEN" O@ SYS"EMS ,EGEN9# I isre&ar
checkin& @
O
,
9
@
O
,
9
in a strai&ht line
! "horax is symmetric
)
Scapulae are place
symmetrically in each
hemithorax
+
A; iameter J trans(erse
iameter 0normal is 1#2 to
+#/2
.
Relaxe posture 'hen
*reathin&
/
8hest skin color is
consistent an e(en
3 8hest surface has lesions
7
"actile fremitus is
symmetrical on *oth sies
1
5
"enerness$ crepitus$
lumps$ masses o(er the
chest
1
1
=ith Normal ,un& souns
0Assess the *rachial$
tracheal$ (esicular$ an
*roncho(esicular2
1
2
A(entitious soun-s note
B 0inicate location an
name of soun eC&C
'heeEes$ strior$ pleural
friction ru*$ etcC2
1
!
Ri*s are slopin& o'n'ar
'ith symmetric
interspaces
1
)
8ostal an&le is 'ithin 75
1
+
;atient<s facial expression
is relaxe an *eni&n
1
.
;t<s *reathin& is automatic
an eKortless$ re&ular an
e(en an prouces no
noise
1
/
012 Retraction or *ul&in& of
the interspaces on
inspiration
1
3
;t uses accessory muscles
'hen *reathin&
1
7
Normal @ull expiration of
0inicate speci%c time4
normal is ) secs2
2
5
012 8yanosis
2
1
012 Nasal Farin&
2
2
2
!
2
)
2
+
2
.
2
/
2
3
2
7
CARDIOVASCULAR SYSTEM YE
S
N
O
REMARKS
1
8aroti artery is smooth$
an is in normal stren&th
0normal stren&th is 21 or
moerate2
2
Symmetrical stren&th of
*oth caroti artery
!
Druit is note at the
caroti artery
)
;M> is at the 0inicate
'hether it is at )
th
$ +
th
$ or
*et'een2

+
Other pulsations 0thrill or
murmur2 are note o(er
the chest as palpate
.
012 8ariac enlar&ement
0as percusse2
/
Normal HR of 0inicate
patient<s HR4 if no$ inicate
'hether hypertensi(e or
hypotensi(e 'ith the ;t<s
HR2

Rhythm is re&ular
3
012 S1 an clear 0assess at
the apex2
7
012 S2 an clear 0assess at
the *ase2
1
5
012 S!
1
1
012 S)
1
2
012 Murmurs 0if present$
inclue location$ uration$
pitch an stren&th2
1
!
;resence of *ilaterally
e:ual an palpa*le
peripheral pulses
1
)
Normal 8R" of 08apillary
Re%ll "est4 normal is J!
secs2
1
+
1
.
1
EASY G6>9E @OR "HE ASSESSMEN" O@ SYS"EMS ,EGEN9# I isre&ar
checkin&
EASY G6>9E @OR "HE ASSESSMEN" O@ SYS"EMS ,EGEN9# I isre&ar
checkin&
/
1
3
1
7
2
5
2
1
2
2
2
!
2
)
2
+
2
.
2
/
2
3
2
7
EXCRETORY SYSTEM YE
S
N
O
REMARKS
1
;atient has micturate 0if
yes$ inclue the fre:uency$
the output$ an the
characteristics of urine2
2
;atient has efecate 0if
yes$ inclue the fre:uency$
the output$ an the
characteristics of stool2
!
Associate pain 'ith
micturation an efecation
) ;atient is iaphoretic
+
.
/
3
7
1
5
1
1
1
2
1
!
1
)
1
+
1
.
1
/
1
3
1
7
2
5
2
1
2
2
2
!
2
)
2
+
2
.
2
/
2
3
2
7
!
5
DIGESTIVE SYSTEM YE
S
N
O
REMARKS
1
,ips is pale pink$ moist an
symmetrical
8rackin&$ 012 lesions$
*luish in color
2
"eeth is 'hite$ strai&ht$
e(enly space$ clean an
free of e*ris an ecay
!
Gums is pink$ moist$ ti&ht
an 'ellIe%ne
012 S'ellin&$ retractions$
spon&y$ *leein&$
iscolore
)
"on&ue is e(en in color an
pink
Sali(a is present
012 =hite patches$ lesions$
mali&nancies
.
Duccal Mucosa is pink$
smooth$ an moist
/
Har palate is 'hite 'ith
irre&ular trans(erse ru&ae
3
Soft palate is pink$ smooth
an up'arly mo(a*le
7 6(ula in the miline
1
5
"onsil is pink
1
1
"onsils siEe &rae is#
1
1
?isi*le
1
2
Half'ay *et'een
tonsillar pillars an
u(ula
1
!
"ouchin& the u(ula
1
)
"ouchin& each other

1
2
012 Ga& reFex
1
!
012 Halitosis 0Da Dreathe2
1
)
A*omen is 'arm$ smooth
an symmetric$ 'ith &oo
skin tur&or an has e(en
color
1
+
Stomach is *ul&in&$ has
moles$ lesions
1
.
6m*ilicus is in miline$ an
in(erte
1
/
;resence of iscoloration$
inFammation or lesions
1
3
?ascular souns or *ruits
are hear upon
auscultatin& the a*omen
1
7
012 Normal *o'el souns
'hich is hi&h pitche$
&ur&lin& noises
2
5
012 A*normal *o'el
souns 0inicate 'hether
hyperacti(e or hypoacti(e2
EASY G6>9E @OR "HE ASSESSMEN" O@ SYS"EMS ,EGEN9# I isre&ar
checkin&
@
O
,
9
EASY G6>9E @OR "HE ASSESSMEN" O@ SYS"EMS ,EGEN9# I isre&ar
checkin&
NERVOUS SYSTEM YE
S
N
O
REMARKS
1 ;t is full alert
2
@acial appearance is
symmetrical
! 012 soft palate mo(ement
)
Has a*ility to maintain &ait
an *alance
+
Gait is smooth$ rhythmic$
an coorinate
. A*le to focus on o*Hects
/
Re&ars to o'n name upon
hearin& someone callin&
him-her
3
A*le to etermine hot or
col
7
8apa*le of smellin&
*ecause he-she turns a'ay
from foulIsmellin& o*Hects
1
5
;t is 'ellIoriente in time$
place an person$
0sometimes as 'ell as
his-her role2
1
1
1
2
1
!
1
)
1
+
1
.
1
/
1
3
1
7
2
5
2
1
2
2
2
!
2
)
2
+
2
.
2
/
2
3
2
7
!
5
1C
2C
!C
)C
+C
MUSCULOSKELETAL SYSTEM
YE
S
N
O
REMARKS
1
Skin o(er the Hoint is e(en
in color
2
S'ellin&$ masses$
eformity$ tenerness are
note o(er the Hoints upon
palpation
!
Spine is strai&ht an hea
erect
)
Spinous processes an the
sternomastoi$ trapeEius
an the para(erte*ral
muscles are %rm 'ith no
muscle spasm or
tenerness
+
"emporomani*ular Hoints
are nontener 'ith
stren&th of 0inclue muscle
stren&th2
.
Mani*le is symmetrical
an at the miline 0inclue
muscle stren&th2
/ Symmetric neck an hips
3
Extremities are 'arm 'ith
Hoints intact
7
E:ual &rips an stren&th of
*oth palms-hans 'ith
stren&th of 0inclue muscle
stren&th2
1
5
012 Diceps ReFex
1
1
012 Drachioraialis ReFex
1
2
012 "riceps ReFex
1
!
012 ;atellar ReFex or
LkneeIHerkM reFex
1
)
012 Ankle Herk ReFex or
Achilles ReFex
1
+
1
.
1
/
1
3
1
7
2
5
2
1
2
EASY G6>9E @OR "HE ASSESSMEN" O@ SYS"EMS ,EGEN9# I isre&ar
checkin&
@
O
,
9
EASY G6>9E @OR "HE ASSESSMEN" O@ SYS"EMS ,EGEN9# I isre&ar
checkin&
ENDOCRINE SYSTEM
0*ase on functions of hormones2
YE
S
N
O
REMARKS
1 ;atient is iaphoretic
2 Has heat-col tolerance
!
Skin is a*le to perspire in hot
en(ironment
) Skin is thick an ry
+
;hysical &ro'th is normal 0not
ha(in& conitions such as
Gi&antism$ 'ar%sm an
acrome&aly2
.
Has &eneraliEe
'eakness-fati&ue
/ 012 ;olyipsia 0excessi(e thirst2
3
012 ;olypha&ia 0excessi(e
hun&er20if possi*le$ inclue
'hat type of foo2
7
012 ;olyuria 0excessi(e
urination2
1
5
;t &aine 'ei&ht 0*aseline
neee2
1
1
;t lost 'ei&ht 0*aseline
neee2
1
2
;t has a*normal pi&mentations
on skin 0hyperpi&mentation or
hypopi&mentation2
1
!
0>f female2 ;t has irre&ular
menses
1
)
Muscle stren&th is normal
0normal is +2
1
+
Scalp an hair is e(enly
istri*ute
1
.
Hair is shiny
1
/
Speech is rhythmic$ e(en
pace an moerate
1
3
Speech is slo'
0hypothyroiism2
1
7
Speech is rapi
0hyperthyroiism2
2
5
Draycaria 0slo' HR2
2
1
"achycaria 0rapi HR2
2
2
,O8 is alert
2
!
9ecrease ,O8 0lethar&ic or
stuporous2
2
)
Hyperacti(e *o'el souns
2
+
Hypoacti(e *o'el souns
2
.
Has nutritional isorers 0iCeC
anorexia$ *ulimia$ or *in&eI
eatin&2
2
/
;t is irrita*le
2
3
Has hallucinations
2
7
012 Eema
!
5
;t has nocturia
!
1
012 ?isual istur*ances
!
2
012 Hypertension
!
!
012 Hypotension
!
)
012 Hyper(entilation
!
+
012 Hypo(entilation
! 012 Hyperthermia