General Appearance The patient is 47 y/o, female, with a height of 52 and a weighs 55kgs (121lbs).

Patients Posture is erect and steady. Nails skin and hair are well maintained and no visible hair loss. The patient is wearing a hospital gown properly tied. She used slippers when walking around the ward. The patient is well kept no signs of body odor. The patient participates willingly on our interview. Patients speech was clear and with coherence. VITAL SIGN Body Temperature Pulse Rate Respiration Blood Pressure Normal Finding 36.5-37.5 60-100bpm 12-20cpm 120/80mmHg Outcome 36 o C 90 bpm 20cpm 140/90 mmHg Analysis normal normal normal Increase Indicates hypertension

Area Assessed SKIN Color Soles and Palms Moisture Temperature Texture Turgor SKIN APPENDAGES Nails Nail Beds Nail Base

Technique Inspection Inspection Inspection/Palp ation Palpation Palpation Palpation

Normal Findings light brown, tanned skin lighter colored palms, soles skin normally dry

Actual Findings Light brown lighter colored palms, soles skin normally dry

Evaluation Normal Normal Normal Normal normal Normal

normally warm Warm smooth and soft Smooth skins snaps back skins snaps back immediately immediately

Inspection Inspection Inspection

Capillary Refill

Inspection/palp ation

transparent, smooth and convex Pinkish Firm white color of nail bed under pressure should return to pink within 2-3 seconds evenly distributed

Smooth and convex Pinkish Firm white color of nail bed under pressure return to pink within 2-3 seconds evenly distributed and well kept. Black Moderately

Normal Normal Normal

Normal

Hair Distribution

Inspection

Normal

Color Texture

Inspection Inspection/palp

Black Smooth

normal normal

ation EYES Eyes Inspection parallel to each other PERRLA -pupils equally round reacted to light accommodation symmetrical in size, extension, hair texture and movement distributed evenly same color as the skin Blinks voluntarily and bilaterally up to 20x/min. do not cover the pupil and the sclera, lids normally close symmetrically transparent with light pink color color is white transparent, shiny black, constrict briskly clearly visible

rough (wavy hair) Parallel to each other normal

Visual acuity

Inspection (penlight)

PERRLA

normal

Eye Brows

Inspection

Eyelashes

Inspection

symmetrical in size, extension, hair texture and movement Evenly distributed.

normal

Normal

Eyelids

Inspection

No discolorations, blink reflex is present and its proportional to the eyes.

normal

Conjunctiva Sclera Cornea

Inspection Inspection Inspection

Pinkish White coloredTransparent and shiny Colored black and reacts well to the environment. Visible

normal normal normal

Pupils

Inspection

normal

Iris EARS Ear canal opening

Inspection

normal

Inspection

Hearing acuity External part of the Ear

Inspection

free of lesions, discharge of inflammation canal walls pink client normally hears words when whispered free of lesions

free of lesions, discharge of inflammation canal walls pink Client hears words and react normally Free of lesions

normal

normal

Inspection

normal

NOSE

Shape, Size and Skin color

Inspection

Naves MOUTH AND PHARNYX Lips Buccal Mucosa

Inspection

smooth, symmetric with same color as the face oval, symmetric and without discharge

Symmetrical to face and is free of lesions. Oval and does not have discharges.

normal

normal

Inspection Inspection

Gums

Inspection

Tongue

Inspection

pink, moist symmetric glistening pink soft moist slightly pink color, moist and tightly fit against each tooth moist, slightly rough on dorsal surface medium or dull red

moist symmetric Soft, moist, pink, and no lesions Pink, wet, no signs of bleeding and intact. Slightly rough, slippery, and is in place without lesions. Yellowish in color, firmly set, no dentures hard palate is dome shaped and soft palate is light pink Neck is symmetrical and has no masses present. neck moves freely without discomfort Skin same color with the rest of the body With dressings on the Right upper quadrant due to surgical incision

normal normal

normal

normal

Teeth

Inspection

firmly set, shiny

normal.

Hard and Soft Palate NECK symmetry of neck muscles, alignment of trachea Neck Roll Abdomen

Inspection

hard palate -dome shaped soft palate -light pink neck is slightly hyper extended without masses or asymmetry neck moves freely without discomfort

normal

Inspection

normal

Inspection

normal

Inspection

Skin same color with the rest of the body

Post-op Cholecystectomy

EXTREMITIES

Symmetry Skin Color Hair Distribution Skin Temperature Presence of Lesion ROM NEUROLOGY SYSTEM

Inspection Inspection Inspection Palpation Inspection Inspection

symmetrical same with the color of other parts of the body evenly distributed Normally warm no lesions moves freely without discomfort

symmetrical same with the color of other parts of the body evenly distributed warm No lesions

Normal Normal Normal normal Due to present condition

Unable to move freely because of Post op cholecystectomy discomfort

Level of Consciousness

Observation

fully conscious, able to respond to questions, perceptive of events makes eye contact with examiner, hyperactive expresses feelings with response to the situation

Patient fully conscious, able to respond to questions. makes eye contact with examiner, hyperactive expresses feelings with response to the situation

Normal

Behavior and Appearance

Observation

Normal