1. General state
Composmentis client awareness, Vital Sign: BP 110/70 mm Hg, pulse 70 beats / minute, the rhythm was regular strength, respiration 26 times / minute, regular rhythm, temperature of 36.50 C.
2. Physical Examination
Head: normal scalp, there was no hematoma, or gross lesions. Brittle hair while revoked, black and no gray hair, and clean.
Eyes: Eyes clients generally normal, symmetrical shape, looks anemic conjunctiva, sclera jaundice not, pupils can respond to light, normal lid, no edema. Normal eye lens, clear, vision right eye and the left normal. Looks black line on the bottom eyelid clients.
Nose: the nose is symmetrical, no septal deviation, polyps, epistaxis, impaired senses of smell, or secret.
Mouth: mouth normal, normal teeth, no holes, and no dentures. Dry lips, no stomatitis, and no cyanosis. Red gums, tongue looked dirty.
Ears: symmetrical ears, clean, and no hearing loss.
Neck: the neck is normal, no enlargement of the thyroid, no neck stiffness, no hematoma, no lesions.
Throat: normal, no tenderness, no hyperemia, and no enlargement of the tonsils.
Chest: normal chest shape.
Pulmo: Inspection: symmetrical chest expansion. Palpation: tactile fremitus equal right to the left. Percussion: right and left pulmonary resonant. Auscultation: vesicular on the right and left pulmonary
Heart: shows the limits of normal heart.
Abdomen: inspection: slightly convex shape. Palpation: tenderness in the lower abdomen. Auscultation: peristaltic per minute.
Genetalia: Male: normal, no bleeding.
Rectal: normal, no hemorrhoids, no prolapse, and no tumor.
Extremities:
above: Muscle strength right / left: 6/6, ROM right / left: active / active
bottom: muscle strength right / left: 6/6, ROM right / left: active / active
