Head: Normal shape and size.
Ear: Normal shape, and size normal external meatus normal tympanic, membrane, and hearing no. Ear wax.
Nose: Normal shape No discharge, No bleeding, per nose Nasal septum, midline.
Eyes: Normal shape, and size. No edema pink, injected, conjunctiva not, to react light, both eye anicteric sclera.
Mouth: Normal shape No oral ulcer Dry,,, Mouth.
Throat:Trachea on midline No mass, abnormal, palpable, not lympnode Normal thyroid glands No jugular, vein engorged.
Chest and. Lung: normal chest transverse Lung expend equally, no retraction normal tactile
Fermatas no lung, sound.
Heart: PMI. At Ics 5th, and MCL Normal S1 S2 Heart rate, 98 / min regular no murmur
Abdomen: Distended and fatty abdomen. No operative. Scar no abdominal mass,,No, tender no
quarding and rigidity. Shift aullness and fluid thrill positive bowel sound, 12 / min
Skin: No lesion no,, Mass
Skeletal and muscle: Normal shape, and size no edema
Anus and Genitalia: No hemorrhoid no edema Normal shape,,, And size
Neurological: conscious stupor pupil 2, mm.
: GCS score 15 E4V5M6
Motor power: Arms for right - left of both. Grade, 5Thigh for right - left of both grade 5
.
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