Professional Documents
Culture Documents
Physical Examination
Vital signs
BP : 80/60 mmHg
HR : 72 bpm
RR : 24 cpm
Temp. : 36.0 C
Skin : Fair – skinned and palms are cold. Nails without cyanosis
and clubbing
Head : Hair – of average texture;
Scalp – no lesions and normocephalic
Eyes : Visual acuity of 20/30 on the left eye; 20/25 on the right
Visual fields full by confrontation
Conjunctiva pink; sclerae are white.
Pupils are round, regular and equally reactive to light.
Ears : Waxes partially obscure both tympanic membranes. Good
acuity to whispered voice. AC BC. Weber is on the midline.
Nose : No mucosal discharges and sinus tenderness
Throat : Tongue in midline position, inflamed left tonsils with exudates
Neck : Trachea is midline. No palpable mass.
Lymph nodes : Lymph node tenderness on left tonsillar and
both periauricular areas
Thorax & : Inspection: No skin retractions and thorax is
Lungs symmetric with good excursion
Palpation: No palpable masses.
Percussion: Right lung is more resonant than the left.
Auscultation: No wheezing
Cardio : Inspection: No irregular bulging.
Palpation: Apical impulse discrete and tapping, barely
palpable in the 5th left interspace midclavicular
line
Auscultation: It is dynamic without heaves and thrills. Normal
S1 & S2 and no murmurs heard.
Breast : Inspection: No skin retractions, breast is symmetrical, no
nipple discharges.
Palpation: No masses and lymph nodes were palpated.
Abdomen : Inspection: No surgical scars were seen and abdomen is flat.
Auscultation: No irregular bowel sounds were heard.
Percussion: Dull on the right upper quadrant where liver is
located and most of the areas are tympanitic.
Palpation: Spleen and liver are not palpable.
Extremities : No varicosities, edema and it is warm to touch. Calves are non
Tender
Diagnosis : Tonsillitis
Neurologic Examination
CN-IX & X : Has good gag reflex and uvula is in midline position