▸ The level of consciousness is examined by Glassgow Coma Scale (GCS) Score. GCS
Score is contain with 3 components, they are eye, verbal and movements which must be
done by order due to its importance.
Score (E) Eye Response (V) Verbal Response (M) Motoric Response
(Opening)
1 No Response No Response No Response
2 To Pressure (to pain) Incomprehensible Abnormal Extension
sounds
3 To Sound (to speech) Inappropriate Abnormal Flexion
4 Spontaneously Confused Flexion withdrawal from
pain
5 - Oriented to time, place, Moves to localized pain
person
6 - - Obeys commands
▸ Vital Sign
▸ Blood Pressure : 120/80 mmHg, left arm, sitting position, appropriate cuff
size
Systolic blood pressure (the upper number) indicated how much pressure
the blood is exerting againts your artery walls when the heart beats
Dyastolic blood pressure (the lower number) indicated how much pressure
the blood is exerting against your artery walls when the heart is resting
between beats
Pulse pressure is the systolic pressure minus the diastolic pressure. If the
aorta becomes rigid in conditions such as artheriosclerosis or
artherosclerosis, the pulse pressure would be very high.
• Low if its lessthan 25% of the systolic valve, cause may because of
low stroke volume, a sign of congetive heart failure and or
cardiogenic shock.
• High, because of the stiffness of the major arteries failure, aortic
regulation, (a leak in the aortic volume), arteriovenosus
malformation, hypertiroidism, or some combinations of those
illness
Based on JNE 8, the increased of blood pressure can be classified :
Blood Pressure Sistole BP (mmHg) Diastole BP (mmHg)
Classification
Pre Hypertension 120-130 Or 80-89
Stage 1 Hypertension 140-159 Or 90-99
Stage 2 Hypertension >= 160 Or >=100
f. Step ladder fever : temperature rise gradually to a higher level with every
spike so tjat new plateau is higher that precesing of just like step ladder.
g. Pel ebstein fever : in this type, there is a regular alternation of recurrent bouts
of fever and afebrile periods. The temperature may be take 3 days to rise,
remains high for 3 days and remits in 3 days, followed by apyremia for 9
days. Caused by : hodgin lymphoma, TBC
h. Siclic fever : arise in body temperature over several days followed by a fever
free period for a few days then followed by an initial temperature rise.
Example : malaria vivax and ovale
▸ Head
o Head : normocephali (+), trauma (-), deformity (-)
o Eyes : conjungtival anemi (-/-), icterous sclera (-/-), pupil siochor (+), red eye (-
/-)
Red Eyes
o Nose : deformity (-), secrete (-/-), septal deviation (-), trauma (-), inflammation
(-), nasal flare (-)
o Ears : normotia (+/+), secrete (-/-), inflammation (-), cerumen (+/+)
o Mouth : sianosis (-), drymouth (-), hyperemic mucous (-), Tonsil T1/T1, muscle
paralysis (-)
o Neck : lymphnode enlargement (-), skin decolorization (-), JVP (5±2), mass (-),
scar (-)
E
D
F
▸ Thorax
Cor
• Inspection : deformity (-) scar (-) ictus cordis (-)
• Palpation : ictus cordis is palpable on ICS V linea midclavicula sinistra
• Percution : cor enlargement (-)
• Auscultation : s1-s2 regular (+) heart murmur (-) s3 gallop (-)
Lung
• Inspection : simetrical movement (+) use of acessory muscles (-) trachea
deviation (-)
• Palpation : tactile fremitus (-) movement (-) pain (-)
• Percution : sonor
• Auscultation : vesicular sound (+/+) ronchi (-/-) wheezing (-/-) crepitation (-/-)
▸ Abdomen
• Inspection : swelling (-) scar (-) inflammation (-)
• Auscultation : intestinal murmur (n) 1x/minute
• Percution : tympanic sound (+) in 13 points, liver span (n) 8 cm, spleen
enlargement (-)
• Palpation : Superficial pain (-), deep pain (-) hepar and lien is palpable (-) skin
turgor(n)
▸ Extremity
General Appearance
Abnormal movement -
Tonus + +
Power of movement 5 5
Clonus - -
Mc Murray Testing