PHYSICAL ASSESSMENT Name: Mr. RC Birthday: Age: 11 y/o Date of Assessment: Weight: 83 lbs. Height: 143.

8cm

Vital signs: Temperature: 38.8C Pulse rate: 160 bpm Respiratory rate: 20 cpm Blood pressure: 100/90mmHg BMI: 16.0

BODY PART ASSESSED GENERAL APPEARANCE Body built

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

INTERPRETATION

INSPECTION INSPECTION

Proportionate, varies with lifestyle Relaxed, erect posture

Posture

INSPECTION Dress, grooming, hygiene (odor) Obvious physical deformities Height Weight INSPECTION INSPECTION INSPECTION INSPECTION

Coordinate movements Clean, neat, no body odor

She has a proportionate body built which is appropriate with her lifestyle. She is slightly unrelaxed and has minimal movements Coordinated She dresses cleanly, neatly and appropriately. She has no body & breath odor. No presence of physical deformities 143.8cm

Normal

Deviation - due to discomfort and illness. Normal Normal

Healthy appearance Underweight = <18.5 Normal weight = 18.524.9 Overweight = 25-29.9 Obesity = BMI of 30 or greater

Normal

83pounds

Deviation - The client is underweight based on the result of BMI.

(143.8cm 83lbs BMI = 16.0)

B. VITAL SIGNS Temperature INSPECTION, PALPATION 36.5-37.5 C 38.8C Deviation Febrile due to increase of inflammation as evidenced by an increase in the number of WBC. Normal Deviation PR-Due to a response to the lowered blood pressure that result from peripheral vasodilation. BP- There is an increase in cardiac output , blood volume, blood viscosity have direct effect on the blood pressure.

RR PR & BP

INSPECTION INSPECTION, AUSCULTATION, PALPATION

12-21 cpm PR: 60-100 BPM BP: 100/60

20 cpm PR:160bpm BP:120/90

C. MENTAL SIGNS Level of Consciousness INSPECTION Responsive, responds to Responds to questions properly Normal

questions clearly and appropriate Orientation Emotional status INSPECTION INSPECTION Cooperative Appropriate to situation Cooperative Answer question when asked, and able to follow instruction with a good mood. Language and Communication INSPECTION Understandable; exhibits thought association Understandable with associated thoughts Normal Normal Normal

D. SKIN AND NAILS 1. Examine the exposed part of the skin INSPECTION AND PALPATION Uniform color, has no lesions, no tenderness The unexposed and exposed area of the skin has erthematous rash with dry skin. Has no tenderness, presence of scars. Deviation -due to generalized erythematous rash, the pathognomonic sign of dengue. -the skin is warm to touch because of hyperthermia. 2. Nails INSPECTION AND PALPATION Highly vascular and pink in color in 2-3 seconds, Convex curvature; smooth texture E. HEAD AND FACE 1. Skull condition and proportion 2. Palpate for mass, presence of infestation: tenderness and INSPECTION PALPATION Normocephalic and symmetrical; smooth skull contour Smooth; uniform consistency; absence of nodules or masses Normocephalic, symmetrical, has smooth contour Smooth, no masses or nodules palpated Normal Normal (+) Blanch test (highly vascular), pink in color, Convex in curvature, with smooth texture Normal

hair condition 3. Face (symmetry and movement) INSPECTION Symmetrical facial features and movements; palpebral fissures equal in size F. EYES 1. Eyebrows INSPECTION Hair evenly distributed; skin intact: eyebrows symmetrical aligned; equal movement 2. Eyelids INSPECTION Skin intact; no discharge; no discoloration; lids close symmetrically Skin is intact, no presence of discharge, no discolorations, close symmetrically, and when lids open: no sclera above and below the cornea 3. Blink response INSPECTION 15-20 involuntary blinks per minute; bilateral blinking 4. Eyeballs symmetrical movement 5. Conjunctive (bulbar and palpebral) INSPECTION AND PALPATION Bulbar; transparent; capillaries sometimes evident. Palpebral: shiny; smooth; pink or red 6. Sclera INSPECTION White Bulbar: has evidence of some capillaries; palpebral: is shiny, smooth and pinkish White w/ presence of some capillaries Normal Normal INSPECTION Symmetric movement Bilateral blinking with 18 blinks/min Moves in unison Normal Normal Hair distributed evenly, symmetrical eyebrow alignment, intact skin, equal movements Normal Normal Facial features are symmetrical, palpebral fissures are equal in size, with symmetric nasolabial folds Normal

7. Pupils

INSPECTION

Black in color; equal in size; round; briskly reactive to light and accommodation. Reaction to light: illuminated pupil constricts (direct) no illuminated pupil constricts (consensual). Reaction to accommodation: pupils constrict when looking at near objects; pupils dilate when looking at far objects; pupils converge when object is moved towards the nose. Peripheral vision is intact

Brown in color, equal in size, round, constricts in reaction to light, constricts when looking at near object, dilates when looking at far object, converge when object is drawn towards the nose, has intact peripheral vision

Normal

8. Lacrimal Apparatus

INSPECTION AND PALPATION

No edema or tearing

No edema, no presence of tearing

Normal Normal

9. Visual Acuity

INSPECTION

Able to read newsprint

Able to read news print at a 1.5ft. distance

G. EARS 1. Auricles INSPECTION AND PALPATION Color, same as facial skin; symmetrical; aligned with the outer canthus of the eye 2. Pinna PALPATION Mobile ; firm: pinna recoils after it is folded Light brown in color, aligned with the outer canthus of the eyes, symmetrical Recoils after folding, firm, mobile Normal Normal

3. External canal 4. Hearing acuity

INSPECTION INSPECTION

No discharge Normal voice tones audible. Sound is heard in both ears or localized at the center of the head.

No discharge noted Responsive to normal voice. Sound is heard in both ears or localized at the center of the head. Weber(-) Rhine (+):AC>BC:23>15

Normal Normal

5. Septum 6. Mucous membrane 7. Patency

INSPECTION INSPECTION PALPATION

Intact and in midline Pinkish Air moves freely in and out if the nasal cavities

Intact and located in midline Pinkish in color Air moves freely as the pt breathes through the nares No presence of obstruction No tenderness felt by the pt. upon palpation

Normal Normal Normal

8. Nasal Cavity 9. Sinuses

INSPECTION PALPATION

No obstruction Not tender

Normal Normal

H. NOSE 1. Deviations in shape, size or color and flaring or discharge INSPECTION Symmetric and straight; no discharge or flaring; uniform color Mucosa pink; clear watery discharge; no lesions His nose are uniform in color same as with the surrounding skin; there are no discharge and flaring She has a clear watery discharge and has no apparent lesions Normal

2. Nasal cavities for presence of redness, swelling, growths and discharge

INSPECTION

Normal

3. Nasal septum between the nasal chambers 4. Patency of both nasal cavities

INSPECTION

Nasal septum intact and in midline Air moves freely as the client breathes through the nares Not tender

The nasal septum is in the middle She usually breathes freely through his nares

Normal

INSPECTION

Normal

5. Tenderness, masses and displacement of bones and cartilage

PALPATION

There are no tenderness, masses or displacement of bones and cartilage

Normal

I. MOUTH 1. Lips INSPECTION Uniform pink color, soft, moist, smooth texture, symmetry of contour, ability to purse lips Moist, smooth, soft, glistening and elastic texture Central position: pink color, moves freely, no tenderness 4. Teeth INSPECTION 28 pediatric teeth, smooth shiny white tooth enamel. She has a pale in color lips, slightly dry and smooth; it has symmetry of contour and has the ability to purse his lips He has a moist, soft, glistening and elastic texture of his buccal mucosa In central position, no presence of tenderness, able to move freely With missing teeth, 26 smooth yellow, shiny tooth enamel. Normal Deviation - due deviation from Normal related toillness.

2. Mucosa

INSPECTION

Normal

3. Tongue

INSPECTION

Normal

5. Gums

INSPECTION AND

Pink gums, moist, firm texture

Pinkish in color, firm in texture,

Normal

PALPATION J. PHARYNX 1. Palates Light pink, smooth, soft palate Lighter pink hard palate, more irregular Soft moist, smooth texture, and pinkish, in midline of the soft palate. 3. Mucosa 4. Tonsils INSPECTION INSPECTION Pinkish Pink and smooth: no discharge

moist

INSPECTION

He has pale in color and smooth soft palate while pale and irregular hard palate In midline of the soft palate, soft moist, smooth and pink texture.

Deviation - related to decrease blood circulation Normal

2. Uvula

INSPECTION

Pinkish in color Pinkish in color, smooth, has no presence of discharge

Normal Normal

5. Gag reflex K. NECK 1. Skin Color 2. Muscle strength

INSPECTION

Present

Present

Normal

INSPECTION

Same as the facial skin, no lesions

Same as the facial skin, no lesions

Normal

INSPECTION and RANGE of MOTION

Coordinated; smooth movements with no discomfort

Coordinated and smooth movements with no discomfort

Normal

3. Trachea

INSPECTION PALPATION

Central placement in mid line of the neck Lobes are not palpable

Central placement in mid line of the neck No palpable lobes

Normal

4. Palpate thyroid

INSPECTION

Normal

PALPATION

L. BREAST AND AXILLA 1. Breast symmetry and contour INSPECTION Breasts are round and generally symmetric; no tenderness, masses and lesions 2. Skin characteristics INSPECTION AND PALPATION 3. Nipple condition and presence of discharges INSPECTION AND PALPATION Skin uniform in color; skin smooth and intact Size is proportional, no discharged or secretions, no masses and lesion Breasts are round and generally symmetric, no tenderness, masses and lesions Skin uniform in color, skin smooth and intact Size is proportional, no discharge, no lesion Normal Normal Normal

M. CHEST AND LUNGS 1. Shape and configuration INSPECTION Anteroposterior to transverse diameter ratio of 1:2; Spine is vertically aligned 2.Chest Expansion PALPATION Full and symmetric chest expansion 3. Breathing pattern 4. Breath sounds 5. Costal angle INSPECTION AUSCULTATION INSPECTION AND PALPATION Quiet, rhythmic, effortless Vesicular and bronchovesicular Less than 90 degrees Thumbs separates 3cm during deep inspiration Effortless Bronchovesicular Approximately 80 Normal Normal Normal Normal 1:2 Anteriposterior to transverse diameter Normal

M. CARDIOVASCULAR 1. Pericardium INSPECTION AND PALPATION a. Aortic and pulmonic INSPECTION AND PALPATION b. Tricuspid INSPECTION AND PALPATION c. Apical INSPECTION AND PALPATION d. Epigastic INSPECTION AND PALPATION e. Auscultating the heart areas above AUSCULTATION S1: usually heard at all sits. Usually louder at apical area S2: usually heart at all sites, louder at the base of the heart S3: in children and young adults S4: older adults 2. Carotid artery PALPATION AND AUSCULTATION Symmetric pulse volume, full pulsations; thrusting quality; quality remains same when client breathes, turns head and changes from sitting to supine Symmetric pulsation volume, full pulsation felt, quality is constant even the pt. Breathes, changes position (head turns, sitting up to laying down) has elastic arterial Normal S1: loudest at apical area S2: loudest at base of the pts heart S3: Audible S4: not audible Normal Some pulsations visible; no lift or heave Aortic pulsation No pulsations; no lifts or heaves No pulsation felt, no lifts or heaves noticed There are some pulsations felt but there are no lift or heave Aortic pulsation felt Normal Normal No pulsations No pulsation felt Normal No pulsations No pulsation felt Normal

Normal

position; Elastic arterial wall

wall

3. Jugular Vein N. ABDOMEN 1. Skin condition

INSPECTION

Veins not visible

Veins are not noticed

Normal

INSPECTION

Unblemished skin, uniform in color.

She has erthematous rash in the skin of the abdomen.

Deviation -due to generalized erythematous rash, the pathognomonic sign of dengue. .

2. Contour and Symmetry

INSPECTION

Flat, rounded, symmetric contour

Flat, symmetric contour. He has symmetric movements because of respiration

Normal

3. Abdominal movements

INSPECTION

Symmetric movements caused by respiration

Normal

O. UPPER & LOWER EXTREMES 1. Motor strength INSPECTION PALPATION Smooth coordinated movements He has a weak and slight un-coordinated movements Deviation -normal related to illness.

2. Muscle tone 3. Tenderness, smoothness of movements, crepitation and nodules

PALPATION PALPATION

Normally firm No swelling, tenderness, crepitation or nodules

Firm There are no tenderness, swelling, crepitation or nodules;

Normal Normal