PHYSICAL EXAMINATION
System Actual findings
VITAL SIGNS  Temperature:
36.5°C
 BP: not assessed
 RR: 24 cpm
 PR: 110 bpm
ANTHROPO-  Weight: 7.8
METRIC kilograms
MEASURE-  Height: 63 cm
MENT  Head
circumference: 45 cm
 Chest
circumference: 47 cm
 Abdominal
circumference: 46 cm
SKIN  Light brown and
uniform in color
 No foul ordor
 No masses, lesions
 No wounds,
laceration
 Skin is
moist
Normal findings Remarks
 Temperature is The child's vital
37.44oC (because of signs are within
excess heat production). the normal range
 apical pulse: 100- in relation to his
120 bpm age.
 RR: 20-30 cpm
 Awake and resting
rates may vary with the
age of the child. Rate
decreases gradually with
age.
 Asians are smaller Head
than Caucasians circumference
newborn. Asian children should be greater
are smaller at all ages than chest and
abdominal
circumference,
which does not
happened to the
client.
 Skin color ranges from Child has a
pale white with pink, healthy skin and
yellow, brown, or olive has no problem
tones to dark brown or on this.
black. No strong odor
should be evident, and
the skin should be lesion
free.
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  No rashes  Skin should be soft
 Warm and warm, slightly moist
uniform to touch with good turgor and
 Good skin without lesions and
turgor edema.
HAIR  Uneven distribution  Unevenly distributed All of the findings
 No scalp lesions  Fine to course for the hair are

 No masses  Absence of infestation found to be within

the normal range.
 Fine to course  No masses
 Absence of infestation  No lesions
NAIL  Pinkish nail bed  Nail bed is pink All of the findings
 Concave shape  Concave shape for the nails are

 Color of the nail  Capillary refill backs found to be within

bed back to original within 1-2 seconds the normal range.

color in less than three

seconds.  Smooth to touch
 Smooth to touch
HEAD  Asymmetrical with  Asymmetrical, rounded Normal findings.
frontal, parietal and Posterior fontanel
flatted occipital should close at
prominences two months while
 No palpable lymph  Uniform consistency; anterior fontanel
nodes absence of nodules or should close by
masses 12 - 18 months.

 No tenderness  Head is non-tender.

 Symmetrical facial  Symmetrical facial
expression such as movements
smiling, frowning
 Posterior fontanel is  The posterior fontanel is
closed and anterior closed; anterior fontanel
fontanel is still open. is still open.

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 EYES  Symmetrica  Eyes are symmetrical All of the findings
l  Hair evenly distributed; for the eyes are
 Equal eye skin intact found to be within
lashes distribution  Eyebrows symmetrically the normal range.
 Eyebrows are aligned
symmetrically aligned
and evenly distributed  Equal movement
 Equal movement  No discharge, no
 No discharge, no discoloration of eyelids
discoloration of eyelids  When lids are close,
 When lids are sclera is not visible
close, sclera is not  Sclera is white
visible  Pink conjunctiva
 Sclera white  No edema or tenderness
 Pink conjunctiva over the lacrimal gland
 No edema or tenderness
over the lacrimal gland
EARS  Symmetrical  Symmetrical All of the findings
 Color same as facial  Color same as for the ears are
skin facial skin found to be within

 Aligned to the inner  Auricle aligned the normal range.

canthus with other canthus of the
 No lesions eye
 Firm and  Absence of lesions
not tender  Firm and not tender
NOSE AND  Symmetrica  Symmetrical All of the findings
SINUSES l  No discharge for the nose and
 No  Absence of nasal sinuses are found
discharges flaring to be within the

 No nasal  Uniform in color normal range.

flaring

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  Uniform in color  Nose is non-tender
 Not tender  No lesions
 No lesions  Pink mucosa
 Pink mucosa  Nasal septum intact and
 Nasal septum intact in the midline
and in the midline  Sinuses are not tender
 Sinuses are
not tender
MOUTH  No tooth yet  Tooth hasn't yet All of the findings
 Lips is soft, erupted for the mouth are
moist and has smooth  Soft, moist, smooth found to be within
texture texture of lips the normal range.

 Gums is  Uniform pink color

pink of gums, tongue and
 Tongue is tonsil
pink
 Tonsil is pink at the
middle  Moist and slightly
 Moist and slightly rough tongue
rough tongue  Smooth tongue
 Smooth tongue base
base  Light pink, smooth
 Light pink, smooth soft palate
soft palate  Light pink hard
 Light pink hard palate
palate  Uvula is positioned
 Uvula is in the midline of soft
positioned in the palate
midline of soft palate
THROAT AND  Uniform in color  Generally uniform in All of the findings
NECK color for the throat and

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  No palpable lymph  No palpable lymph neck are found to
nodes nodes in the be within the
 Neck can move  Neck can move freely normal range.
freely
BREAST AND  Skin is smooth and  Skin is smooth and All of the findings
AXILLA uniform in color uniform in color for the breast and
 Symmetrical breast  Symmetrical breast and axilla are found to
 Symmetrical axilla axilla be within the

 No tenderness  No tenderness normal range.

 No secretion  No secretion

 No masses or  No palpable masses

nodules or nodules

CHEST & RES-  Skin is intact  Intact skin All of the findings
PIRATORY  Regular interval in  Regular pattern of for the chest and
breathing breathing the respiratory are

 No lesions  Absence of tenderness, found to be within

 No tenderness lesions and palpable the normal range.

 No masses masses

 Shoulder height is  Symmetrical shoulder

symmetrical height

 No observed  Absence of dyspnea and

difficulty in breathing. has regular depths of

There equal rise and respiration

fall of the chest with

regular depths of
respiration.
CARDIOVAS-  Apical pulse:110  Apical pulse is All of the findings
CULAR AND bpm palpable for the
PERIPHERAL  No cold extremities  Absence of cold cardiovascular
and discolored extremities and are found to

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 extremities  No discolored be within the
extremities normal range.
ABDOMEN  Uniform skin color  Uniform in color All of the findings
in the abdomen for the abdomen
 Symmetric contour  Symmetric contour are found to be

 Rounded  Rounded or within the normal

protuberant abdomen range.

 No lesions  Absence of lesions

 No tenderness and tenderness
REPRODUC-  Not assessed  Not assessed Not assessed
TIVE
MUSCULO-  Uniform in  Uniform skin color All of the findings
SKELETAL skin color  Smooth coordinated for the
 Mobile movements musculoskeletal

 Equal size on both sides are found to be

 Equal size of the body within the normal

on both sides of the  Absence of deformities, range.

body fractures and dislocation

 No
deformities noted  Absence of tenderness
 No fractures  Absence of swelling
and dislocations noted  No tremors
 No  No palpable nodules
tenderness and swelling
 Does not
have tremors and
palpable nodules
 10 fingers
and toes
ENDOCRINE  Rapid weight gain  Gradual weight gain Infant 0-6 months
(gained 10.16 lbs in old should gain 0-

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 four months time) 2 lbs per month.
HEMATOLO-  No bleeding  No bleeding Normal findings.
GICAL  No bruises  No bruises
 Type O  Blood Type
LYMPH  No palpable lymph  No enlarged lymph Normal findings.
NODES nodes nodes
 No tenderness  Not tender
noted

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