PHYSICAL ASSESSMENT FORM

Name: Jamaica Silva Age: 7 Address: Buloc-Buloc, Sibulan Birthday: October 8, 2003 GENERAL SURVEY 1. Signs of distress 2. Body type 3. Gait 4. Posture 5. Speech 6. Dress, Grooming, Hygiene 7. Mental State-level of consciousness VITAL MEASUREMENTS 1. Temperature 2. Pulse 3. Respiration 4. Blood Pressure 5. Weight, Height INTEGUMENTARY SYSTEM 1. Skin a.1 Color a.2 Odor a.3 Lesions a.4 Edema b.1 Temperature b.2 Moisture b.3 Texture b.4 Mobility/ Turgor 2. Nails a.1 Color (nail bed, nail plate, nail edge) a.2 Shape a.3 Angle a.4 Thickness b.1 Texture b.2 Capillary Refill 3. Hair and Scalp Sex: Female Religion: Roman Catholic Grade: 1

no visible signs of ditress slim good manner of moving and walking upright and good posture Able to understand and give an intelligent response, is confident Hair unkempt and nails are dirty Mentally alert and oriented to time, place and person 37C 86 bpm 25 cpm 90/60 mmHg 46 lbs, 43.5 inches

dark skinned no unusual odor no lesions no edema warm, equal bilaterally dry, with minimal prespiration and oiliness smooth, soft, even and flexible lifts easily and snaps back immediately to its resting position nail bed is pinkish, nail plate is transparent, nail edge is transluscent Well-rounded, convex 160 hard and thick firm prompt return of blood flow in 2 seonds

a.1 Check scalp for presence of nits, Hair is black, thick, no presence of nits, scaliness and dandruff, scaliness and lesions, lesions. The hair is evenly distributed. The scalp is assess hair for color, quantity, lighter in color than the face and there is presence of distribution & texture. minimal dandruff. b.1 Deformities No deformities b.2 Lumps no lumps b.3 Tenderness no tenderness HEAD AND FACE a.1 Size normocephalic a.2 Shape oval a.3 Symmetry symmetrical a.4 Position held upright and still a.5 Involuntary movements no involuntary movements a.6 Edema no edema b.1 Masses no masses b.2 Tenderness no tenderness EYES 1. Eyebrows a.1 Distribution evenly distributed a.2 Alignment aligned with each other a.3 Position/ Symmetry symmetrical a.4 Skin Quality skin intact a.5 Presence of Scaliness no scaliness present a.6 Movement (raising & lowering eyebrows) eyebrows rise and fall symmetrically a.7. Masses no masses 2. Eyelashes a.1 Distribution evenly distributed a.2 Direction of curl curled outward 3. Eyelids upper eyelids cover the portion of iris, cornea and a.1 Position sclera when eyes are open a.2 Color same as with surrounding skin a.3 Edema no edema a.4 Lesion no lesions a.5 Adequacy of closure meets completely when eyes close b.1 Masses no masses 4. Eyeball a.1. Protrusion no protrusion b.1 Firmness globe is firm b.2 Tenderness no tenderness 5. Lacrimal Gland & Nasolacrimal Duct

a.1 Swelling a.2 Redness b.1. Tenderness 6. Visual Acuity

no swelling no redness no tenderness able to read (The quick brown fox, jumped over the lazy dog) without hesitancy and without moving the material farther away O.D. 20/20 with 2 mistakes. O.S. 20/20 with 2 mistakes. O.U. 20/20 with 1 mistake. Without corrections. correctly identified the colors the palpebral conjunctiva is smooth, glistening and pinkish in color with minimal blood vessels visible. The bulbar conjunctiva is clear with few underlying blood vessels and china white sclera visible. cornea has no opacities or cloudiness, it is transparent, shiny and smooth with no abrasions. The lens has no cloudiness. Brown Circle Brown 3 mm round equal in size in both eyes positive for direct and consensual reaction PERRLA parallel eye movement Auricles are level with each other whose upright point of attachment is in straight line with the lateral canthus of the eye. Color is same with that of the face, without deformities. Symmetrical. Position almost vertical soft and pliable, nontender Canal is pink, with tny hairs, with presence of dry cerumen (brown), no presence of mass client was able to repeat the whispered words proportion to other facial features and midline

6.1 Near Vision

6.2 Far Vision 6.3 Color Vision

7. Conjunctiva & Sclera

8. Cornea & Lens 9. Iris a.1 Color a.2 Shape 10. Pupils a.1 Color a.2 Size a.3 Shape a.4 Equality a.5 Test for direct reaction & consensual reaction 11. Accomodation & Convergence 12. Extraocular Movements EARS

1. Inspect for angle of attachment, color, size, position, symmetry, deformity, swelling and skin lesions 2. Consistency & tenderness 3. Auditory canal 4. Auditory acuity NOSE a.1 Size

a.2 Shape & Symmetry a.3 Color a.4 Deformity b.1 Tenderness b.2 Nodules c.1 Nasal mucosa (color, exudates, bleeding, swelling) SINUSES a.1 Frontal, maxillary sinuses (tenderness) MOUTH 1. Lips 1.1 Color 1.2 Condition 1.3 Lesions 1.4 Odors 1.5 Consistency 1.6 Tenderness 1.7 Nodules 1.8 Masses, lumps 2. Oral mucosa & Gums 2.1 Color 2.2 Lesions 2.3 Condition of Mucosa 2.4 Condition of Gingiva 3. Teeth 3.1 Color 3.2 Number of teeth 3.3 Caries 4. Hard and soft palate 3.1 Color 3.2 Architecture 3.3 Deformities 5. Tongue 5.1 Color 5.2 Texture 5.3 Moisture 5.4 Papillae

shape symmetrical and consistent with age, gender and race same color with face no deformity noted no tenderness, nasal bone is firm and stable. no nodules Nasal mucosa is pink and there is presence of mucus as she is experiencing colds. No bleeding.

no tenderness

pinkish moist no lesions no unusual odor soft no tenderness no nodules no masses and lumps glistening pink no lesions soft, moist, and intact no bleeding or retraction and the gums are pink, smooth , moist with a tight margin at each tooth. some are white, some are black and brown (due to cavities) 19 teeth presence of caries hard palate is whitish, soft palate is pinkish hard palate is dome shaped, soft palate is smooth No deformities the dorsum is dull red slightly rough on the top surface, smooth along the lateral margins moist raised papillae

5.5 Hypoglossal nerve 5.6 Size & symmetry 5.7 Consistency 5.8 Masses, lumps 5.9 Tenderness 6. Oropharynx 6.1 Instruct client to say AH and inspect for rise of soft palate. 6.2 Inspect for: 6.2.1 Color 6.2.2 Symmetry 6.2.3 Discharge 6.2.4 Ulcerations 6.2.5 Enlargement of Tonsils 6.2.6 Alignment and characteristics of uvula NECK 1. Symmetry 2. Scars 3. Growth 4. Enlargement of Parotid glands 5. Palpate the nodes. POSTERIOR AND ANTERIOR CHEST 1. Rate, Rhythm, Depth of Respiration 2. Use of Accessory Muscles 3. Shape and Symmetry of Chest AXILLAE A. Inspect for: a. Color b. Lesions c. Odor B. Palpation of nodes ABDOMEN 1. Size 2. Shape 3. Symmetry 4. Color 5. Lesions EXTREMITIES 1. Inspect for:

intact when child was asked to stick out his tongue and move it side to side symmetrical and regular in size smooth no massess no tenderness

uvula rised with soft palate pinkish symmetrical no discharges no ulcerations no enlargement of tonsils uvula raises centrally symmetrical no scars no abnormal growth no enlargement of parotid glands no palpable nodes

regular and shallow respiration no using of accessory muscles in breathing shape is elliptical and symmetrical

same as with surrounding skin no lesions no unusual odor no palpable nodes not enlarged, proportional to the body flat symmetrical consistent with patient's ethnicity no lesions

a. Size b. Symmetry c. Rashes/ Lesions d. Edema 2. Knee Reflex

proportional symmetrical no rashes no edema 2+ reflex