I.

Profile
Name: Patient XYS
Address: Quezon Hill, Baguio City
Age: 5 months
Birthdate: August 14, 2015
Birthplace: Olongapo City
Nationality: Filipino
Religion: Roman Catholic
Attending Physician: Dr. Domingo, Dr. Reyes, Dr. Laoagan
Admission Diagnosis: Lumbar Mass T/C Meningococele
Chief Complaint: Lumbar Mass
II. History of Present Illness
The patient was born with a mass on the lumbosacral area which was noted to be
gradually enlarging. Consultations were done at Olongapo City but was referred to a
neurosurgery specialist. But due to financial constraints no further interventions were done. A
relative then suggested to sought consultation at BGHMC hence patient was admitted.
III. History of Past Illness
No known past medical history or previous confinement.
IV. General Appearance

The patient is conscious, responds to pain stimuli.

The patients Vital Signs are normal with a temperature of 36.9 centigrade, pulse
rate of 131 beats per minute, respiration rate of 27 breaths per minute.
Upon receiving the patient, the patient was pale looking but with loud cry.
The patient has a visible lumbar mass.
The patient showed no sign or potential signs of distress.
Physically, the patients nutritional status and body built/stature is appropriate to
his age.

V. Cephalocaudal Physical Assessment

1. Skin
The patients skin is uniformly brown in color except in areas exposed to the sun, has no
lesions, edema or abrasions, is not moist because of the air ventilated environment, has
uniform temperature, and when pinched, the skin springs back to the previous state. The
tissues surrounding the nails of the patient are intact. And when blanched test is
performed, color of the nail of the client returns into pink in less than 4 seconds.
2. HEAD AND FACE
The patients scalp is lighter than the color of his skin and has no areas of tenderness. The
hair is evenly distributed and is thick. The patient has symmetric facial movements.
3. EYES
The patients eyebrows have evenly distributed hair, has intact skin, symmetrically
aligned, and has equal movement. The conjunctiva is transparent, capillaries sometimes
evident, and sclera appears white and clear. The cornea is transparent, shiny and smooth,
details of iris are visible. The iris is brown, flat and round. The patients visual acuity is
normal.
4. EARS

The patients external ear canal is dry, has presence of hair follicles, no pus or
blood. Normal voice tones are audible to patient. Sound is heard on both or localized at
the center of the head. Ear is without masses.
5. NOSE
The patient has no tenderness on sinuses. The nose is in the midline, has no
discharges, no nasal flaring, both nares are patent, and no bone and cartilage deviation
noted on palpation.
6. MOUTH AND THROAT
The patients buccal mucosa is uniformly pink in color, moist, smooth, soft, glistening and
elastic in texture, and has no lesions. Teeth are white to yellowish in color, gums are pink, moist,
firm, has no retraction and bleeding of gums. Tongue is pink, has thin whitish color. Uvula is
positioned in the midline of soft palate. The tonsils are pink in color, and have no discharges.
7. NECK
The trachea is on central placement in the midline of the neck, spaces are equal on both
sides. The thyroid gland is not visible in inspection, gland ascends during swallowing, no
masses palpated.
8. CHEST (POSTERIOR AND LATERAL)
Posterior thorax is asymmetric, ribs are sloped downward, and muscle development is
equal. Spines are slightly aligned, are uniform in temperature, visible mass on the lumbar
area. Chest is symmetric upon expansion.
9. CHEST (ANTERIOR)
Breathing pattern is quiet, rhythmic and effortless. Chest is symmetric upon expansion,
has flat sound on the part with heavy muscles and bony prominences, tympani on the
stomach, dullness on the liver and spleen, bronchovesicular and vesicular.
10. HEART
The patients heart has no palpable pulsation over the aortic, pulmonic, and mitral valves,
no noted abnormal heaves, and thrills felt over the apex, and no abnormal heart sounds is
heard like murmurs.
11. UPPER EXTREMITIES
Both extremities are equal in size, have the same contour with prominences of joints, no
involuntary movements, no edema, color is even, temperature is warm and even, has
equal contraction and even, can perform complete range of motion, no crepitus noted on
joints, and can counter act gravity and resistance on ROM.
12. ABDOMEN
The patients abdomen skin color is uniform, no lesions, have scar, flat, rounded, no
tenderness noted, with smooth and consistent tension, and has no muscle guarding.
13. LOWER EXTREMITIES
Both extremities are equal in size, have the same contour with prominences of joints, no
involuntary movements, no edema, color is even, temperature is warm and even, has
equal contraction and even, can perform complete range of motion, no crepitus noted on
joints, and can counter act gravity and resistance on ROM.
14. MUSCULOSKELETAL
The patients muscles are bilaterally symmetric, has no contractures and tremors, normal
muscle tension, adequate strength of the muscle. The bones are uniform in structure, no

deformities, tenderness or edema. Joints are not tender, has smooth movement and no
nodules.