I.

PHYSICAL EXAMINATION (ON ADMISSION)

General Survey
Vital Signs

Anthropometric
s

Awake, alert, conversant and responsive, in respiratory distress

Conversant, Responsive
BP: 100/70 mmHg
HR: 140 bpm (range: 75-155, normal)
RR: 59 cpm (range: >50/min, tachypnic)
T: 39.5 oC (range: 36.8-37.2 oC, above normal)
O2 Sat: 98%
Weight: 8 kg
Height: 73.5 cm (z-score 0, normal)
BMI: 14.81 kg/m2 (z-score 0, normal)
Interpretations:
Waterlow classification:
For wasting: (15 kg / 18 kg) x 100 = 83.3% [MILD WASTING]
For stunting: (109 cm / 103.5 cm) x 100 = 105.3% [NORMAL]

Ave BW = 3000g (3kg); ave BL = 50cm

Skin

HEENT

Warm, soft, smooth skin with good turgor and mobility.

(+) bruises on the left antecubital fossa which is secondary to blood
extraction.
No masses, lesions, or tenderness, no jaundice, pallor or cyanosis
HEAD
Head is symmetrical, normocephalic, with no sign of trauma or masses
EYES

Anicteric sclera, slightly pale palpebral conjunctiva

transparent bulbar conjunctiva, (-) sunken eyeballs
No ptosis of the eyelids, symmetrical
(-) periorbital edema
EARS
Ears normoset, (-) skin tags, masses, lesions, (-) erythema, (-) discharge or
bleeding
Tympanic membrane is intact, dull and gray. Visible cone of light on the 5 o
clock and 7o clock position in the right and left tympanic membranes
respectively.
NOSE
Patent nares; No gross deformity, lesion or bleeding
Midline septum
Visible nasal turbinates with no evidence of hyperemia and swelling.
Sinuses are non-tender and no discharge is present.

THROAT
Dry lips, moist oral mucosa, pinkish gums, no bleeding
Pink tongue, (+) dentures
(-) tonsillopharyngeal congestion

Chest & Lungs

Cardiovascular
Abdomen

NECK
Trachea midline
(-) masses / lesions
(-) CLADS (cervical lymphadenopathies)
Equal & symmetrical chest expansion
(+) bilateral fine crackles on both lung fields, (+) diffuse wheezing
Clear breath sounds
(+) intercostal retractions, labored breathing, use of accessory ms, alar
flaring
(-) No chest deformities or tenderness
(-) cyanosis
Midline trachea
Symmetric and normal tactile fremitus
Percussion on all lung fields resonant
Adynamic precordium, normal rate, regular rhythm, distinct S1 and S2
No deviations, retractions. No heaves, lifts, thrills and bruits. (-) murmurs.
PMI at 5th ICS L MCL.
Globular abdomen, umbilicus sunken, normoactive bowel sounds,
tympanitic on all quadrants, (-) tenderness, masses, striae, scars,
superficial vessels or discoloration

Genitalia
Penis without lesions/discharge, prepuce can be retracted, no discharge

Extremities
Neurologic

Scrotum no lesion or deformity

Full and equal pulses, CRT <2 seconds, no cyanosis, no edema / cyanosis
No ROM limitation
MENTAL STATUS
Patient is coherent and cooperative
FRONTAL - awake, conversant, follows command
TEMPORAL - intact immediate, recent and remote memory
PARIETAL - no R-L disorientation
OCCIPITAL - able to identify objects and colors
CRANIAL NERVES
I - able to identify test substance
II - 3-4mm EBRTL OU, J1 OU, +ROR
III, IV, VI - full and intact EOMS
V - intact sensory V1, V2, good temporalis and masseter tone
VII - no facial asymmetry at rest
VIII - gross hearing intact
IX, X - (+)gag reflex, able to swallow
XI - able to turn head and shrug against resistance
XII - tongue midline
MOTOR
Upper Extremities - 5/5
Right Lower Extremities - 1/5
Left Lower Extremities - 1/5
SENSORY
Was able to localize and discriminate tactile stimuli on all extremities, trunk
and head.
C1-C8 - 100%
T1-T3 - 100%
T4 - 80%
T5 - 50%
T6-T8 - 0%
T9-L2 - 50%
L3-L4 - 0%
L5 - 50%
REFLEXES
+2 triceps, brachioradialis, patellar
+3 ankle
+babinski bilateral
+clonus bilateral
Cerebellar:
(-)dysmetria, (-)dysdiadokokinesia
Meninges:
(-) Brudzinkis & Kernigs