V. PHYSICAL ASSESSMENT A. GENERAL SURVEY Head to Toe Assessment PART 1) HEAD AND FACE a).

Hair NORMAL WHITE scalp, no lice, no dandruff, no lesion hair evenly distributed Free from lesions, lumps and any discoloration symmetrical in shape, Good coordination and good movement With good vision. Eyebrows gradually aligned equal Eyelashes equally distributed Eyelids are intact Moist and pinkish In good coordination Reaction to light with blinking FINDINGS WHITE scalp, no lice, no dandruff, no lesion hair evenly distributed Free from lesions, lumps and any discoloration symmetrical in shape,with wrinkles, and eye bugs. Presence of facial grimacing. normal Normal Normal Normal Normal Normal Normal With eye bugs due to sleep disturbance and with wrinkles because of aging. Due to chest pain. normal Normal Normal Normal Normal Normal ANALYSIS

b). Face

c). Facial 2). Eyes and Vision a).External Structure

b). Extraocular Normal Normal

3). Ears and Hearing a) External structure

Symmetrical at the level of outer canthus, clean no discharge.

With discharge and clean.

not

not clean because of the un healthy lifestyle .

) Hearing With good hearing, not impaired normal No nasal discharges goods smelling condition, air moves freely Reddish in color no cracks dental cavities and over crowning With dental caries c). Gums Pinkish/ reddish in color, no signs of bleeding Normal No bad odor d). Breath No difficulty of swallowing No masses present Normal 7). Lungs a) Sounds b) Pattern of Breathing Clear sounds Normal breathing pattern Crackles Use of accessory muscles in breathing Tachypnea Normal No murmurs With heart murmurs which is the s3 sounds. abnormal Abnormal Normal Due to cough Due to difficulty of breathing. With foul odor . Normal Normal Due to lack of hygiene. Normal Pale in appearance and with cracks normal normal Due to lack of water intake Due to excessive eating of chocolates or sweet foods and bad hygiene. normal

4). Nose 5). Mouth a). Lips b). Teeth

6). Neck a). Tonsils b).Musculoskeletal

c) Rate 8) heart

9) upper extremities a) Skin

and lower Good skin turgors, no lesions, no rashes Pale With skin lesions and skin rashes Due to mosquito bite.

b) Nail c). capillary refill

Returns after 2 seconds when pinch. Normal Returns after 2 seconds when pinch.

10) abdomen a) 4 quadrant

With good structure and symmetrical

Increase in size with ascites

Fluid accumulation of abdomen