PhysicalAssessment Name: GRT Chief Complain: Abdominal Pain Age: 4 y/o Diagnosis: Wilms TumorSex: Male Attending Physician:

Dr. IDate and time P.A done: Jan. 21, 2010; 9 AM Height : 99 cmWeight: 13 kg General Survey: On sitting position, awake, moaning, oriented to person, time, andplace, ambulatory, appropriately dressed and neat in appearance. Appears to be skinny.Complained of pain, facial grimace noted graded with a score of 8/10 with 10 being themost painful and 0 as no pain. With IVF of D5IMB 500 cc x 24 cc/hr attached at right cephalic vein, patent and infusing well. Vital signs revealed: Temp: 36.3 degree CelsiusPR: 112 bpm RR: 24 bpm BP: 110 / 90 mmHg. Skin : Skin is dark brown in color, uniform to all parts of the body except for the palmsof the hand and the soles of the feet. Excessive sweating noted. Scar noted at 5cm inlength on the right anterior forearm, and 7cm on the left brachial area. Intact, cold andclammy to touch. Has good skin turgor of two seconds when pinched . Nails : Nail beds are pinkish. No yellowish discoloration noted. With dirty anduntrimmed free edges. Absence of clubbing. Smooth in texture with intact surroundingtissues. Convex in curvature with an approximate angle of 160 degrees. With goodcapillary refill of 2 seconds upon blanched test. Hair : Terminal hairs are evenly distributed on the scalp, with short and slightly curvedendings, black in color, absence of infestations noted. Shiny, oily and smooth in texture. Scalp : Color is lighter than facial skin, absence of dandruff, lesions, scars and anyinfestations noted. Intact and smooth in texture. Absence of masses or lumps noted. Head : Normocephalic, size is proportionate with the body. Presence of scar on botheyebrows about 3 cm in diameter. With head circumference of 49 cm, with absence of lumps and masses. With palpable temporal pulse, frontal and occipital prominences. Neck : In midline position of the body, in full range of motion with no limitations of movement, no pain and rigidity while moving. No deviation upon inspection, lymph nodes not palpable, trachea is in midline position of the neck, thyroid glands are not enlarge or swollen and moves upward when swallowing upon palpation, carotid pulsepalpable. Eyes : Eyebrows are symmetrically aligned as well as the eyelashes, they are black incolor and evenly distributed. The inner and outer canthus of the eyes are both properlyaligned to the pinna of the ears. Eyelid surfaces have no discharges, intact, no presenceof lesions, edema and scars. Eyelids completely cover the cornea when closed and coloris same with facial skin. Upper eyelids are symmetrical, lesion and scar free and doesnot sag or droop when the client opens his eyes. Eyeballs are not protruding and roundin shape. Conjunctivas are shiny and smooth, pinkish in color with visible small bloodvessels. Both scleras are anicteric with transparent, smooth and shiny cornea. Pupils areblack in color, equally round reactive to light and accommodation and in equal sizeapproximately 2mm in diameter. Iris are round and flat with grayish discolorationaround it, blinking reflex counts at 3x /minute, upon palpation eyelids show no evidenceof swelling and tenderness. Eyeballs felt equally firm and not overly hard or spongy,both eyes move in unison. Ear : Auricles has same color with facial skin, no inflammation, lesions, scars, andnodules are apparent. No crackling, thickening, scaling or lesions detectable behind theears. Presence of light yellow cerumen noted on both ear canals, no other dischargesseen. No redness or swelling apparent, the pinna is properly aligned with the inner andouter canthus of the eyes, pinna recoils within 2 seconds after folding, both auricles arenon tender, firm, nonsymmetrical in size(the left auricle appears larger than the right)no masses or tenderness on auricles upon palpation. Lymph nodes are non palpable.Mastoid process has well defined bony edges with no signs of tenderness. Has goodhearing acuity, can repeat whispered voice from 1 foot away. Nose : Nose is in midline position of the face, color is same with facial skin, absence of lesions and scars. Septum is intact with no deviation. Nasal mucosa is pinkish with noobstructions. Both nostrils are patent and air can freely move upon ventilation. Externalstructure of nose is free from structural deviations, tenderness and swelling. Frontal andmaxillary sinuses are free from tenderness and edema has good smelling acuity, able toidentify the smell of coffee and scent of orange. Mouth:

Lips are symmetrical, pinkish, absence of crust and cracks on the upper andlower lips, with minimal dryness, smooth in texture, gums are pinkish, smooth and firmwith no presence of ulcers and lesions. Tongue is centrally located inside the mouth,with whitish rough surface on top, can move freely without rigidity and pain, prominent veins noted on base of the tongue. Hard palate has ridges and soft palate is smooth, no presence of lesions and swelling noted. Uvula is intact and in midline, moves upwardwhen told to say ah. Tonsils are pinkish, lesion free with no swelling or enlargement noted. With yellowish pigmentation on tooth enamel, with dental carries noted on bothupper and lower molars. Central incisors, lateral incisors and cuspid teeth are intact. Noretractions noted. With good gag and swallowing reflex. Thorax : ( Anterior)Skin color is the same with the rest of the body, no lesions andrashes noted. Chest configuration is symmetrical from side to side. Thorax expansion issymmetrical to the back and chest. Chest shape is normal with no deformities noted.Chest wall expands symmetrically during respiration. No tender spot, masses, lumps orbulges upon palpation. Lymph nodes are non palpable. Resonant sound heard at bothlung fields noted upon percussion. Bronchovesicular sounds heard upon auscultation. Thorax : (Posterior) Skin color is same with the body, intact with no presence of lesions and scars noted. Upon palpation, no lumps and masses noted. Scapula aresymmetrically aligned. Spine is in midline position of the body, with normal respiratoryexcursion. Thumbs separate at a distance of 3cm. No tenderness noted upon palpation.Tactile fremitus are bilaterally heard. Upon auscultation, bronchovesicular sounds areheard all over the lung fields. Heart : Cardiac rate is regular in rhythm and rate. With cardiac rate of 112 bpm. Apical pulse palpable. Abdomen : Color is same with the rest of the body, free from vascular lesions, surgicalscars and rashes. Umbilicus is clean and positioned midway between the xiphoidprocess and the symphisis pubis. There is movement caused by respiration. Guardingbehavior and protective gestures noted. Distention noted with abdominal girth of 57cm. Left lumbar region of the abdomen has circular in shape. Upon percussion tympanyis the predominant sound over hollow organs including the stomach, intestine, bladder,abdominal aorta and gallbladder, normoactive bowel sounds heard on each quadrant at 7 cycles/ min. Genitals : Skin color of the penis is light brown, Urinates 3-4 times a day at approximately 20 cc per void, and moves his bowel 3 times a week or once every otherday as claimed by the mother. Uncircumcised. No lesions, masses or discharges noted. ExtremitiesUpper : Same color with the rest of the body, left arm appears bigger than the right arm, right arm circumference measures 12 cm while the left circumference measures14cm. Has full range of motion with no weakness, deviations or pain noted. Nolesions, masses, lumps or swelling noted. Brachial and radial pulse palpable. Lower : Same color with the rest of the body, left leg is bigger than the right leg, left thigh circumference measures 23cm while the right thigh circumference measures21cm. No lesions, masses, scars and lacerations noted.Has full ROM with no deviations,weakness and pain noted. Absence of varicosities. Femoral, tibial, dorsal and popliteal pulse palpable.