Last September 16, 2011 at exactly 9 o’clock in the morning, we conducted a physical assessment to Patient X who is 12 years old. He was admitted last September 15, 2011 at 12:30 am due to edema on the right ankle. He is under Dr. Uy. Patient X was admitted per wheelchair with watcher. General Survey
Patient X was lying on bed. He was awake and coherent and responsive to any kind of stimulus. He had an IVF of PNSS 1 liter at KVO rate infusing well at his left metacarpal vein. Elastic bandage was well attached at his right ankle. Vital Signs| 12:00 nn| Normal Range|
Blood Pressure | 90/60 mmHg| 110/70- 130/90 mmHg|
Cardiac Rate| 95 bpm| 70-80 bpm|
Pulse Rate| 93 bpm| 70-80 bpm|
Respiration| 23 cpm| 13-20 cpm|
Temperature| 36.6 degree celcius| 36.5- 37.5 degree celcuis|
Appearance and Mental Status
As we observed the patient’s body built, it appears to be ectomorph. Patient X has height of 4 feet and 6 inches and weight of 30 kilograms. His body mass index is 16 kg/ m2 which result as underweight. He was well-groomed. No body and breath odor noted. He was attentive and oriented upon assessment and respond appropriately in conversation with good eye contact.
Skin and Fingernails
Upon inspection, the patient’s skin was uniform in color. Good skin turgor was noted, Smooth skin texture was noted upon palpation. He has an ideal skin temperature when touched using the back of the palm and compared to other parts of the body. Bruises were noted on his right elbow and in some portion in his both lower extremities which is the sign of hemophilia. No birthmarks and tenderness noted. His nails were clean and well-trimmed and have a convex curve. When his nails were pressed, it immediately returns to its usual color which is pink with a capillary refill time of 2 seconds. Head
Upon assessment, the patient’s skull appears to be normocephalic. No masses were noted. Hair is equally distributed. Eyes
Upon inspection, eyebrows are symmetrical with equal movement and hair distribution. Eyelashes are long, evenly distributed and turned outwards. Palpebral fissures are equal in size when yes were open. Lacrimal ducts had no signs of swelling and tenderness noted. Bulbar conjunctiva was transparent in color. Sclera appeared white in color. When cornea was observed, it was smooth and shiny. Both of her nares were patent and symmetrical.Pupils were black in color with 3 mm in diameter and it was equally round and briskly reactive to light accommodation. When extraocular muscles were assessed, converging eye follows the object within 5-8 centimeter of the nose. Ears
Ears are symmetrical with color consistent with facial skin. Superior aspects of auricles are aligned with the outer canthus of the eyes. It was mobile upon palpation with no tenderness noted. External canals were clean without cerumen present. Gross hearing acuity was good. Nose
Upon inspection of the nose, it has uniform in color. There were no discharges and nasal flaring noted. When it palpate, there was absence of tenderness noted. Both of his nares were patent and symmetrical. Nasal septum was intact and in midline found in between the nasal chambers. Upon palpation of facial sinuses (frontal and maxillary), there was absence of tenderness noted.
His buccal mucosa was pinkish, moist and smooth. The entire oral cavity was pinkish without ulcers. Teeth were not complete. One molar was missing which was located in left lower portion. Some teeth have caries specifically both lower left and right molars. Tongue was able to move freely without tenderness noted. Uvula was position at the midline of soft palate. Hard palate has a lighter pink color compared to the soft palate. Tonsils were pink and there were no discharges. Neck
Neck muscles are equal in size. When it assessed, equal strength was noted. Trachea is position at the midline of the neck. Thyroid glands ascend during swallowing...