Physical Assessment

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mentPHYSICAL ASSESSMENT 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

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