Physical Assessment Name: Patient X Age: 3 years old Body part examined Actual Findings Normal Findings Interpretation

/ Analysis

Vital sign: Temperature Pulse rate 36C 111bpm 35.6 37.7 80 to 140bpm Normal Normal

Respiratory rate

22bpm

20 to 30bpm

Normal

Weight Height Body Mass Index Scalp Texture

19.3kg 94cm 22.8 18.5 to 24.9 Normal

Smooth and firm

Smooth and firm

Normal

Presence of lesions Hair a. Color of hair b. Distribution c. Thickness/ thinness d. Texture e. Oiliness f. Presence of lice, nits

None -Black color -Evenly distributed hair -Moist and smooth hair -no presence of lice or nits

None Hair Evenly Distributed, Thick hair silky and resilient no infection or manifestations

Normal Normal

Skull a. Size b. Shape c. symmetry

-Symmetrical - Firm -Smooth

-Symmetrical - Firm -Smooth

Normal

Eyes

Shape

-Round

-Round -Hair evenly distributed, skin is intact

Normal Normal

-Black Eyebrows -Evenly distributed a. Color b. Hair distribution and eye brow pigments Eyelashes a. Distribution b. Direction of curl -Equal distribution -Curl outward -Lashes short

-Equally distributed, curled slightly outward

Normal

a. b. c. d.

Eyelids Surface characteristics Position in relation to corner Ability to blink and frequency Lower lids when eyes is closed

Moist and pink Symmetrica l Ability to blink Ability to close the eye lids

Eyelids close symmetrical; Blinks approximately 1520 times per minute, when lids open, no visible sclera above corneas, upper and lower borders of cornea are slowly covered

Normal

Conjunctiva a. Color b. Texture c. Lesions d. Foreign bodies

Color is transparent Smooth in texture No presence of lesions or foreign bodies

Color is transparent Smooth in texture No presence of lesions or foreign bodies White ring around eyelids Appears clear Smooth in

Normal Normal Normal

White ring around eyelids Appears clear Smooth

Normal

Cornea a. Clarity b. Texture c. Transparency

in -

Normal Normal

d. Depth Lacrimal, sac and nasolacrimal a. No tenderness Pupil a. b. c. d. Color Shape Symmetry of size Direct and consensual reaction to light e. Reaction and accommodation to light -

texture Transparent No edema or tenderness Black in color round symmetrical of size illuminated pupil

texture Transparen t No edema or tenderness

Normal Normal

Black in color, equal in size, normally 3- 7 in diameter Round, smooth and smooth border and the iris is flat and rounded. Illuminated pupil pupils (direct response) constricts Non illuminated when pupil constricts( looking at near objects, consensual dilate when response ) - black in looking at color far object - round - symmetrica l of size - illuminated pupil pupils constricts when looking at near objects, dilate when looking at far object Brown in color Smooth and soft Three flexion creases present in palm

Normal

Skin

Color Texture

Brown in color Smooth and soft Three flexion creases present in palm

Normal Normal

Hands Creases Appearance

Normal

With IV at right metacarpal vein Nail is round and hard Smooth, firm and pink Nail is round and hard Smooth, firm and pink Normal Normal

Nail

Texture Condition of nail bed -

Abdomen Shape Size

Rounded or flat Symmetrica l

Rounded

Normal

Upper Extremities and Lower Extremities Range of Motion Shoulder Arms Elbow Wrist Hands Small extremities Weak muscle strength Decreased reflexes No tenderness or swelling No tremors - equal size on both sides of body - no tenderness, swelling, crepitation, or nodules - equal strength on each body - even temperature - no tremors Normal