DEMOGRAPHIC DATA

A. Initials of the Client’s Name – ER

B. Address – Kaytapos Indang, Cavite

C. Age – 12 y.o.

D. Birth Date – August 12, 1998

E. Birth Place –Trece Martires Primary Informant: Patient

F. Gender – Male Secondary Informant: None

G. Civil Status – Single Other Data Sources: N/A

H. Religion – Iglesia ni Cristo

I. Highest Educational Attainment – Still on GradeSchool

J. Occupation – none

K. Monthly Income / Budget – the client’s don’t know

I. Reason for Seeking Health Care

Pt. ER goes to Clinic for his Check up.

II. History of Present Illness

The patient has no history of present illness.

IV. Past Medical History

A. Childhood/Adult diseases

According to patient ER, He didn’t experienced any major illness until now.

B. Injuries/Accident

The patient does not experienced any accident as verbalized by him.

C. Hospitalization

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 Based on Pt. ER he didn’t experienced any hospitalization

D. Operation

Pt. ER did not undergo any operation.

E. Allergies

Pt. ER have no known allergy.

F. Medication

Presently, Pt.ER is taking Vitamin C once a day particularly on every morning.

G. Immunization

According to Pt. ER he completed his vaccination when he was a child.

H. Last Examination

Patient ER’s Last examination for his check up was last November 11, 2010.

VI. Heredo-Familial History

A. Genogram

E.R S.R
43 46
A&W A&W

2
 D.R E.R
18 12
A&W A&W

Legend:

- Female

- Male

- Patient

B. Family APGAR

Constructs Questions Almost Some of Hardy

Always the Time Ever
(2) (1) (0)
Adaptation I am satisfied with the
help that I receive from
my family when
something is troubling
me.
Partnership I am satisfied with the
way my family discusses
items of the common
interest and shares the

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 problem-solving with me.
Growth I find that my family
accepts my wishes to take
on new activities or make
changes in my lifestyle.
Affection I am satisfied with the
way my family expresses
affection and responds to
my feelings such as
anger, sorrow and love.
Resolve I am satisfied with the
way my family and I
spend time together.

VII. Developmental History

A. J. Piaget’s Cognitive Development

The patient is in the formal operational stage of cognitive development which is he
is able to think abstractly and has the ability to reason out logically as evidence, he can
answer my questions appropriately and he together with his family, they are able to solve
the problems that are arising.

B. E. Erikson’s Psychosocial Development

The patient is currently on the stage of Love: Intimacy vs. Isolation which he is
afraid of rejection and the feeling of being isolated.

VIII. GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

A.HEALTH PERCEPTION-HEALTH MANAGEMENT

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 Pt E.R is positive about his overall health condition. According to him
feeling bad and moody sometimes is normal to him.

B.NUTRITIONAL-METABOLIC

Pt. ER currently weighed 46 kg and stands 158cm tall. According to Pt ER he is

currently taking milk. He does not take any Herbal medicine and any other supplements.
There is no particular time of his meal and snack and according to him; he eats whenever
he feels hungry. He often eats bread, meat and rice.

*3-day Diet Recall

MEALS DAY 1 DAY 2 DAY 3

Breakfast  1 mug  2 glasses of  1 mug of coffee
of Coffee water  Rice
 2 bread  3 bread  Fried fish

Snack  None  Juice  None

 Biscuits
Lunch  2 glasses of  None  2 glasses of
water water
 2 cups of rice  2 cups of rice
 Meat  Chicken and
vegetable
Snack  Banana – cue  2 glasses of  none
 1 glass of water water
 2 cups of rice
 Fish and
vegetables
Dinner  1 ½ cups of rice  1 ½ cups of rice  1 cup of rice
 Fish  Vegetables  Meat
 2 glasses of  Water  Banana
Juice
Snack No snack No snack No snack
Total Fluid Intake 700ml 500ml 600ml

Interpretation:

5
 This table shows the 3 Day Diet recall of Patient ER. Based on the table he has
not definite time for meals and snack and he needs more fluid intake to aid in her
digestion. In addition, Pt. ER eats meat and vegetables randomly because according to
him he only eats what he feels like eating.

C.ELIMINATION
Pt ER defecates everyday at no definite time which happens on a morning or
afternoon. He has no problem in controlling his defecation. He stated that the color of his
stool is sometimes brownish or yellowish.
D.ACTIVITY-EXERCISE

*7-day Activity Table

Tim Days of the Week & Date
e Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Sept.23 Sept.24 Sept.25 Sept.26 Sept.27 Sept.28 Sept.29
Thurs. Fri. Sat. Sun. Mon. Tues. Wed.
1 Playing Playing Playing Playing Playing Playing Playing
am Video Video Video Video Video Video Video
games games games games games games games
2 Sleep sleep sleep sleep sleep sleep Sleep
am
3 Sleep Sleep Sleep Sleep Sleep Sleep Sleep
am
4 Sleep Sleep Sleep Sleep Sleep Sleep Sleep
am
5 Wake Wake sleep sleep Wake Wake Wake
am up for up for up for up for up for
school school school school school
6 Eating Eating Eating Eating Eating Eating Eating
am
7 Go to Go to Lying on Lying on Go to Go to Go to
am school school his bed his bed school school school
8 School School Going Going School School School
am outside outside
9 School School Waking Waking School School School
am
10 School School Sleep Sleep School School School
am
11 School School Playing Sleep School School School
am

6
 12 School School Eat Eat School School School
nn lunch lunch
1 School School Watch Watch School School School
pm televisio televisio
n & rest n & rest
2 School School Playing Playing School School School
pm
3 School School Rest Rest School School School
pm and eat and eat
4 School School Sleep Sleep School School School
pm
5 Play Play Play Play Play Play Play
pm with with with with with with with
friends friends friends friends friends friends friends
6 Dinner Dinner dinner dinner Dinner Dinner Dinner
pm
7 Rest Rest Rest Rest Sleep Sleep Rest
pm
8 Rest Sleep Sleep Sleep Rest Sleep Rest
pm
9 Watchin Watchin Watchin Watchin Watchin Watchin Watchin
pm g TV g TV g TV g TV g TV g TV g TV
10 Playing Playing Playing Playing Playing Playing Playing
pm Video Video Video Video Video Video Video
games games games games games games games
11 Playing Playing Playing Playing Playing Playing Playing
pm Video Video Video Video Video Video Video
games games games games games games games
12 Playing Playing Playing Playing Playing Playing Playing
mn Video Video Video Video Video Video Video
games games games games games games games

Interpretation

The table shows that the client has different daily routine.He has no particular
time on eating meals and snacks.Pt ER has excessive time for playing video games.
Katz Index of Independence in Activities of Daily Living

Activities Independence Dependence

Bathing 1 0
Dressing 1 0
Toileting 1 0

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 Transferring 1 0
Continence 1 0
Feeding 1 0
TOTAL POINTS 6 0

Interpretation:

The table shows that the client scored 6 which shows that she is fully independent
on doing her ADL.

E.SLEEP-REST

Pt. ER experience difficulty in sleeping because of his routine. Because he sleeps

almost 1am in the morning because of playing computer games. Pt. ER have a irregular
sleeping , he don’t sleep at exact 8 hrs.

Constructs Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

Hours of sleep 5 4 6 6 4 4 5
Sleeping time 2am 2am 2am 2am 2am 2am 2am
Waking time none none none none none none none
Bedtime none none none none none none None
rituals
Problem none none none none dreams none None
Encounterd

F.SELF-PERCEPTON-SELF-CONCEPT
He describes himself as simple. According to him, he is satisfied w/ himself and
his family. He easily got mad when he is cleaning their house.

G.ROLE-RELATIONSHIP
Their family structure is nuclear. He and his Brother usually talk about their problems
and how to solve it. They seldom argue about their problems. He has close friends but
doesn’t confide his problems with them. He mostly stayed at home playing his computer.
His relationship to his neighbors is not strong since he doesn’t go out much. Regarding
his relationship to his parents, they sometimes misunderstood each other
ECOMAP

8
 RELATIVES CHURCH

ER S.R

DR ER
SCHOOL
HOSPITAL

NEIGHBORHOOD

LEGEND:

- stressed

- strong - Family

- very strong

Interpretation

Pt. ER and his family are tightly closed with their relatives as well
as the church because in times of crisis, they tend to hold on to their faith. Other
than that they are still close with hospital and neighbors because they socialize
well.

J.COPING-STRESS

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 According to Pt ER when he and her family have a problem, they talk about it and
thy try to fix it. When he is having stressful times, he prays and he tries to think about his
good experience in other not to feel sad.

K.VALUE-BELIEF

Generally, his family is his priority in life. He just wants tobe a good son to his
father and even to his mother. Religion is important in his life because he hold on to his
faith when difficulties arise. Other than that, he does not practice any unusual religious
practice.

IX. Physical Examination

A. Vital Signs
T =36.9 degree Celsius
PR =83bpm
RR =25cpm
BP =90/70 mmHg
Pain
B. Anthropometric Data
Height =158cm
Weight=46 kg

C. General Appearance
1. Body build and height-weight proportionality
Pt. ER build is proportion with his head and body. His height is
coherent with his body weight.

2. Posture and Gait

The client appears to have good posture. He denied having any illness.
As I observed, he has a good balance control coordinated with his
movements.

3. Over-all hygiene and grooming

While the interview, Pt ER is wearing his clean uniform. According to
him, he takes a bath twice a day.
4. Body and breath odor

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 5. Obvious signs of distress / illness
6. Mental status
7. Attitude
8. Affect/mood; appropriateness of responses
9. Quantity and quality of speech
10. Relevance and organization of thoughts

D. Cephalocaudal Assessment

Assessment Actual Findings Normal Findings Clinical Significance

Procedure
INTEGUMENTA
RY
Skin Inspection reveals Pallor skin is seen in
I: color, Skin color brown evenly colored skin arterial insufficiency,
uniformity edema, absence of scars tones without decreased blood
lesions unusual or supply, and anemia.
P: moisture, prominent Jaundice mostly
temp., turgor discoloration. results from liver
problem.

Edema Absence of edema Skin rebounds and .

does not remain
indented when
pressure is
released.
Temperature Warm to touch Skin is normally a Cold skin may
Normal Temp w/c is warm temperature. accompany shock or
37 degree celcius hypotension. Cool
skin may accompany
arterial disease. Very
warm skin may
indicate a febrile state
or hyperthyroidism.

Hair -The hair is evenly

I: evenness of Upon inspection, the distributed Nutritional
growth, hair of the patient is -the scalp should deficiencies may
thickness, thick. be non- tender cause patchy gray
texture, oiliness, -the scalp is clean hair in some clients.
infection or During palpation, the and dry without
infestation, body scalp is non tender. lesions
hair
P: smoothness

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 Body hair Normal growth of Varying amounts of If there is excessive
body hair. terminal hair cover generalized hair loss,
the scalp, axillary,it may occur with
body, and pubic infection, nutritional
areas according to deficiencies, hormonal
normal genderdisorders, thyroid or
distribution. liver disease, drug
toxicity, hepatic or
renal failure or a result
from chemotherapy.
P: smoothness Smooth and firm hair Hair is smooth and As people age, hair
firm, somewhat feels coarser and
elastic. drier.
Nail
I: plate shape Rounded nail shape, Round or square If there is an early
P: Blanch test 160-degree angle nail shape clubbing (180-degree
Upon blanch test, the according to the angle w/ spongy
color of the nail cuticle. There is sensation) and late
return to its normal normally 160-clubbing(greater than
color which is pinkish degree angle180-degree angle)
red in less than 1 between the nail can occur from
second. base and the skin. hypoxia. Spoon nails
may be present w/
iron deficiency
anemia.
texture Thick nails in hands Nails are hard and Thickened nails
and toenails. basically immobile. (especially toenails)
Dark-skinned may be caused by
clients may have decreased circulation.
thicker nails.
Surrounding Soft tissue and intact Soft tissue and The cuticle provides
tissue skin. without any lesions. protection.
HEAD
Skull and Face Upon inspection, the
I: size, shape, shape of the head is - The shape of the If there is acromegaly,
symmetry symmetrical, no head is symmetrical. the skull and facial
:facial features edema are No presence of bones are larger and
:eyes for edema inspected. edema. thicker because of
and hollowness increased production
In palpating the of growth hormone.
patient’s face, there
P: nodules, are no masses,
masses, nodules or any
depressions depressed part,
tenderness, all facial

12
 features is within
normal and is
properly positioned.
…
shape, Symmetric and oval Shapes of skull Acorn-shaped,
symmetry in shape. vary. Head is enlarged skull bones
symmetric, round, are seen in Paget’s
erect and in disease of the bone.
midline.
: facial features When I saw her she Facial features are When there is poor
welcome me a big symmetric with eye contact clients are
smile . movement. Client depressed. An
establishes good expressionless,
eye contact when masklike face is
conversing with common in
others. Parkinson’s disease.
An inappropriate facial
expression may
indicate mental
illness.
: eyes for In inspecting the Absence of edema Presence of
edema and eyes, the color of the and hollowness hollowness may be
hollowness eyes are dark brown, due to lack of sleep or
cornea is clear, no rest, and stress.
unnecessary eye
movements, and is
symmetrical to each
other; eyebrows are
thin and evenly
distributed.

P: nodules, Absence of nodules Absence of If there are lesions or

masses, masses or nodules, masses, lumps on the head, it
depressions depression. or depression. may indicate recent
trauma or cancer.
Eyes and
Vision Evenly distributed Aligned, evenly Their function is to
I: Eyebrows for hair in the eyebrows, distributed hair, fine protect the eye from
distribution and aligned, fine and able and able to move sweat and rain, and it
alignment, to move. eyebrows. is also used as a
quality and facial expression.
movement.
: Eyelashes Eyelashes are evenly Eyelashes are If there is an inverted
for evenness of distributed and evenly distributed eyelash, it could
distribution and curved outward along and curved outward cause pain and injure
direction of curl. the lid margins. along the lid the cornea as the

13
 margins. eyelash brushes
against the
conjunctiva and
cornea.
: eyelidsfor The color of her Eyelids depend on If there is presence of
surface eyelids is light-brown the color of skin lesions or swelling it is
characteristics like the color of her tone, absence of caused by trauma.
skin. Absence of swelling, lesions
swelling, lesions, and and discharges.
discharges.
position in Eyelids are Upper lid margin If drooping of the
relation to symmetrically aligned should be between upper lid, (ptosis) it
cornea w/ the cornea. the upper margin of may be attributed to
the iris and the oculomotor nerve
upper margin of the damage, myasthenia
pupil. The lower lid gravis, weakened
margin rests on the muscle or tissue, or a
lower border of the congenital disorder.
iris.
ability to blink She has the ability to The upper and Failure of lids to close
and frequency blink. lower lids close completely puts client
easily and meet at risk for corneal
completely when damage.
closed.
: bulbar Bulbar conjunctiva If there is generalized
conjunctiva for Upon inspection and is clear, moist, and redness, it suggests
color, texture, palpation, the upper smooth. Underlying conjunctivitis.
and lesion. palpebral structures are
conjunctiva are pink clearly visible.
in color and clear Sclera is white and
without lesions absence of lesions.

Palpebral The lower and upper The lower and A foreign body or
conjunctivafor palpebral conjunctiva upper palpebral lesion may cause
color, texture, is clear and free of conjunctiva is clear irritation, burning, pain
and lesion swelling or lesions. and free of swelling and/or swelling of the
or lesions. upper eyelid.
I/P:lacrimal Absence of edema or No swelling or Swelling may be
gland tenderness. Able to redness should caused by blockage,
sac,nasolacrim tear in a right amount appear over areas infection, or an
al duct for as stated by the of the lacrimal inflammatory
edema, client. gland. No drainage condition. Excessive
tenderness/ should be noted tearing may indicate a
tearing from the puncta nasolacrimal sac
when palpating the obstruction.

14
 nasolacrimal duct.
I: corneafor The cornea is clear, The cornea is If there is area of
clarity, texture smooth and sensitive transparent w/ no roughness or dryness
and sensitivity to light. opacities. The on the cornea, it is
oblique shows a often associated w/
smooth and overall injury or allergic
moist surface. responses.

direct and The normal direct The normal direct It is considered

consensual and consensual and consensual abnormal, if pupils do
reaction to light pupillary response is pupillary response not react at all to
constriction is constriction. direct and consensual
papillary testing.
 Visual Normal distant vision Normal distant *Impaired far vision
Acuity(near & acuity is 20/20.vision acuity is (myopia)
far vision test) Normal near visual 20/20. Normal near *Impaired near vision
acuity is 14/14. visual acuity is (presbyopia)
14/14.
 Visual Field Inferior: 70 degrees Inferior: 70 degrees A delayed or absent
Test Superior: 45 degrees Superior: 50 perception of the
Temporal: 90 degrees examiner’s finger
degrees Temporal: 90 indicates reduced
degrees peripheral vision.
 EOM test
Corneal light Parallel alignment of The reflection of If there is an
reflex test both eyes. light on the corneas asymmetric position of
should be in the the light reflex, it
exact same spot on indicates deviated
each eye, w/c alignment of the eyes.
indicates parallel This may be due to
alignment. muscle weakness or
paralysis.
Cover test The uncovered and The uncovered eye The uncovered eye
covered eyes remain should remain fixed will move to establish
fixed straight. straight ahead. The focus when the
covered eye should opposite eye is
remain fixed covered. This finding
straight ahead after indicates a deviation
being uncovered. in alignment of the
eyes and muscle
weakness.
Positions test The eyes are able to Eye movement Failure of eyes to
move symmetrically should be smooth follow movement
with coordination in and symmetric symmetrically in any
all six directions. throughout all six or all directions
directions indicates a weakness

15
 in one or more
extraocular muscles
or dysfunction of the
cranial nerves that
innervates the
particular muscle.
Ears and In inspecting the The ears are evenly Malaligned or low-set
Hearing ears, the auricle is colored. It is equal ears may be seen
I: auricles for brown in color, in size bilaterally. with genitourinary
color, symmetry symmetrical to each The auricle aligns disorders or
and position other and the tip of with the corner of chromosomal defects.
the ear is horizontal each eye and within
to the outer canthus a 10-degree angle
of the eye. of the vertical
position.
: external There is no seen A small amount of *Foul-smelling, sticky,
canal for lesions pus or blood odorless cerumen yellow discharge—
cerumen in the outer canal of is the only otitis externa or
the ears. discharge normally impacted foreign
Upon palpating the present. body.
auricles, it easily
came back to each
original state after
pinching it. There is
no tenderness

lesions, pus Without lesions, pus The canal walls *Bloody, purulent
or blood or blood present as should be pink and discharge—otitis
seen with the use of smooth and without media with ruptured
penlight. nodules. tympanic membrane.
P: auriclesfor The auricles are The skin is smooth A painful auricle is
texture, smooth. It is with no lesions, associated with otitis
elasticity and somewhat elastic lumps, or nodules. externa or a post
areas of and absence of Normally the auricle auricular cyst.
tenderness tenderness. is not tender.
 Rinne’s test to Not performed… Air conduction *With conductive
compare air sound is normally hearing loss, bone
and bone heard longer than conduction sound is
conductions bone conduction heard longer than or
sound. equally as long as air
conduction sound
(BC>AC).
*With sensorineural
hearing loss, air
conduction sound is
heard longer than

16
 bone conduction
sound (AC>BC) if
anything is heard at
all.
NOSE
Upon inspecting the Color is the same Flaring or discharges
I: nose nose, there is no as the rest of the is an abnormal signs.
deviation in discharge, it has two face; the nasal
shape, size, nostrils are patent, structure is smooth
color, flaring, It is brown in color. and symmetric;
discharge; No nose flaring while
:nasal mucosa breathing.
for redness, Upon palpating the
swelling, growth nose, there is no
or discharge tenderness, masses,
P: tenderness, swelling
masses,
displacements;
: nasal patency
: maxillary and
: frontal
sinuses for
tenderness
Pe: the above
sinuses for
tenderness

: nasal Is able to sniff Is able to sniff Client cannot sniff

patency through each nostril through each nostril through a nostril that
while the other is while the other is is not occluded, nor
occluded. occluded. can he or she sniff or
blow air through the
nostrils. This may be
a sign of swelling,
rhinitis, or a foreign
object obstructing the
nostrils.
: maxillary Frontal and maxillary Frontal and Frontal or maxillary
and frontal sinuses are non- maxillary sinuses sinuses are tender to
sinuses for tender as palpated. are non-tender to palpation in clients
tenderness palpation, and no with allergies or acute
crepitus is evident. bacterial
rhinosinusitis.
Pe: the above Sinuses are not Sinuses are not The frontal and
sinuses for tender on tender on maxillary sinuses are
tenderness percussion. percussion. tender upon

17
 percussion in clients
with allergies or sinus
infection.
Mouth /
Oropharynx Upon inspecting, lips Lips are smooth Pallor around the lips
I: lips for are symmetrical, pink and moist without is seen in anemia and
symmetry of to red in color, no lesions or swelling. shock. Bluish lips may
contour, color, lesion, and not dry. Pink lips are normal result from cold or
texture, in light-skinned hypoxia. Reddish lips
moisture, lesion In teeth, the patient clients as are bluish are seen in clients
has no dentures, or freckled lips in with ketoacidosis,
teeth are equal. some dark-skinned CO poisoning, and
clients. COPD with
polycythemia.
Swelling of the lips is
common in local or
systemic allergic or
anaphylactic
reactions.
: teeth for In teeth, the patient 32 pearly whitish Clients who smoke,
alignment, loss, has no dentures, teeth with smooth drink large quantities
dental fillings teeth are equal. surfaces and of coffee or tea or
and caries. edges. Upper have an excessive
molars should rest intake of fluoride may
directly on the have yellow or
lower molars and brownish teeth. Tooth
the front upper decay (caries) may
incisors should appear as brown dots
slightly override the or cover more
lower incisors. No extensive areas of
repaired or chewing surfaces.
decayed areas; no Missing teeth can
missing teeth or affect chewing as well
appliances. as self-image.
: gums for Gums have no Gums are pink, *Red, swollen gums
bleeding, color, swelling, lesions. moist, and firm with that bleed easily are
retraction, Sometimes, bleeding tight margins to the seen in gingivitis,
lesions, swelling gums are present tooth. No lesions or scurvy (vit. c
due to her masses. deficiency), and
pregnancy. leukemia.
*Receding red gums
with loss of teeth are
seen in periodontitis.
It is abnormal in
younger clients.
*Enlarged reddened

18
 gums (hyperplasia)
that may cover some
of the normally
exposed teeth may be
seen in pregnancy,
puberty, leukemia,
and use of some
medications, such as
phenytoin.
: tongue for Upon inspection, her Tongue should be Among possible
position, color & tongue was pink in pink, moist, a abnormalities are
texture color with white moderate size with deep longitudinal
coloration, moist, and papillae present, fissures seen in
symmetric. There is a and symmetric in dehydration; a black
presence of papillae position. tongue indicative of
on it. bismuth toxicity:
black, hairy tongue; a
smooth, reddish,
shiny tongue without
papillae indicative of
niacin or B12
deficiencies, certain
anemia, and
antineoplastic
therapy.
: salivary Upon inspecting the Absence of swelling Abnormal findings
gland ducts for salivary gland in the and redness in the include lesions,
swelling, lower portion of the client. ulcers, nodules or
redness tongue, there is no hypertrophied duct
redness and openings on either
swelling. side of frenulum.

: palates for Presence of torus The hard palate is A candidal infection

color, shape, palatines in the hard
pale or whitish with may appear as thick
texture, palate. The soft
firm, transverse white plaques on the
presence of palate is pinkish and
rugae. Torus hard palate. Deep
bony smooth while the palatinus is a purple, raised, or flat
prominences hard palate is firmnormal variation lesions may indicate a
and has the
seen more often in Kaposi’s sarcoma
presence of
females, Eskimos, (seen in clients with
transverse rugae. Native Americans, AIDS).
and Asians.
: uvula for The uvula is The uvula is a Asymmetric
position & symmetric and fleshly, solid movement or loss of
mobility moves when saying structure that hangs movement may occur
“aaah”. freely in the after a

19
 midline. No redness cerebrovascular
of or exudates from accident (stroke).
uvula and Palate fails to rise and
symmetric elevation uvula deviates to
of the soft palate. normal side with
cranial nerve X
(vagus) paralysis.

: oropharynx Pink and smooth in Pink and smooth in Any deviation in color
for color & texture as inspected texture. is considered
texture by penlight. abnormal.
Neck Muscles Upon inspecting the
patient’s neck, there
I: abnormal is no seen swelling,
swelling or inflammation and the
masses, head patient can move her
movement and head freely. Left to
muscle strength right is 180 degrees.
She can turn up and
down

Chest and  Chest  Chest  Pectus

Thorax symmetric symmetric carinatum
 Skin intact  Lordosis  Pectus
 Chest wall  Thorax is excavatum
intact; no slightly  Kyphosis
tenderness; elliptical in  Scoliosis
no masses shape  Having one
 Absence of  Shoulders at shoulder or
chest pain the same scapula is
 Absence of height higher than the
Dyspnea  Dilated other
 Absence of superficial  Presence of
Orthopnea veins are not dilated
seen superficial
 Respiratory veins
rate is 12-20  Respiratory
breaths per rate greater
minute than 20 breaths
 Normal per
respiration minute(tachypn
are regular ea)
and even in  A respiratory
rhythm rate lower than
 Depth of 12 breaths per
inspiration is minute(bradypn

20
 nonexaggera ea)
ted and  Irregular
effortless respiratory
 Chest wall pattern
intact; no  Orthopnea
tenderness;  Continous
no masses mouth
 Crepitus breathing
should be  Presence of
absent pulsation on
 Absence of thorax
chest pain  Presence of
 Absence of thoracic mass
Dyspnea  Presence of
 Absence of crepitus
Orthopnea  A high
 No thoracic diaphragm
tenderness level
 Decrease
breath sound

Cardiovascular Not performed Not performed Not performed

Genitalia Not performed Not performed Not performed
Musculoskelet Body height and Excessively tall or
al weight should be short,or overweight or
appropriate for age underweight
and gender Structural defects
The torso and head Forward slouching of
are upright the shoulders
Walking forward in a Atrophy
straight path Involuntary muscle
Arms swings freely movement
The heel of the foot is Enlargement of joint
well elevated off the Deformity of joint
floor capsule
No observed Hypotonicity
involuntary muscle Spasticity
movement Muscle spasm
Muscle masses
Nodules
Presence of pain and
tenderness
Decrease movement
Elbows that are not
symmetrical
Extra finger, loss of

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 finger or webbing
A neck that is not erect
and straight
A change in size of the
neck

Cranial Nerves
-I to XII I Olfactory - able to
smell coffee.

II Optic Vision – pupil

contracts. Light pen
test
Visual acuity using
near card at 14
inches.

III, IV, VI Oculomotor,

Trochlear, Abducens
Eye movement Gaze
in nine directions by
the use of the pen.

V , Vll Trigeminal
Facial – able to show
different expressions
such as frown, smile
and laugh.

VIII
Vestibulocochlear –
able to hear the tick
of the watch.

IX, X
Glossopharyngeal,
vagus – able to
swallow by giving the
patient to drink water.

XI Spinal accessory
–able to shrug on
assessing the
strength of trapezius
muscle.

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 XII Hypoglossal –
able to extrude
tongue. Move the
tongue up and down
and left and right.

Neurologic Affect amd mood are Affect/mood:

appropriate to her Appropriate of the
current situation client’s responses
appropriate to
Oriented to time, place situation
and person Mentally alert
(oriented to time,
place, and person)
memory, ability to
follow command,
response to stimulus.

III. Diagnostic Test

A. Non-Invasive

Specific Test Actual Finding Normal Clinical

Finding Significance
Sputum
Microscopy
Urinalysis
Fecalysis
Radiology
Others: ECG,
MRI, CT
B. Invasive

Specific Test Actual Finding Normal Clinical

Finding Significance
Blood Chemistry
Hematology
Electrolytes
ABG
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 Visualization
procedures
(surgical
approach)

Review of System

A. Neurologic
Client ER. is aware and can answer all the questions ask by the examiner. The
client can walk independently and can maintain balance when standing.

B. Pulmonary
The client stated that he can breathe normally without experiencing any pain. He
snores whenever he’s’ tired.

C. Cardiovascular
According to client ER. he does not experience chest pain and weakness. swelling
of the extremities is not present.

D. Hematologic
The client verbalized that he is not anemic.

E. Immunologic
The client states that he does not easily acquire colds and cough. If he got colds, it
only last for a day or two.

F. Gastrointestinal
The client stated that he doesn’t feel anything unusual in his gastrointestinal tract.
Defecation is regular and is not painful. The color of the stool is brown.

G. Renal
According to the client he don’t have urinary tract infection. He does not have
urinary incontinence.

H. Musculoskeletal
The client verbalized that he don’t have any problem with his body.

I. Reproductive

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 The client stated that there was not something wrong with hs body

J. Integumentary
When the skin is pinched, the client feels pain; there is no abnormal discoloration
on the skin surface and no itching.

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