5.

Physical Examination (Cephalocaudal Approach) Name: Hansel Date Assessed: July 26, 2013 Age: 15y/o VITAL SIGNS: T= 37C PR= 90bpm RR= 24bpm BP= 120/80mmHg

Body Part Head And Neck Head

Inspection

Palpation

Percussion

Auscultation

The head is normocephalic , the size is proportionate to the body, no

Her skull is smooth, no tendernes palpated

lesions and scars s Hair The hair is long and curly with even hair Scalp distribution Pale white without lesions No lesions

and scars, not Forehead swollen No pimple, fair in color. No lesions noted Face or found. Symmetrical, color match with the exposed body parts, no involuntary movements in the facial muscle (negative Eyes Chvosteks sign) Symmetrically aligned, no involuntary Brows movements Bilateral, even distribution of Lashes thick black hairs Even distribution of hair on the lid margins, Lids: Upper Smooth in texture, no lesions and scars, brown in Lower color Smooth in

noted Temporal pulse are felt

texture, no lesions and scars, brown in Sclera color White with the presence of superficial Conjunctiva arteries Pale pink and free of Cornea discharges Clear, smooth and reacts with Iris Pupil light Round, black in color, no lesions Are equal, round and reacts to light and Muscle Function accommodation Cover test: uncovered eye reacts every time the cover is removed the Muscle Balance Peripheral Vision same as the eye Both eyes are equal in movements The patient can see my finger without moving her head

Nose

No lacerations and scars symmetrical with face Transilluminate with diffused red appearance

Frontal Sinuses

Patient doesnt complain of pain when palpated Patient doesnt complain of pain when palpated

No pain felt

Maxillary sinuses

No pain felt

Mouth Lips Pinkish and dry, close symmetrically of Gums free lesions Pinkish, no swelling and Teeth bleeding Yellow in color and has 28 teeth, and 3 of them were seen Tongue Frenulum with cavities Pinkish taste buds Light pink, no lesions, Dry and crack

Sublingual

moistened Soft, pale, pink, no lesions, moistened Pale pink, no lesions, moistened Soft, pale pink no lesions, moistened Centrally located, no lesions, pink in color, hangs freely Not swollen, pink in color, pink Presence of earwax, smooth without lesions Bilateral; symmetric No perforations Able to hear whispered words Presence of incision Non palpable Located in the midline Noted incision line with dressing from post No tendernes s, palpable,

Hard palate

Soft palate

Uvula

Tonsils Ears

External Internal Auditory canal Neck Lymph nodes Trachea Thyroid gland

thyroidectomy. The patient was assessed with effective Thorax swallow reflex. Chest is symmetric rises and falls during respiration

no pain felt

No tendernes s, palpable, no pain felt No scars, no lesions, no swelling

Chest anterior

Smooth, good, skin turgor

Vibrations on the right side is the same as the left side Vibrations on the right side is the same as

Resonance

Lungs

RR of 24 bpm

Heart

Nonpalpable beats are felt No pain felt

he left side Dull sound Apical pulse (90 bpm)

Chest posterior

Symmetrical, spine is vertically aligned, spinal

Vibrations on the right side is similar

Resonance

column is straight Diaphragmat ic excursion Chest rises during inhalation and falls when exhaling Abdomen Fair in color; umbilicus is at midline Liver Spleen Kidney Extremities Upper Bilateral, even distribution of fine hairs, no abrasions, no lesions Lower Bilateral, even distribution of fine hairs, no abrasions, no lesions, no scars Warm extremiti es Non palpable Non palpable Non palpable

as the left side

BP of 120/80 mmHg