You are on page 1of 9

X.

Physical Examination

System Normal findings Actual findings Remarks


General  Appears as its age  Appears as its age Inappropriate
appearance  In good hygiene  Good hygiene speech from its

 Appearance is  Appears age is deviated

appropriate for appropriate for age from normal

age  Alert & active


 Alert and active  Appears happy
 Appears happy  Cooperative
 Cooperative  Has lordotic
 Lordotic posture posture
 Appears well-  Appears well-
nourished nourished
 Can speak two  he cannot speak
word sentence other than mama,
papa, boom-boom
Vital signs  RR: 20- 40 bpm  RR:27 cpm All of the findings
 heart rate 90 -  heart rate: 100 for the vital signs
110 bpm bpm are found to be
 temperature: within the normal
37.44°C  Temperature: 37 range.

°C
Anthropometric  Asians are  Height: 31 in All of the findings
measurement smaller than  Weight: 12kg for the
Caucasians Head anthropometric
newborn. Asian circumference: 19 measurement are
children are in found to be within
smaller at all ages the normal range.
Skin  Skin color ranges  light brown All of the findings
from pale white no foul odor for the skin are
with pink,  no lesions / edema found to be within

23
yellow, brown, or  smooth and even the normal range.
olive tones to  slightly moist
dark brown or  soft
black. No strong
 warm to touch
odor should be
 returns after
evident, and the
pinched: good
skin should be
turgor
lesion free.
 skin is intact
 Skin should be
soft warm,
slightly moist
with good turgor
and without
lesions and
edema.
Hair  Even distribution  Well distributed All of the findings
throughout the for the hair are
body, fine hair found to be within
 No scalp lesions covers body the normal range.

 No masses  No lesions

 hair is clean,  No masses


neatly arranged  Clean and dry
 Characteristics of
hair is elastic,  Silky, elastic,
lustrous and silky lustrous
 Absence of
infestation  Absence of
infestations
Nails  Pinkish nail bed  Pinkish nails, have All of the
some longitudinal findings for the
ridges nails are found

24
 Concave shape,  The nails are has to be within the
has longitudinal concave shape normal range.
ridges  Clean
 Nails are clean
and well  Capillary refill:
manicured pink tones return <
 Color of the nail 2sec
bed back to
original color
after 1-2 seconds  160º angle

 The angle of the between


nail base and ski nail base and skin
is 160 º
 Head  Symmetrical,  normocephalic All of the findings
rounded and &symmetric for the head are
normocephalic found to be within
 head is steady  head can be steady the normal range.

 No palpable  No lymph nodes


lymph nodes
 full range of  full range of
motion motion: up, down,
sideways
 No tenderness  No tenderness
 Symmetrical  Symmetrical facial
facial expression expression
such as smiling,
frowning  No masses
 No masses
Eyes  eyes are  eyes are both All of the findings
symmetrical symmetric for the eyes are
 eye lashes are  eye lashes is thin, found to be within

25
evenly curled outward the normal range.
distributed, thin and evenly
and curled distributed
outward
 inner canthus  inner canthus
distance is 2-3 cm distance is 2
 Sclera white cm
 No discharge, no  sclera is white
discoloration of  no discharge,
eyelids lesions, lacerations
 When lids are
close, sclera is  when lids are
not visible close, sclera is not
 Pink conjunctiva visible

 No edema or  pinkish
tenderness over conjunctiva
lacrimal gland  no edema or
 equal eye tenderness in the
movement eyes

 alignment of  Equal eye


outer canthus movement
with the tip of the  Outer canthus
pinnas aligns with tip of
 pinnas
Ears  Symmetrical  3cm equal in size All of the findings
bilaterally for the ears are
 Aligned to the  top of pinna cross found to be within
inner canthus eye-ociput line the normal range.

 No lesions  smooth without


lesions
 Color same as  the same with the

26
facial skin facial color
 Firm and not  auricle, tragus and
tender mastoid process is
non tender
 Aligned to the
 No masses inner canthus
 no discharge
 No discharges present
Nose and sinuses  Symmetrical  midline in face All of the findings
 No discharges  no discharge for the ears are

 Uniform in color  Same color as found to be within

skin the normal range.

 Not tender  no tenderness


 Pink mucosa  turbinates are pink
 No lesions  absence of lesions
 Nasal septum in the nose
intact and in the  septum is straight
midline
 Sinuses are not  Sinuses are not
tender tender
 No nasal flaring  No nasal flaring
Mouth  Deciduous teeth  14 deciduous teeth All of the findings
present erupted for the mouth are
 pink tone of  pinkish tone of found to be within
gums, tongue, gums, tongue and the normal range.
and tonsils tonsils
 Moist and  Moist
slightly rough  absence of lesions
tongue
 absence of  smooth tongue
lesions in oral base with

27
mucosa capillaries
 Smooth tongue  pinkish in color
base and smooth
 pinkish soft and
 Light pink, hard palate
smooth soft  Uvula is
palate positioned in the
 Light pink hard midline.
palate
 Uvula is
positioned in the
midline of soft
palate
Throat and neck  No palpable  No palpable lymph All of the findings
nodes for the throat and
lymph nodes
 Generally  Uniform in color neck are found to
uniform in color be within the
 No edema normal range.
 No edema
 Neck can move  Neck can move
freely
freely
 neck is short with
 neck is short with some skin folds
skin folds

Breast and axilla  Symmetrical  Symmetrical All of the findings


breast and breast and axilla for the breast and
symmetrical axilla are found to
axilla  No tenderness be within the
 absence of normal range.
tenderness  No secretions
 No secretions or
discharges  No masses or

28
 No masses or nodules
nodules
Chest and  Symmetrical  rounded, All of the findings
respiratory placement of all symmetric, for the chest and
structures shoulder and respiratory are
 Bilaterally equal scapula are equal found to be within
shoulder height horizontal position the normal range.

 regular breathing
pattern  unlabored, regular
breathing,
 No hyperresonance
lesions/masses  skin are free from
lesions and masses
 No tenderness  no tenderness
Cardiovascular  Apical pulse:80-  PR:110 bpm All of the findings
and peripheral 140 bpm for the
 Apical pulse  presence of apical cardiovascular
audible pulse and peripheral are

 Absence of cold found to be within

 No cold extremities and no the normal range.


extremities and discolored
discolored extremities
extremities
Abdomen  Uniform skin  Uniform in color All of the findings
color in the for the abdomen
abdomen  prominent when are found to be
 Symmetric standing and within the normal
contour is supine positions range.
rounded  Absence of lesions

 No lesions  no tenderness

29
 No masses
 No tenderness palpable
 No masses
Reproductive  Not assessed  Not assessed  Not assessed
Musculoskeletal  Uniform color of  uniform in color Less muscle
extremities strength in lower
 10 fingers and  10 fingers and toes extremities as
toes  feet & legs are deviated from

 Symmetrical symmetric normal.

 Absence of
 No fractures, fractures,
dislocations and dislocations and
deformities deformities
 full range of  full range of
motion motion without
tenderness
 No tremors and  Absence of
palpable nodules tremors and
 extremities warm nodules
to touch  warm to touch
 lordotic posture
 bow-legged gait  lordotic
 bow-legged (genu
 strong muscle varum)
strength  Less muscle
strength noted in
the lower
extremities

Endocrine  Gradual weight  Gradual weight All of the findings

30
gain gain for endocrine are
found to be within
the normal range.
Hematological  No bleeding  No bleeding All of the findings
 No bruises  No bruises for hematological

 Blood type  blood type B are found to be


within the normal
range.
Lymph nodes  No palpable  No palpable lymph All of the findings
lymph nodes nodes for lymph nodes
 No tenderness  No tenderness are found to be
within the normal
range.

31