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Physical Examination System General appearance Normal findings Actual findings  Appears as its age  Appears as its age  In good hygiene  Appearance is appropriate for age  Alert and active  Appears happy  Cooperative
 Lordotic posture

Remarks Inappropriate speech from its age is deviated from normal

 Good hygiene
 Appears

appropriate for age  Alert & active  Appears happy  Cooperative
 Has lordotic

posture  Appears wellnourished  he cannot speak other than mama, papa, boom-boom  RR:27 cpm  heart rate: 100 bpm  Temperature: 37 °C  Height: 31 in  Weight: 12kg
Head

 Appears wellnourished  Can speak two word sentence Vital signs  RR: 20- 40 bpm  heart rate 90 110 bpm
 temperature:

All of the findings for the vital signs are found to be within the normal range. All of the findings for anthropometric measurement are found to be within the normal range. All of the findings for the skin are the

37.44°C Anthropometric measurement  Asians are smaller than Caucasians newborn. Asian children are Skin smaller at all ages  Skin color ranges from pale white with pink,

circumference: 19 in  light brown
no foul odor

 no lesions / edema found to be within

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yellow, brown, or olive tones to dark brown or black. No strong odor should be evident, and the skin should be lesion free.  Skin should be soft warm, slightly moist with good turgor and without lesions and Hair edema.  Even distribution

 smooth and even  slightly moist  soft  warm to touch  returns after pinched: good turgor  skin is intact

the normal range.

 Well distributed throughout the body, fine hair

All of the findings for the hair are found to be within the normal range.

 No scalp lesions  No masses  hair is clean, neatly arranged  Characteristics of hair is elastic, lustrous and silky  Absence of infestation Nails  Pinkish nail bed

covers body  No lesions  No masses  Clean and dry
 Silky, elastic,

lustrous
 Absence of

infestations  Pinkish nails, have some longitudinal ridges

All

of

the

findings for the nails are found

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 Concave has ridges

shape,  The nails are has concave shape
 Clean

to be within the normal range.

longitudinal

 Nails are clean and manicured  Color of the nail bed back to color
 160º angle

well  Capillary refill: pink tones return < 2sec

original

after 1-2 seconds  The angle of the nail base and ski  Head is 160 º  Symmetrical, rounded and normocephalic  head is steady  No palpable lymph nodes  full range of motion  No tenderness  Symmetrical facial expression such as smiling, frowning Eyes  No masses  eyes are symmetrical  eye lashes are

between nail base and skin  normocephalic &symmetric  head can be steady  No lymph nodes  full range of motion: up, down, sideways  No tenderness  Symmetrical facial expression  No masses
 eyes are both

All of the findings for the head are found to be within the normal range.

All of the findings for the eyes are found to be within

symmetric  eye lashes is thin,

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evenly distributed, thin and curled outward  inner canthus distance is 2-3 cm  Sclera white  No discharge, no discoloration of eyelids  When lids are close, sclera is not visible  Pink conjunctiva  No edema or tenderness over lacrimal gland  equal eye movement  alignment of outer canthus with the tip of the pinnas Ears   Symmetrical  Aligned to the inner canthus  No lesions  Color same as

curled outward and evenly distributed  inner canthus distance is cm  sclera is white
 no discharge,

the normal range.

2

lesions, lacerations  when lids are close, sclera is not visible  pinkish conjunctiva  no edema or tenderness in the eyes  Equal eye movement  Outer canthus aligns with tip of pinnas  3cm equal in size bilaterally  top of pinna cross eye-ociput line  smooth without lesions  the same with the 26 All of the findings for the ears are found to be within the normal range.

facial skin  Firm and not tender

facial color  auricle, tragus and mastoid process is non tender  Aligned to the

 No masses  No discharges  Symmetrical  No discharges  Uniform in color  Not tender  Pink mucosa  No lesions  Nasal septum intact and in the midline  Sinuses are not tender Mouth  No nasal flaring  Deciduous teeth present  pink tone of gums, tongue, and tonsils  Moist and slightly rough tongue  absence of lesions in oral

inner canthus  no discharge present  midline in face  no discharge  Same color as skin  no tenderness  turbinates are pink  absence of lesions in the nose  septum is straight  Sinuses are not tender  No nasal flaring  14 deciduous teeth erupted  pinkish tone of gums, tongue and tonsils
 Moist

Nose and sinuses

All of the findings for the ears are found to be within the normal range.

All of the findings for the mouth are found to be within the normal range.

 absence of lesions  smooth tongue base with 27

mucosa  Smooth tongue base  Light pink, smooth soft palate  Light pink hard palate  Uvula is positioned in the midline of soft Throat and neck palate  No palpable lymph nodes  Generally uniform in color  No edema  Neck can move freely  neck is short with skin folds Breast and axilla  Symmetrical breast and symmetrical axilla  absence of tenderness  No secretions or discharges

capillaries
 pinkish in color

and smooth  pinkish soft and hard palate  Uvula is positioned in the midline.

 No palpable lymph All of the findings nodes for the throat and  Uniform in color  No edema  Neck can move freely  neck is short with some skin folds  Symmetrical breast and axilla  No tenderness  No secretions  No masses or All of the findings for the breast and axilla are found to be within the normal range. neck are found to be within the normal range.

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 No masses or Chest and respiratory nodules  Symmetrical placement of all structures  Bilaterally equal shoulder height  regular breathing pattern  No lesions/masses  No tenderness  Apical pulse:80140 bpm  Apical pulse audible  No cold extremities and discolored Abdomen extremities  Uniform skin color in the abdomen  Symmetric contour is rounded  No lesions

nodules  rounded, symmetric, shoulder and scapula are equal horizontal position  unlabored, regular breathing, hyperresonance  skin are free from lesions and masses  no tenderness  PR:110 bpm  presence of apical pulse  Absence of cold discolored extremities  Uniform in color  prominent when standing and supine positions  Absence of lesions  no tenderness All of the findings for the abdomen are found to be within the normal range. All of the findings for the chest and respiratory are found to be within the normal range.

Cardiovascular and peripheral

All of the findings for cardiovascular and peripheral are found to be within the

extremities and no the normal range.

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 No masses  No tenderness Reproductive Musculoskeletal  No masses  Not assessed  Uniform color of extremities  10 fingers and toes  Symmetrical  No fractures, dislocations and deformities  full range of motion  No tremors and palpable nodules  extremities warm to touch  lordotic posture  bow-legged gait  strong muscle strength  lordotic  bow-legged (genu varum)  Less muscle strength noted in the lower extremities palpable  Not assessed  uniform in color  Not assessed Less muscle strength in lower  10 fingers and toes extremities deviated  feet & legs are symmetric  Absence of fractures, dislocations and deformities  full range of motion without tenderness  Absence of tremors and nodules  warm to touch normal. as from

Endocrine

 Gradual weight

 Gradual weight

All of the findings

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gain

gain

for endocrine are found to be within the normal range. All of the findings for hematological are found to be within the normal

Hematological

 No bleeding  No bruises  Blood type

 No bleeding  No bruises  blood type B

Lymph nodes

 No palpable lymph nodes  No tenderness

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

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