PHYSICAL ASSESSMENT

Name: Rod Alden C. Laude Age: 4 y/o Sex: Male

Birthday: October 31, 2015 POB: Atimonan, Quezon Religion: Roman Catholic

Address: Purok Ilang-ilang Brgy. Caridad Ibaba Atimonan, Quezon

GENERAL APPEARANCE
The client is alert and cooperative. Speech clear, without slur and stutter. Express ideas and
feelings clearly and concise. Maintain eye contact and conversation. Follows verbal cues. Dress is
clean and appropriate for the season. Has good posture and gait.

VITAL SIGNS
Height: 103 cm Weight: 15 kgs Temperature: 36.3C
Heart rate: 80 bpm Respiration rate: 21bpm BP: 60/40mmHg
HEALTH HISTORY
Reason for Seeking Health Care  General Health Assessment
History of Present Health Concern No present health concern.

Past Health History Has history of Typhoid fever, cough, common cold and dog
bite. He was admitted to the hospital at 1 year old due to
Typhoid fever. Admitted again at four years old for doses of
anti-rabies vaccine due to dog bite.

Both parents has history of Diabetes mellitus

Family Health History
Lifestyle and Health Practices
The patient is always playing with his older sister and
sometimes plays with his friends outside. He loves to watch
YouTube videos especially Peppa pig, Kaycee and Rachel in
Wonderland and Paw Patrol. He also loves to sing, dance
and draw.

Culture and Religious Practices
Nutritional History
Sleep History
The client goes to their community chapel every Sunday
with his mom before the pandemic. He knows how to pray
but not practicing it at night
The client rarely eats vegetables but he like potatoes and
carrots. He frequently eats fish. His favourite foods are any
kind of soup and chiffon cake. He loves to eat candies and
biscuits.
The client sleeps in the afternoon. He goes to bed 7;30-8;30
at night and wakes up at 6-8 in the morning.

Mental Health Status The client can state feelings, he is alert and cooperative.
PHYSICAL EXAMINATION
 Review of System

Skin: Skin is soft and moist, no discoloration, no odor of respiration, skin intact, has lession
on left knee

Hair: no scalp lesions, scalp is clean and dry, no visible dandruff. Client’s hair is smooth
and firm, hair color is black.

Nails: Nail cut short and clean, pinkish, hard and immobile, normal capillary refill

Eyes: Skin on both eyelids is without redness, swelling, or lesions. no swelling of eye, no
blood in anterior chamber, cornea is clear, pupils equal and reactive to light, Bulbar
conjunctiva is clear, moist, and smooth. Underlying structures are clearly visible. Sclera is
white. Frainage present from the puncta when palpating the nasolacrimal duct.

Ears: Equal in size, auricle is aligned with the corner of each eye. Auricle alligned at outer
cantus bilat. earlobe is attached, ears are smooth, with no lesions lumps, or nodules. ear
color is consistent to the facial color. Small amount of cerumen or

earwax is present.

Nose and sinuses: Frontal and maxillary sinuses are non-tender to palpation, and no
crepitus is evident. Sinuses are not tender on percussion

Neck: Has palpable lymph node at the lateral posterior part of the neck.

Mouth: MM/lip/gums/buccals moist, pink; tonsils wnl; 12 teeth: 4 lower/4 upper incisors,
2 lower/2 upper molars.

CV: RRR, no murmurs, femoral pulses positive/equal bilat. Exts warm and well perfused.

Chest/Lungs: Symmetrical movement with respirations, unlabored

Abdomen: Soft, BS+, NTND, no masses, no umbilical protrusion/hernia.

Genitalia: Normal normal external genitalia, has diaper rash.

Extremities: Pink color, bilat symmetrical movements, normal ROM, capillary refill brisk.

Skin: Turgor good, no rashes/edema/erythema.

Neurological: Alert/playful, responds appropriately to parents/sibling. Motor, sensory,

reflexes intact. Coordination

and gait wnl