HEALTH ASSESSMENT

Patient J was my patient when we went to Children’s Home. Home for the neglected, abandoned and

orphaned children. Jason Arevalo is 12 years old and his birthday is on June 17, he is currently a grade

2 student. His mother died years ago because of cancer and he didn’t know where his other siblings

were because after his mother died, their stepfather abandoned them. He blamed his stepfather on

what happened to his mother. Jason misses his family, especially his siblings so much, but with the

help of other children there he sometimes forgets his problem and enjoys playing with other children.

That is one of the relaxes he is doing there and also he likes to draw. And when he is stressed he just

sleeps and just relaxes. For his description of a typical day he said it was fine, sometimes he was

bored. They are also helping their houseparent in sweeping and cleaning. For the dietary intake they

eat 3x a day and he drinks a lot of water.

For his previous illness his forehead swells because of junk foods, he suffers for almost a week. Years

ago he experienced a bike accident that’s why his right leg was injured, but now he said he doesn’t feel

pain anymore. Inside the children’s home his head bump at the corner of the wall, by that he has a scar

at the occipital part of his head. When I palpate it he said it doesn’t have tenderness. He also has

bruises because some children beat him, he said it has tenderness when he presses it. And also the

scars on her arms.

For his vital sign, blood pressure is 100/80 mmhg, respiratory rate 12 breaths/min, pulse rate 49

beat/min. His pulse rate is not in normal range, when I palpate his pulse it’s really weak and slow. His

weight is 34 kg and his height is 54m and his BMI is 14.99. His eye vision is 20/20. For the mental

status examination, his level of consciousness is alert and he responds to my questions. His body

movements are smooth and posture is erect. His speech is in a moderate tone and it is clear. He is also

cooperative and he is friendly.

For skin assessment, his color is brown, the texture of his skin is smooth, and there are lesions in his

arms, and bruises on his legs, no edema is present, and his skin temperature is warm. For head and
face, head is symmetric and round. Scars are present at the back of his head, because he bumps in the

corner of a wall. The hair color is black and the hair is evenly distributed. For testing the cranial nerve

VII, movements are symmetric and he had a full range of motion against resistance. No tenderness

when I palpate the temporal arteries. And for temporomandibular joints there are no clicking and

tenderness that present.

In assessing eyes, his pupils constrict when I test his pupillary reaction to light. His eyes did converge

and constrict when I tested for accommodation of pupils. For ears, the auricle, tragus, and lobule are

symmetric and no tenderness in the auricle and mastoid process when I palpate. Non tender in the

external nose and he is able to sniff while the other is occluded.

For mouth and throat, his lips are smooth and he has crooked teeth. For the neck no bulging, masses

and lumps are present. He has a full range of motion against resistance when I test his neck for range

of motion. He has flex and hyperextend his neck without pain. In palpating his preauricular,

postauricular, occipital, tonsillar, submandibular, and submental nodes there was no tenderness he felt.

For trachea it is in the midline location and for thyroid gland it has no nodules. Palpating and

auscultating his carotid arteries there are no masses and no swishing sound and no thrills.

Arms, hands, and fingers. For his upper extremities there are small scars, the color of the scars is

white. In testing the cranial nerve XI the patient should shrug and turn head against resistance as I

observe there is a full range of motion against resistance. In palpating his arms and elbow he said it

has a pain in his olecranon process. For the range of motion of the elbow the right elbow decreased

range of motion against resistance while the left elbow has a full range of motion against resistance.

His ulnar and radial has no tender and the ROM of wrist has a full range of motion against resistance.

For his palms and hands, there is no tenderness and palm are smooth and there are no lesions. For the

range of motion of fingers it has a full range of motion against resistance.

For assessing the heart, the apical pulse is palpated and palpable in the mitral area since he is thin and

the pulsations are visible. Auscultating the apex, left sternal border and base of the heart I heard the lub

dub sound, and the S1 is loudest at the apex of the heart and the S2 sound is loudest at the base of the

heart, and there are no murmurs or extra heart sounds I heard. Same in the aortic area, pulmonic area,
erb’s point, tricuspid and mitral valve. For assessing feet, legs and toes, no tenderness and it has a full

range of motion against resistance on his hips. There is tenderness on his leg because of bruises and

no tender on his feet. For knees and ankles no tenderness, swelling, deformities, lesions are present.

Assessing musculoskeletal and neurologic systems. His cervical spine and lumbar spine are concave,

his thoracic spine are convex and his spine are straight there are no abnormalities I observe on his

back. For his gait, his arm swings are opposite lateral on his feet when he walks, and he is able to

stand on his heels and toes and his posture are erect, his weight is evenly distributed and he has a

balance when he walks. For tandem walking, I ask him to walk in heel to toe fashion and he maintains

the balance with tandem walking. By hopping on each leg, he can stand on one foot and he doesn't

lose his balance. Then I perform the Romberg test, I ask him to close his eyes and stand erect for 10

seconds, he stands erect with slightly swaying while eyes are closed, and for the last test, the finger to

nose test, he touches fingers to nose with smooth movement and accurate movement.

The second child that I assessed named Ariel Agravante, he was 15 years old. I didn’t get his birthday,

because when I asked him if he had just left, I thought he was just going to look for his birthday but I

just realized he was nervous and can’t talk about it. When I interviewed him I observed that he had a

teary eye so I didn’t ask about his family that might have triggered him. When I asked about his

description about his typical day he said sometimes he felt sad, since he said he is a lonely person and

he is always about his family and his parents. For his self-concept he said he was a chill person, he

played chess and he drew for relaxation and he just slept when he was stressed. For his basic hygiene

he did take a bath every day and they take their meal 3x a day.

For the vital sign, his blood pressure is 110/80, respiratory rate 15 breaths/min, pulse rate 15 beats/min,

his weight is 41kg. I didn’t take his height because when I looked for him he was lying on his bed so I

didn’t disturbed him.

For mental status examination, his level of consciousness is alert, posture is straight and balanced

except on his right arm that is injured. For his speech, it is moderate in tone and clear. For mood,

feelings and expressions, I observed a little hesitation and he said he was nervous and not ready and a

little bit uncomfortable.

Skin assessment, texture are smooth, he has a warm skin, brown in color, and has a lesion on his arm.

For head and face assessment, there was no tenderness and lesion when I palpated his head and it

was hard. The head is symmetric and round. Hair is evenly distributed and for the face, it is symmetric;

the features of his face are also aligned. The skin color of his face is the same as his body color. When

I asked him to smile, frown, show teeth, blow out cheeks, raise eyebrow and tightly close eyes the

movements are symmetric and have a full range of motion against resistance. For his temporal arteries

he said there are no tender same in temporomandibular joint there’s no tenderness he felt and no

clicking.

For eyes assessment, the pupil constricts in reaction to light, the eye does constrict and converge when

testing accommodation of pupils. Ear assessment, auricle, tragus, and lobule are symmetric and there

are no lesions present. In palpating auricles and mastoid processes there is no tenderness. For nose

and sinuses assessment, no tenderness when I palpate his external nose. And his nasal patency is

good he is able to sniff while the other is occluded. For his lips it is smooth and it is not dry.

For his neck assessment, he has a full range of motion against resistance when testing ROM of the

neck. There is no tenderness when I palpate his preauricular, postauricular, occipital, tonsillar,

submandibular, and submental nodes. In palpating his trachea there are no tenderness and masses

and it is in midline location. In the thyroid gland there are no nodules and no thrills in carotid arteries.

Arms, hands and fingers assessment, his right arm is injured and it’s almost a year and still his hand

isn't back to normal. He said he had a bad experience with that injured arm. In testing cranial nerve XI

he has a full range of motion against resistance when he shrugs and turns his head side to side. In

palpating his arms, left arm has no tenderness and his right arm is in pain. Testing ROM of elbow, for

his left elbow he has a full range of motion against resistance but in his right elbow he can’t move it to

flex and extend so he has no range of motion against resistance for his right elbow. In palpating

brachial, ulnar, radial there is no tenderness and masses are present. To test his ROM of wrist he

needs to do flexion, hyperextension, and ulnar and radial deviation. Same in testing the elbow, the left

wrist has full range of motion while the right wrist has nothing. When I inspect and palpate his palms it
is a little pale and it is smooth and there are no tenderness and masses and lesions. For the legs, toes

and knees they are all non-tender when palpating.

For musculoskeletal and neurologic systems assessment. He has no scoliosis and his cervical spine

and lumbar spine are concave and his thoracic spine is convex and for his spine it was straight. In

observing his gait, he can walk with his heels and toes and evenly distributed weight and he has a

balance when walking and his posture is erect. There were no abnormalities on his gait when I

observed it. In performing the Romberg test I asked him to stand straight and close his eyes for 60

seconds and the result is he can stand erect with a little swaying. And in the finger to nose test, the left

arm is the only one moved and coordinated since his right arm is injured.