Assess the patient (Initial/Focus/General)

General Facial expression is mask like in feature and movement. Patient sits
comfortably on the bed but appears pale and weak. Temperature of
37.9°C
Skin Color is brown, fair, no skin lesions noted, warm to touch. There is no
unusual odor and with a good skin turgor. Pale skin.
Head, Eyes, Ears,  Scalp is intact and free from lesion. Hair is black, evenly distributed
Nose, Throat and fine in texture, without dandruff.
 Face and head is symmetrical. No mass, no depression, no
tenderness and lesions noted. There is no tenderness noted.
 Eyelashes are present, curving outward. No lesions noted. Smooth,
white, glistening and anicteric sclera. Color of conjunctiva is pale.
Eyes evenly placed and inline with each other, none protruding and
equal palpebral fissure.
 Ear skin is intact. No lesions noted. Color is brown and consistent.
 Nasal bridge is at the middle, no deformities and discharges noted.
The shape is symmetrical, internal mucosa is intact and no lesions.
No tenderness and mass noted. Both nares are patent.
 Dry and pale lips noted. Teeth are slightly white; gag reflex is
present. Oral mucosa is pinkish and intact.
Neck Color is the same as with the face, symmetrical. Lymph nodes non
palpable. Passive range of motion.
Breast Breasts are flat and symmetric.
Respiratory Irregular, shallow sounds, breaths through mouth and unable to breathe
in supine position, and Respiratory Rate of 44 bpm.
Auscultation
Bilateral course crackles on low lobes with decreased breath sounds at
posterior area.
Cardiovascular Uses accessory muscles for breathing and audible breath sounds within
few feet. Pulse rate of 125 bpm.
Gastrointestinal Normal abdominal contour, scaphoid sunken with prominent rib cage,
umbilicus is pink, no discharge, odor, redness, or herniation.
Urinary Spleen, tip of the right kidney, and bladder slightly palpable.
Genital Labia minora and majora are pink and moist. No deformities or lesions
seen.
Peripheral/Vascula Light brown color without edema, feverish skin temperature.
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Musculoskeletal Upper extremities and lower extremities
Symmetrical both hands and legs. No deformities noted. Able to sense
any stimuli applied. Able to flex and extends both upper and lower
extremities.
Neurologic Alert and responds appropriately. Speech easily understood. Able to
perform balance and coordination tests. Sensitivity to touch and
discrimination is present. Gross and fine skills are slightly delayed for
developmental age.
Hematologic RBC and platelets are normal, and >WBC at 14,000
Endocrine Urinalysis is normal.
Psychiatric The child’s emotional and behavioral development are normal.