PHYSICAL EXAMINATION

 Bio-Demographic data of my Patient:

• Name: Babil Newar

• Age: 4year
• Sex: Male
• Address: Sindhuli
• Education: Literate
• Religion: Christian
• Nationality: Nepalese
• Date of Admission: 2076/02/21
• Ward: Surgical ward
• Date of Interview: 2076/02/22
• Diagnosis: Vesicle calculi
• Date of surgery: 2076/2/22
• Date of Discharge:2076/2/26
• Development Age: Pre-Schoolar
• Attending Doctor: Dr. SCS
• Information Obtained from: Mother (Renuka Newar)

While doing physical examination, I followed systematic approach of head to toe examination
and use following method for physical examination
 Inspection
 Percussion
 Palpation
 Auscultation
 Measurement

I could get more objective data and another additional health problem which is helpful to plan
for care. The findings are listed below:

MEASUREMENTS:
 Length : 99cm
 Weight :15 kg
 Temperature :98.4F
 Pulse :96/min
 Respiration :26/min
 Patient is conscious, oriented to time, place & person.
GENERAL APPEARANCE:
 Consciousness: He is oriented to time, place and person.
 Nutritional status: Well nourished
 Looks : Healthy
 Posture/Gait :Straight
 Hygiene and grooming : Well groomed
 Behavior : good and co-operative
 Mood : Appropriate to situation

SKIN:
 Color of skin : Brown in colour.
 Edema: Not present on examination
 Cut or abrasion : Not present
 Loose of elasticity: Skin returns to previous status in less than 2 seconds.
 Thrush : Not present

HEAD:
• Round in size and shape
 Head No any masses, nodules or scar

FACE:
 Asymmetry: absent
 Skin: Normal texture, no any scars present.

EYES:
 symmetrical in shape.
 Eye brows: Equally distributed hair, symmetrical, equal movement of eyebrows.
 Eyelid : No ectropion and no entropion, symmetrical closing, no swelling redness,
no drooping
 Sclera: White in colour, no blood vessels dilated, no jaundice.
 Cornea: No opacity is present, smoothly rounded, no abrasions, transparent
cornea.
 Lens: Equal, light reflex is equal, clear, no opacities.
 Pupils: Symmetrical perfectly round, B/L uniform size and shape prompt response
to direct and consensual light. Stimulus and accommodation for near vision. No
sluggishness or absence of reactivity.
 Visual Acuity: Normal in both eye.
 Ocular Movement: Smooth, symmetrical, bilateral, equal movement through all
six cardinal positions of gaze, no divergence in any position/no squint present.
 Discharge: No any discharge from eyes.
 Conjunctival Hemorrhage: Not present.
EARS:
 Location: B/L equally located the margin of the pinna meets with outer canthus of
eye.
 Pinna: No lesion, lump, smooth rounded contour and B/L symmetrical.
 External Ear Canal: No redness, discharge, mass or foreign body, presence of wax
in little amount.
 Lymph nodes and mastoid area: Not palpable, no swelling and tenderness.
 Hearing acuity test: Normal

NOSE:
 Location: Centrally located on face
 Nostril: Nostrils are uniform flaring while respiration, no nasal discharge.
 Nasal septum: Normal, not deviated, no extra growth or polyps.
 Nasal canal: Pinkish mucosa, no extra growth
 Nasal flaring; Absent
 Smelling: Good (Identified the smell of vicks).
 Sinuses: When pressure is applied with fingers and while palpating maxillary and
frontal sinuses there is no sign of tenderness and pain was present.

MOUTH AND THROAT:

 Lips: Pink in colour, no cyanosis, moisturize lips, symmetrical, no cracks and
injury.

 Mucosa: Smooth and moist

 Teeth: No any dental carries present, lower two incisors were absent..
 Gums: Tight margins at teeth, no ulcer or inflammation/gingivitis or swelling and
no bleeding.
 Tongue: Pink, irregular taste buds apparent, midline fissures was present, no
ulcer.
 Palate: Soft palate-pink; hard palate-whiter in color
 Thrush: Absent.
 Tonsil: Redness,inflammation was not present
 Taste: Not performed as patient was in NPO.
 NECK:
 Skin fold: Absent
 Head control : Present
 Range of motion: Full range of motion was present.
 Thyroid Gland: No enlargement, not visible, no any swelling lump on the neck.
 Jugular vein: Not distended
 Lymph Nodes: No tenderness, palpable, no any swelling.

CHEST (THORAX AND LUNGS):

 Size, shape and symmetry: Normal size and shape
 Location of sternum: Symmetrical, located in mid-sternum
 Respiration excursion: Symmetrical range of movement on inspiration and
expiration.

On Palpation:
 No any tenderness, lump, depression along the ribs.

On Percussion of lungs field:

 Deep resonant sound is heard.

On Auscultation:
 Breath sound: Breath sound heard in all areas of lungs, wheezing sound absent

 Axilla: No enlarged lymph-nodes or massed on right and left.

HEART:
 Heart sound: In Aortic, pulmonary, tricuspid and bicuspid region, there is normal lub dub
sound heard. No additional sound heard.

BACK:
 Spine:
 Location: Centrally located.
 Spinous process: Vertically aligned, non-tender, no any deformities.

 Muscles: Symmetrically smooth, firm, non tender, muscle mass equal, no any lesions.
 Breath sounds: Normal, no(rales, wheezes, crackles)
 ABDOMEN:

On Inspection:
 Flat in shape and is in uniform shape, no scar, slight swelling is present.

On Auscultation:
 Bowel sound was heard over only on right lower quadrant near umbilical region.

On Percussion:
 Dull and tympanic sound is present.

On Palpation:
 Liver: no tender, not palpable.
 Spleen: no tenderness and enlargement of spleen was present.
 Kidney: no tender, not palpable.

GENITALS:

 According to patient, no any presence of signs and symptoms of discharge, foul

smelling, or swelling but burning sensation during micturition was present..
 Rectum: No history of difficulty in defecation, absence of hemorrhoids.

EXTREMITIES:

Upper Extremities/Arms;
 Symmetry: Symmetrical shape and size.
 Nails: Pink colored, no clubbing or thickening
 Range of motion: Full in all joints, bilaterally equal.
 Joints: No tenderness, no swelling.
 Sensation: Able to feel light touch.
 Pincer grasp: present.
 Reflexes: All reflex are present.
Lower Extremities/Legs:
 Symmetry: Both are symmetrical
 Dislocation of hip : Not present
 Nail beds: pink colored
 Range of motion: Full in all joints.
 Joints: No tenderness, no swelling
 Walking, running, jumping : Present

 Reflexes: all reflexes are performed.

 present(Brudzinski sign)
 Kernig sign was negative.
Abnormal findings
 Lower two incisors was absent.
 History of painful micturition and heamaturia.