Physical Assessment

General Santos Doctors’ Medical School Foundation, Inc.
Bulaong Subd., Brgy. West, General Santos City, Philippines

Telephone Nos. (083) 552-9793 | gsdmsfihumanresource@gmail.com
BIOGRAPHICAL DATA
Patients Full Name: Wuttichai Boriphet Marital Status: Single Immunization: Complete Covid 19
Age and Sex: 5 years old, Male Educational Level: Kindergarten vaccination
Birth Date: January 14,2017 Occupation: N/A Allergies: N/A
Religion: Unification Recent Travel: N/A Medication: Salbutamol Sulfate
(Nebulization)
Other complaints: Cough
Vital Signs: Circumference:

Temperature Rate: 36.7 °C Weight: 19 kg
Pulse Rate: 60 BPM Height: 115 cm
Respiratory Rate: 33 CPM Head Size: 49 cm
Blood Pressure: 90/70 mmHg Chest Size: 55 cm
Abdomen Size: 54 cm
Family History Illness: History of Past Illness (childhood History of Present Illness:
illness/ surgeries/injuries/chronic
• Mom’s mother has history of illness): • Cough but in nebulization with
Hypertension. Salbutamol Sulfate.
• Mom’s father died of Pneumonia.
• Mom’s niece has Ovarian Cancer.
• Mom’s niece died of Appendicitis.
• Dad had Tuberculosis but is already
well.
• Dad had Pneumonia.
CEPHALOCAUDAL ASSESSMENT
Inspection Palpation Percussion Auscultation Interpretation
Skin • Has scars due • The skin is • The client had scars
to scratching warm and skin from scratching due to
• Skin is dry, no turgor is mosquito bites as we
redness, no reactive upon were inspecting.
lesions. palpation. Although the client's
skin is dry, we were
unable to see any
lesions or evidence of
redness. The client is
warm and skin turgor is
reactive when palpated
indicating that he is
hydrated.
Hair • Hair is black, • The client's hair is

thick, and color black, thick,
equally and evenly
distributed. distributed. Given
that his age group
doesn't typically
experience baldness,
we didn't see any signs
of baldness.
Nails • Nails are • Capillary refill • Client’s nails are round

round and well is responsive in shape and is well
groomed. groomed. His capillary
refill responded quickly
to palpation, which
shows the client is
extremely well
hydrated.
Head • The head is • Head has no • Head is symmetrical

symmetrical bumps, skull and has no lesions,
and no signs depression, dundruff, or redness.
of redness, mass, or We palpated the
lesions, and tenderness. head and found no
dandruff in the signs of bumps, a
scalp. depressed skull, a
mass, or tenderness.
Eyes • Pupils are • Conjunctiva is • We tested the client’s 6

equal, round, pink cardinal fields of gaze
reactive to and the client
light, and responded very well.
accommodatin The client’s sclera is
g. white and conjunctiva
• Sclera is color isa pinkish in color.
white.
Ears • Ears are • Ears doesn’t • The client's ears are

symmetrical, have bumps, symmetrical and free of
no redness, no swelling, and lesions or indications of
lesions, but tenderness. redness. To the client's
has light ear, there is a drainage
yellow that is light-yellow in
drainage. color. The client also
• Reactive to responds to the
whisper test. whisper test, and when
the ears are palpated,

there are no lumps,
swelling, or
tenderness.
Nose • Nose is • No masses • There is no presence

symmetrical found in nasal of blockage in the
and no area and breathing airway.
discharges. sinuses. • The nasal mucosa is
• Normal color pinkish red with no
of nasal discharge, bleeding,
mucosa. and any malformations
• The frontal and (Meneghett, 2020).
maxillary • It has bright
sinuses is transmission of light
normal suggests a normal
airfilled sinus .There is
no presence of edema
and discoloration of the
sinuses (Pressbooks,
2020).
Mouth and • Perfect set of • No tenderness • The client had a full set
Throat teeth with in the lips and of milk teeth, pinkish
pinkish gums. tounge. gums, and no evidence
No soreness of tongue or lip
and bleeding tenderness while we
were found, were palpating.
can stimulate Cranial nerve IX
gag reflex and (glossopharyngeal) is
acuity of taste functioning well.
is well
functioning.
Neck • No lesions and • No masses • Neck is symmetric with

redness seen and upon the head centered
• Normal palpating he without bulging
muscular can’t feel any masses.
strength pain in his • The client is able to
cervical lymph perform the neck
nodes, trachea reflexes and he does
and thyroid not feel any pain upon
gland. No performing it.
masses felt
during
palpation.
• No signs of
pain during the
procedure of
range in
motion
• (ROM).
Thorax and • No redness • No tenderness • Has normal • Has • Upon inspection and
Back and lesions in or pain upon resonance normal palpation, there is no
(cardiopulm thorax area palpation. sound for breathing sign and visible scars
onary) • Regular rate, tracheal sound for past surgeries and
rhythm, depth sound • Has other malignancy.
and symmetry • Normal normal • As we observed in his
thoracic resonant bronchovesic facial expression and
movements sound for ular breath the way he performs
during areas such sounds breathing exercises, he
respiration. as the lungs. was able to do the
• No lesions and • Normal breathing for 4
redness seen dull or thud seconds, holding the
like sounds breath for 7 seconds,
are normally and exhaling for 8
heard over seconds.
dense area (NursingTimes, 2020).
such as the • As we percuss, we’ve
heart noticed that his airway
• Normal has normal sound and
extreme dull no presence blockage.
sounds for • We did not hear any

solid areas. odd noises in the
bronchovesicular as
we auscultated.
(PressBooks, 2021).
Breast • Nipples are • No discharges, • Nipples are equal

pinkish and no masses, and bilaterally in size and in
redness and tenderness the same location on
lesions are were felt upon each breast. Has no
seen. palpating. signs for malignant
tumor and cyst.
Abdomen • Abdomen is (Auscultation) (Percussion) (Palpation) • It does not indicate any

not distended abnormalities in the
and no lesion • Normal bowel • Normal dull/ • No pain and abdomen and the 4
and redness sounds tympanic masses quadrants.
were seen. sounds indicated
upon light
and deep
palpation in 4
quadrants.
Genito- • The mother
urinary verbalized that
Peemak
urinates 3 to 5
times a day
Musculoskel • No deformities
etal/ in upper and
Extremities lower
extremities.
• Able to
balance when
walking with
both hands
swinging
sideways.
• able to
balance with
only 1 foot.
• ROM is good,
able to perform
flexion,
extension,
abduction, and
adduction.
• No signs of
pain during
ROM.
Sensory- • The mother

Neurologic stated that
and cerebral Peemak never
function. had any head
trauma history,
consciousness
, and seizure.
• The client is
very well
aware f what’s
happening and
where he is.
He can also
determine
colors and
shape.

Physical Assessment

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General Santos Doctors’ Medical School Foundation, Inc.

Bulaong Subd., Brgy. West, General Santos City, Philippines

Birth Date: January 14,2017 Occupation: N/A Allergies: N/A

Religion: Unification Recent Travel: N/A Medication: Salbutamol Sulfate

Other complaints: Cough

Vital Signs: Circumference:

Hair • Hair is black, • The client's hair is

Nails • Nails are • Capillary refill • Client’s nails are round

Head • The head is • Head has no • Head is symmetrical

Eyes • Pupils are • Conjunctiva is • We tested the client’s 6

Ears • Ears are • Ears doesn’t • The client's ears are

the ears are palpated,

Nose • Nose is • No masses • There is no presence

Neck • No lesions and • No masses • Neck is symmetric with

sounds for • We did not hear any

Breast • Nipples are • No discharges, • Nipples are equal

Abdomen • Abdomen is (Auscultation) (Percussion) (Palpation) • It does not indicate any

Sensory- • The mother

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