Date of Assessment: September 17, 2023

Name: K.C.R. (Second child)

Age: 15 years old

Vital Signs

Blood Pressure: 90/60 mmHg

Temperature: 35.9°C

Pulse Rate: 81 bpm

Respiratory Rate: 23 bpm

Height: 155 cm

Weight: 53kg

BMI: 22.1(Normal)

O2Sat: 90%

PAST MEDICAL HISTORY:

The client is completely immunized. She has history of hospitalization on year 2019
diagnosed with Tonsillitis and Anemia and have experience sickness such as cough,
fever, stomachache, and headache. No history of childhood illnesses.

PRESENT MEDICAL HISTORY:

The client has no complaint on her present health condition.

GENERAL SURVEY

On September 17, 2023, K.C.R. was wearing gray shirt and green shorts and a pair of clean
slippers for her footwear. She is attentive and shy during the assessment.

INTEGUMENTARY
SKIN

 Has a fair skin color with warm temperature.

 No other complaints.
 Uses soap for skin care.

HAIR

 Hair is black and no presence of lice.

 Scalp is intact and no lesion noted.
 Uses shampoo and conditioner for her hair care habits.

NAILS

 Has untrimmed dirty nails with pinkish color and no clubbing

 Capillary refill not less than 2-3 seconds.

HEAD

 Head is round and symmetrical.

 No complains of head problem.
 No lesions, mass and nodules noted.
 Upon assessing range of motion, movements are not limited.

EYES

 Eyes are black and symmetrical.

 Canthus is aligned from the tip of the ears.
 Eyebrows are black and well distributed.
 Pupils are equal, round and react to light.
 Iris is black, round and smooth.

EARS
  Ears have the same color with the rest of the body.
 No pain, tenderness and lesions noted.
 Auricle are line with the canthus of the eyes.
 No nodules and swelling noted upon palpation.
 Presence of ear wax.

NOSE AND SINUSES

 Nose is located at midline

 No nasal flaring observed and has patent airway.
 No mass and lesions noted.
 Nose has the same color with the color of the face.
 No tenderness and no masses noted upon palpation

MOUTH AND PHARYNX

 Lips and tongue are pinkish in color, moist and intact

 The uvula is positioned in the midline.
 Teeth are white in color.
 No lesions noted
 Oral brushing is done twice a day

NECK

 Neck has the same skin tone with the rest of the body.
 The trachea is in the midline.
 No masses, lesions and distention palpated.
 She is able to perform range of motion without difficulty.

BREAST AND AXILLA

 Refuses to check axilla but claims that there are presence of hairs.

LUNGS
  Chest symmetrically expands and do not use accessory muscle upon breathing.
 Has respiratory rate of 23 cycles per minute.
 No signs of abnormal rhythm upon auscultation.
 No tenderness upon auscultation.
 Trachea is located in midline.

HEART

 No abnormal sounds heard upon auscultation.

 Normal pulsation noted.
 She has a cardiac rate of 81 beats per minute.

GASTROINTESTINAL

 Refuse to check her abdomen but stated that she does not experiencing stomachache
during assessment.

PERIPHELAR VASCULAR

 Arms are equal in size, without swelling of hands and clubbing of fingernails.
 Has even skin tone, warm to touch and has a presence of mosquito bites on leg part.
 No lesions noted.
 All pulses are palpable.

GENITOURINARY

 K.C.R refused the assessment for genitourinary but claims that it has a presence of pubic
hairs and no lesions or rashes.
 No pain felt in genitals and during urination.

MUSCULOSKELETAL
  Normal posture.
 Head is in the midline and body alignment is normal.
 No history of falls and spinal deformities.
 Gait is normal and no complaints of pain upon assessment.

NEUROLOGIC

 Behavior is normal.
 She is oriented upon assessment.

CRANIAL NERVES RESULT

Cranial Nerve - I (Olfactory)
Cranial Nerve - II (Optic)
Cranial Nerve-III, IV & VI (Oculomotor,
Trochlear and Abducens)
Cranial Nerve - V (Trigeminal Nerve)
Cranial Nerve - VII (Facial)
Cranial Nerve - VIII (Acoustic Nerve)
Cranial Nerve - IX and X (Glossopharyngeal
& Vagus)
Intact. Client is able to identify the smell of
vinegar.
Client can’t be able to identify letter from 10
ft. away from her. Have complaints of blurry
vision.
Intact. Pupils equally round and reactive to
light and accommodation, able to perform 6
cardinal eye movements.
Intact. No pain felt with mastication. Can
identify sharp from dull. Eyelids blink
bilaterally.
Intact. Client is able to smile, frown, wrinkle
the forehead, show
Intact. Client is able to hear the bell sound 2
ft. away from her.
Intact. Client is able to swallow and identify
sweet from sour (chocolate and salt).