I.

PHYSICAL EXAMINATION

Head-to-toe assessment:

PHYSICAL EXAMINATION FINDINGS

Dress, Grooming, and Hygiene

GENERAL APPEARANCE  wearing patient gown looks clean upon observation
short and clean fingernails and toenails
 Hair is short, thin, black in color, and evenly distributed
 lips and gums are pinkish in color
Level of consciousness:
 Awake and Oriented

 Appears pale in color, dry, and with good skin turgor noted
SKIN (returns in less than 3 seconds), skin is hot to the touch due to
high body temperature


Head:
 Head is symmetrical and round erect and in the midline. No
presence of lesions. Head held still and upright.
 No presence of lesions, pediculosis, and dandruff.
 Fontanels are flat, soft, and firm
HEENT Eyes and Ears:
 Tearless, reacts to light when eyes are open, sclera appears white
in color the palpebral conjunctiva appeared pinkish in color
 The Auricles are symmetrical and have the same color as her
facial skin. The auricles are aligned with the outer canthus of the
eye. When palpating for the texture, the auricles are mobile, firm,
and not tender.
Nose:
 The nose appeared symmetric, straight, and uniform in color. There
was no presence of discharge or flaring. When lightly palpated, there
 were no tenderness and lesions.
 RR of 25 cpm, regular and effortless breathing.
LUNGS AND CHEST  Chest is expanding symmetrically during inhalation
 No retraction or bulging of the intercostal spaces.
 Crackles heard on the right lower lobe lungs field upon
auscultation

Essentially Normal
HEART
 flat shaped abdomen
ABDOMEN  No presence of constipation and diarrhea.
 No distention, bruising and tenderness
 Scars noted.

GU (IE)  able to pass stool and urine after 8 hours

 Genitalia: Complete external parts

UPPER & LOWER EXTREMITIES:

EXTREMITIES  fair colored skin; no pimples with lesions noted.
 skin is moist and hot to touch;
 Maintains posture of flexion, equal and bilateral movement and tone,
no signs of polydactyl and syndactyl

NEUROLOGIC