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ANTHROPOMETRIC MEASUREMENTS

•HEIGHT: 144 cm.

•WEIGHT: 37 kgs

PHYSICAL ASSESSMENT

•General Appearance: The child is well groomed, and behaves according to age.

•Head: Skull is proportional to the size of the body. Scalp is clean and free from scars, lumps,

dandruff and lesions. Hair is balck evenly distributed and no areas of tenderness.

•Face: Rounded and with presence of scar from burn.

•EYES: Has brown iris and rounded eyes, not protruding and symmetrical.

•EYEBROWS: Hair of eyebrow is symmetrical, same color with the hair and evenly

distributed.

•EYELASHES: Black color, symmetrical and can raise both eyebrows without difficulty.

•EYELIDS: Symmetrical on both left and right eyelids.

•LID MARGIN: Clear, symmetrical to both sides of the eyes and without scaling and lesions.

The duct openings are evident at the nasal ends of the upper and lower eyelids.

•SCLERA: Symmetrical on both sides of the eyes, with and clear in color.

•IRIS: Proportional to the size of the eye, round brown, and symmetrical on both sides of the

eyes.

•PUPIL: PERRLA, round and asymmetrical on both sides of the eyes


•EYE MOVEMENT: Able to move eyes in full range of motion and able to move in all

directions.

•VISUAL ACUITY: 20/20

•FIELD OF VISION: Able to see 90 degrees laterally and 70 degrees inferiorly.

•EARS: Parallel, symmetrical and proportional to the size of the head with firm cartilage.

•EAR CANAL: Pale, clear with scant amount of cerumen and few cilia

•NOSE: In the midline of the face and patent clean, pinkish red and with presence of few

cilia.

•NASAL SEPTUM: In midline and straight.

•LIPS: Upper and lower lips are moistured, pale color, thin. Upper lip is slightly portruding.

•GUMS: Pinkish red in color, no swelling and no discharge.

•TEETH: Minimal presence of plaque and dental carries.

•TONGUE: Reddish in color and moistured.

•BUCCAL MUCOSA: Moist and pink in color.

•VOICE: No hoarseness and well-modulated.

•NECK: Proportional to the size of the body and straight. No palpable mass, lumps and no

areas of tenderness.

THORAX AND LUNG

 Respirations 18/minute, relaxed and even. Anteroposterior less than transverse

diameter.

 Chest expansion symmetric. No retraction or bulging of interspaces. No pain or

tenderness on palpation. Tactile fremitus symmetric. Percussion tones resonant


over all lung fields. Vesicular breath sounds auscultated over lung fields. No

adventitious sounds present.

INSPECTION OF THE HEART

 Pulsation of the apical impulse may be visible. (this can give us some indication of the

cardiac size).

 There should be no lift or heaves.

PALPATION OF THE HEART

 No, palpable pulsation over the aortic, pulmonic, and mitral valves.

 Apical pulsation can be felt on palpation.

 There should be no noted abnormal heaves, and thrills felt over the apex.

AUSCULTATION OF THE HEART

 S1 & S2 can be heard at all anatomic site.

 No abnormal heart sounds are heard (e.g. Murmurs, S3 & S4).

 Cardiac rate ranges from 60 – 100 bomb.

INSPECTION OF THE BREAST

 The overlying the breast should be even.

 May or may not be completely symmetrical at rest.

 The areola is rounded or oval, with same color, (Color varies from light pink to dark

brown depending on race).

 Nipples are rounded, everted, same size and equal in color.

 No “orange peel” skin is noted which is present in edema.

 The veins may be visible but not engorge and prominent.

 No obvious mass noted.


 Not fixated and moves bilaterally when hands are abducted over the head, or is

leaning forward.

 No retractions or dimpling.

PALPATION OF THE BREAST

 No lumps or masses are palpable.

 No tenderness upon palpation.

 No discharges from the nipples.

INSPECTION OF ABDOMEN

 Skin color is uniform, no lesions.

 Some clients may have striae or scar.

 No venous engorgement.

 Contour may be flat, rounded or scaphoid

 Thin clients may have visible peristalsis.

 Aortic pulsation may be visible on thin clients

PALPATION OF THE ABDOMEN

 No tenderness noted.

 With smooth and consistent tension.

 No muscles guarding.

LIVER PALPATION

 The liver slightly palpable.

KIDNEY

 Can able to palpate both right and left kidney.


BEHAVIOR AND APPEARANCE

 Appearance and behavior are appropriate for his age

LANGUAGE

 Able to names objects correctly and follows commands

 Orientation (person,time and place, self)

 Able to recognize correctly other persons

 Aware of residence, time of day and date

MEMORY

 In assessing the Immediate, Recent, and Past Memory, the child was able to follow and

respond correctly

ATTENTION SPAN AND CALCULATION

 The child is able to recite the alphabet

 Able to count backward with correct subtractions of 5 from 100

 Able to spell correctly a 5 letter word

B. Cranial Nerves

CN I: Olfactory

 The child is able to identify different aromas

CN II: Optic Nerve

 with 20/20 vision

 no visual fields defect noted

CN III: Oculomotor

CN IV: Trochlear – The child is able to follow fingers through all cardinal gaze
CN VI: Abducens

CN V: Trigeminal – The child is able to feel equally on all areas

– Able to identify sharp and dull feeling

–Able to palpate the contractions of temporal and masseter muscles

CN VII: Facial – The child is able to identifies various taste

–Child’s facial muscles are symmetrical at rest and even at smile or frowns

CN VIII: Acoustic – The child is able to repeat words

– Negative Romberg

CN IX: Glossopharyngeal – There’s no presence of voice hoarseness

CN X: Vagus – There is presence og gag reflex

CN XI: Accessory – The child is able to resist against resistance

CN XII: Hypoglossal – The child is able to protrude tongue on midline then move it side to

side

C. Reflexes

I. Deep Tendon Reflex

• Biceps – Slight flexion of arms and elbow

• Triceps – Slight flexion of arms and elbow

• Patellar – Extension of lower leg

• Achilles – Plantar flexion of the foot

II. Cutaneous Reflexes

• Plantar – Plantar flexion of the foot


D. Motor Function

Gross Motor and Balance Tests – The child can maintain his balance for 5 seconds with

slight swaying

Fine Motor Tests for the Upper Extremities – The child is able to perform the test with ease

Fine Motor Tests for the Lower Extremities – The child is able to perform the test with ease

E. Sensory Function

Pain – The child is able to discriminate sharp and dull sensations

HEALTH ASSESSMENT

HISTORY OF PRESENT ILLNESS:

Raine was having remittent fever for 3 days (August 31-September 2, 2019) with the

temperature ranging from 38-39 degree. He experienced severe pelvic pain last September

2. 2019 (around 7Pm).

He was given paracetamol (250mg) to check if his temperature will be lessened.

•HISTORY OF PREVIOUS HOSPITALIZATION:

Last August 2, 2019, he is rushed to the emergency room in Ospital ng Maynila for having

constant fever of 39 degrees of three days.

After having series of laboratory examinations such as CBC, urinalysis, he was clinically

diagnosed with Urinary Tract Infection.

•HISTORY OF ALLERGIES:
Raine was allergic to semi-cooked hotdogs.