Demographic Data

Name Address Age Sex Date of Birth Place of Birth Nationality Religion Civil Status Occupation Father Occupation Mother Occupation

Lumasac, Francis Llanita Brgy. Pingit, Baler, Aurora 21 years old Male February 26, 1985 Baler, Aurora Filipino Roman Catholic Single Construction Worker Domingo Lumasac Deceased Clarita Llanita Housekeeper

Physical Assessment & General Appearance

MEASUREMENTS Weight Height Level of Consciousness FINDINGS 57 kg 171 cm Spontaneous, oriented Medium Erectposture, active purposeful stride Good

Body Build Posture & Gait

Overall hygiene & Grooming

Head to Toe Assessment

BODY PART HEAD Skull TECHNIQUE USED palpation FINDINGS proportional to the size of the body, round, with prominences in the frontal area anteriorly & the occipital area posteriorly, symmetrical in all planes, gently curved scalp is white, clean, free from masses, lumps, nits, dandruff & lesions, with no areas of tenderness upon palpation; hair is black, evenly distributed & covers the whole scalp, thick & shiny oblong shaped, symmetrical, smooth & no involuntary muscle movements eyes are parallel & evenly placed, symmetrical, nonprotruding, with scant amount of secretions, both eyes black & clear; sclera is white & clear; eyebrows are black, INTERPRETATION Normal

Scalp/ Hair

inspection palpation

Normal

Face

inspection

Normal

Eyes/ Vision

inspection palpation

Normal

symmetrical, thick, can raise both symmetrically & without difficulty, evenly distributed & parallel with each other; eyelashes are evenly distributed & turned outward; upper eyelids cover a small portion of the iris, cornea & the sclera when the eyes are open, when the eyes are closed the lids meet completely, symmetrical & the color is the same as the surrounding skin; lid margins are clear, without scaling or secretions; lower palpebral conjunctiva are shiny, moist, transparent & salmon pink in color; iris are proportional to the size of the eye, round & symmetrical; pupils are from pinpoint to almost the size of the iris, round, symmetrical, constricts with increasing light & accommodation; able to move eyes in full range of direction

Ears/ Hearing

inspection palpation

ears are parallel, symmetrical, proportional to the size of the head, bean-shaped, helix is in line with the outer canthus of the eye, skin is the same color as the surrounding area & clean; ear canal is pinkish, clean, with scant amount of cerumen & a few cilia; able to hear whisper spoken 2 feet away; 2 piercing are found in left ear and 1 piercing in right ear nose is in midline, symmetrical, patent; internal nares are clean, dark pink with few cilia lips are dark pink, symmetrical, lip margin is welldefined, smooth & moist; gums are dark pink, smooth, moist, no swelling, no retraction, no discharge; 32 teeth are present, aligned, with no dental caries; tongue is pinkish, slightly rough on top, smooth along

Normal

Nose

inspection palpation

Normal

Mouth/ Lips

inspection palpation

Normal

the lateral margins, moist, shiny & freely movable; cheeks are pinkish, moist & smooth; frenulum is in midline, straight & thin; soft palate is pinkish, smooth & moist; hard palate is slightly pinkish; uvula is at the center, symmetrical & freely movable NECK inspection palpation proportional to the size of the body & head, symmetrical & straight, no palpable lumps, masses or areas of tenderness chest contour is symmetrical, spine is straight, no lumps, no masses, no tender areas, with clear breath sounds; a circular scar is found in his right upper abdomen no abnormal pulsations, pulsations are palpable & visible in apical area symmetrical, dark pink nipples, no cracks & discharges, Normal

THORAX & LUNGS

inspection palpation percussion auscultation

Normal

HEART

inspection palpation percussion auscultation

Normal

BREAST

inspection palpation

Normal

uniform in skin color, smooth & intact, no lumps, masses & tenderness ABDOMEN inspection auscultation percussion palpation abdominal skin is unblemished, no scars, color is uniform with the body color, abdomen is rounded with symmetric movements caused by respiration; umbilicus is concave symmetrical, with visible veins, fine hair evenly distributed, warm, dry & elastic upon palpation, with area of tenderness on the left arm; palms are pinkish, warm, soft & elastic; nails are transparent, smooth & convex with light pink nail beds & white translucent tips; 5 fingers in each hand; both shoulders, arms, elbows, hands & wrists can be moved in different range of motion with relative ease; left wrist with tattoo; scars on Normal

UPPER EXTREMITIES

inspection palpation

Normal

the left arm LOWER EXTREMITIES inspection palpation skin is smooth, fine hair is evenly distributed, absence of varicose veins, muscles symmetrical, length symmetrical, 5 toes in each foot, sole & dorsal surface is smooth with pink nail beds & white translucent tips; right leg, knee, ankle, & toe can be moved in different range of motion with relative ease; scar on both patellar; scar on right sural; with external fixator on left crural. Deviated