PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS

REVIEW OF SYSTEMS

PHYSICAL EXAMINATION

General Survey Physical Appearance

Nagtitikagasa la hiya. - The patients As verbalized by the appearance is mother. congruent with his age. - thin appearance and enlarged head noted. - Muscle wasting noted - Well groomed - Appropriately dressed for the weather - Ht: 88cm - Wt: 9kg

PHYSICAL EXAMINATION Mental Status pirmi la hiya - lethargy, pinipiraw as verbalized responsive to by the mother stimuli - Blunt facial expression noted Vital Sign Nagbibinalikbalik gad it iya hiranat. as verbalized by the mother. - Temp: 38 - PR: 164 bpm - RR: 65 cpm

REVIEW OF SYSTEMS

Skin

Maiha na ito na iya I: mga katol, kay it iya - Brownish color of the bugto may ada gihap.as skin noted verbalized by the - Dry and flaky skin mother. noted - Active lesions noted at the upper and lower extremities P: - Warm skin noted - Skin pinch returns to place after one second.

Hair
Manipis ito it iya buhok. As verbalized by the mother. - Black, brittle and dry hair noted

Nails
guinbabakluhan ko ito hiya kada semana. As verbalized by the mother.

I: - Pale nail bed, fingernails medium length, no clubbing noted. Pal: - Upon performing blanch test Capillary refill is 3 seconds - Nail base is firm

Head and neck

Kaya man ni-ya lumingi.as verbalized by the mother.

I: - Enlargement of the head noted - HC: 54cm - Head positioned at the center - Bulging fontanelles noted - Dilatation of scalp veins noted - Scalp is thin and shiny - No lesions noted Pal: - Delayed fusion of anterior fontanelles noted - Palpable lymph nodes noted

Eyes
Diri na ito hiya nakakita.as verbalized by the mother.

I: - White sclera noted - Pale palpebral conjunctiva noted - Cornea is transparent and smooth - Protrusion of the eye globes noted - Blink reflex: 3-4/min - Pupils are equal in size: 6mm,fixed and dilated, not reactive to light and accommodation Pal: - No tenderness in the lacrimal gland or discharges noted when pressure is applied

Ears Diri gud ito hiya nabati.as verbalized by the mother

I: - Equal in size, similar in appearance - Pinna is aligned with the corner of the eyes - No abnormal discharges noted. Pal: - No tenderness upon palpation

Mouth and throat

Diri hiya naka-abri hit iya baba.as verbalized by the mother. Talagudti la it amon ginhuhungit ha iya nga pagkaon.as verbalized by the mother.

I: - lips are smooth and moist without lesions - pinkish gums without lesions noted - yellowish discoloration of the teeth noted

Nose and sinus

I: Waray man ito hiya - External nose is same problema ha in color as with face; irong.as verbalized symmetrical appearance by the mother. - nasal mucosa is dark pink , moist and free of exudates Pal: - smooth consistency; - no nodules, masses or pain on palpation - Sinuses are both nontender on palpation

Thorax and Lungs

dire ito hiya nkaubo as verbalized by the mother

I: - RR: 65 cpm - Uses accessory muscles to assist breathing. - Deep respiration with regular rhythm - equal chest symmetry A: - crackles on the lower base of the lungs upon auscultation noted

Heart

Pal: - HR: 164 bpm - Regular Rhythm - No murmurs heard - Apical pulse at left midclavicular line at fourth ICS

Abdomen

Nagtitikagasa la hiya. As verbalized by the mother.

I: - Scaphoid abdomen noted - Umbilicus is at the midline depressed and beneath the abdominal surface. - No lesions noted A: - Gurgling sounds is heard at a rate of 15/min Pal: - Abdomen feels smooth with consistent softness

Musculoskeletal

Diri ni-ya kaya I: lumingkod ngan - Thin upper and tumukdaw.as lower verbalized by the extremities mother. noted Maluya it iya - Unable to lawas.as verbalized stand and sit. by the mother.

Neurology Mental Status

- lethargy, responsive to stimuli - Blunt facial expression noted - GCS: 9

Cranial Nerve I
Cranial Nerve II

- Not tested
- Not tested

Cranial Nerve III, IV, VI

- Pupils are equal in size: 6mm, not reactive to light and accommodation, dilated and fixated

Cranial Nerve V Cranial Nerve VII Cranial Nerve VIII Cranial Nerve IX and X Cranial Nerve XI

Eyelids blink laterally Not tested Not Tested Not Tested

Cranial Nerve XII

- Client not able o shrug shoulders against resistance - Not able to protrude the tongue