GENERAL APPEARANCE
The patient is conscious, well-oriented of his present condition and showed interest in the environment, alert
during assessment, and lethargy during assessment.
The patient’s Vital Signs are elevated with a temperature of 39 centigrade, pulse rate of 170 beats per minute,
respiration rate of 40 breaths per minute and blood pressure of 120/60.
Upon receiving the patient, the patient was pale-looking and complains abdomen was distended. Infant
shows drawing his legs to chest and crying incessantly
The patient showed sign or potential signs of distress, such as crying, and lethargy
Physically, the patient’s nutritional status and body built/stature is appropriate to his age.
The patient is lethargy, has an abdominal distended which can be palpable “sausage-shaped mass” as
described , cant freely move, flex and extend his extremities shows pain such as crying.
The patient show facial distress expression during assessment.
The patient’s mood is lethargy during assessment to the situation, has alert response, distress and
uncomfortable.
The patient is distress, and pale.
The patient physically looks clean and neat.
CEPHALOCAUDAL PHYSICAL ASSESSMENT
SKIN
The patient’s skin is uniformly, has no lesions, edema or abrasions, is not moist because of the air ventilated
environment, has warmed temperature during touch, and when pinched, the skin springs back to the previous state.
The tissues surrounding the nails of the patient are intact. And when blanched test performed, color of the nail of the
client returns into pink in less than 3 seconds.
HEAD AND FACE
The patient’s scalp is lighter than the color of his skin and has areas of tenderness in anterior and posterior head of
baby . The hair is evenly distributed and is thick. The patient has symmetric facial movements.
EYE
The patient’s eyebrows have evenly distributed hair, has intact skin, symmetrically aligned, and has equal movement.
The conjunctiva is transparent, capillaries sometimes evident, and sclera appears white and clear. The cornea is
transparent, shiny and smooth, details of iris are visible. The iris is brown, flat and round. The patient’s visual acuity is
normal.
EAR
The patient’s external ear canal is dry, has presence of hair follicles, no pus or blood. Normal voice tones are audible
to patient; patient is able to response to noise around area. Sound is heard on both or localized at the center of the
head. Ear is without masses.
NOSE
The patient has no tenderness on sinuses. The nose is in the midline, has no discharges, no nasal flaring, both nares
are patent, and no bone and cartilage deviation noted on palpation.
MOUTH AND THROAT
The patient’s buccal mucosa is uniformly pink in color, moist, smooth, soft, glistening and elastic in texture, and has
no lesions. Teeth are has no presence of teeth yet, gums are pink, moist, firm, has no retraction and bleeding of gums.
Tongue is pink, has thin whitish color. Uvula is positioned in the midline of soft palate. The tonsils are pink in color,
and have no discharges.
NECK
The trachea is on central placement in the midline of the neck, spaces are equal on both sides. The thyroid gland is
not visible in inspection, gland ascends during swallowing, no masses palpated.
CHEST (POSTERIOR AND LATERAL)
Posterior thorax is asymmetric, ribs are sloped downward, and muscle development is equal. Spines are slightly
aligned, are uniform in temperature, have no tenderness and masses. Chest is symmetric upon expansion.
CHEST (ANTERIOR)
Breathing pattern is quiet, rhythmic and effortless. Chest is symmetric upon expansion, has flat sound on the part
with heavy muscles and bony prominences, tympani on the stomach, dullness on the liver and spleen,
bronchovesicular and vesicular.
HEART
The patient’s heart has no palpable pulsation over the aortic, pulmonic, and mitral valves, no noted abnormal heaves,
and thrills felt over the apex, and no abnormal heart sounds is heard like murmurs.
UPPER EXTREMITIES
Both extremities are equal in size, have the same contour with prominences of joints, no involuntary movements, no
edema, color is even, temperature is warm and even, has equal contraction and even, can perform complete range of
motion, no crepitus noted on joints, and can counter act gravity and resistance on ROM.
ABDOMEN
The patient’s abdomen skin color is uniform, no lesions, noted tenderness abdomen is distended, a reveal “sausage-
shaped mass”, with smooth and consistent tension, and skin is smooth but warm.
LOWER EXTREMITIES
Both extremities are equal in size, have the same contour with prominences of joints, no involuntary movements, no
edema, color is even, temperature is warm and even, has equal contraction and even, can perform complete range of
motion, no crepitus noted on joints, and can counter act gravity and resistance on ROM.
MUSCULOSKELETAL
The patient’s muscles are bilaterally symmetric, has no contractures and tremors, normal muscle tension, adequate
strength of the muscle. The bones are uniform in structure, no deformities, tenderness or edema. Joints are not
tender, has smooth movement and no nodules.
ANUS, RECTUM AND PROSTATE
(NOT ASSESSED)
