Physical Assessment

Date of Assessment: August 14, 2014

General Survey

The patient was seen sitting on bed, sleepy and coherent. She was wearing a terno blue shirt and a pair of shorts.

Initial Vital Signs

Body Temperature: 37.1°C

Cardiac Rate: 130

Respiratory Rate: 33

Blood Pressure: 70/60

Height: 102 cm

Weight: 12.5 kg

Head to Toe Assessment

Head Normocephalic Round in shape, erect and in midline Hair is black in color and fairly distributed Facial features are symmetrical No lesions Face is oval in shape Face is pale in color

Eyes With pale palpebral conjunctiva With white sclera With brown color of the iris With long and thin eyelashes With black, fairly distributed eyebrows No lesions or swelling in both eyelids Eyelids closes and opens easily PERRLA (Pupil Equally Round and reactive to Light and Accommodation)

Ears Symmetrical, in line with the outer canthus of the eye With attached earlobes Color is consistent with facial color No discharges, lesions and tenderness

Nose Color is consistent with facial color With patent airway Symmetrical nostrils No visible discharges and no lesions No tenderness on the sinuses

Mouth No foul odor Lips are smooth, dry and pale in color With yellowish teeth with one missing tooth Gums are moist and pink in color No lesions or swelling With pinkish and moist tongue and with papillae With shiny, moist, pale in color with visible veins and without lesions in ventral surface With white hard palate and pinkish soft palate With moist and pinkish uvula, hangs freely and in midline

Neck In midline with head centered No lesions or masses No bruits sounds No enlargement of the lymph nodes

Chest Breathes easily With an Heart rate of 130 With respiratory rate 33

Abdomen Whiter in color than the rest of the body No lesions, masses, tenderness or scars Umbilicus in midline Abdomen is scaphoid upon lying on bed

Upper Extremities With symmetrical upper extremities With good ROM With pale nail beds With poor capillary refill of 2-3 seconds

Lower Extremities With symmetrical lower extremities With pale toe nails With good capillary refill of 1-2 seconds