I.

Vital Signs
July 19, 2018
8:00am
Blood Pressure: 110/80 mmHg
Temperature: 34.8⁰C
Pulse Rate: 101 bpm
Respiratory Rate:22 bpm

12:00 nn
Blood Pressure: 110/80 mmHg
Temperature: 36.3⁰C
Pulse Rate: 88 bpm
Respiratory Rate:22 bpm

Physical Appearance

1.General Appearance

He has a tan complexion. His lips is dry and dark in color. He have a foul smelling odor. He can smell, hear and taste. He
has an IVF of

2.Head

His hair is short and black. It appears to be unclean upon assessment. His hair has a minimal amount of dirt but no foul
odor was smelled. The scalp is dry and unclean upon inspection.

Upon observation the head is symmetric,hard,erect and in middle. No lesions are visible.

Upon palpation, the head is hard and smooth without lesions or wounds.

3.Face

The color of the face is same with the color of the body . Upon inspection, he have an acne on his face.

4.Eyes

He doesn’t wear eyeglasses. His eyes were rounded. Skin on both eyelids is without swelling or lesions. Upon observation
bulbar conjunctiva is clear,moist and smooth.

For vision, he can see as evidenced by reading a story on his cellphone.

5.Ears

His ears are equal in size in a distance of approximately 7ft. The external ear is clean and doesn’t have any discharge. The
ear canal when assessed have presence of minimal cerumen. The skin is smooth without lesions,lumps or nodules.

The color of the ear is consistent with the facial color.

Upon palpation, the auricle is non tender
Upon inspection of internal ear canal, presence of yellowish cerumen are present

For sense of hearing, he can hear from both ears by responding whenever he was called signifying he can hear.

6.Nose

The skin color of the face the nasal structure is smooth and symmetric: The nasal mucosa is dark pink.
The nasal septum is intact and free of ulcers or any perforations.
Nasal turbinates are dark pink,moist and free of lesions.

No presence of secretions were observed

Upon palpation, frontal and maxillary sinuses are non tender.
For the sense of smell, he can smell as evidenced by smelling the perfume of his mother and that the alcohol has a strong
odor.

7.Mouth

His lips are dark in color. His gums are pinkish but not moist because of dehydration. He has a total of 24 teeth. Buccal
mucosa appears slightly pinkish in color. Frenulum is midline. No lesions, ulcers or nodules on the sides of the tongue. No
halitosis notes.

For the taste he can’t eat because his diet is Nothing per orem.

8.Neck

His neck is symmetric with head centered without the presence of mass. He can move his neck freely. No swelling or
inflammation of the lymph nodes was observed.

9.Chest and Back

No retractions were observed upon inspection. No adventitious breath sounds were auscultated. No lumps or swelling was
observed. Scapulae are symmetric and non protruding spinal process is straight. The patient doesn’t use accessory muscle
in breathing.

10. Abdomen

Upon inspection abdominal skin is lighter/ paler than the general skin tone. He had a post appendectomy. He is wearing
abdominal binder.

11. Genitalia
Not Assessed

12. Upper Extremities

He has an IVF

His fingernails are short and no accumulation of dirt was seen on it. His hands were clean. Palmar pallor is not evident.
His arms are bilaterally symmetric and its color is same with the body and facial color.
No swelling noted.
No limitations on both hands.
He can perform range of motion

13. Lower Extremities

Legs are free of lesions or ulcerations. Swelling are not present sole pallor is not evident.

No scars, lesions or bruises were observed

He can perform range of motion.