HEALTH ASSESSMENT:

GENERAL SURVEY:

Upon assessment held on October 21, 2021, Patient NDJJ., a 11-months-

old male was conscious and a little bit sleepy upon arrival. NDJJ is a bit weak
and irritable. He is always crying and doesn’t drink much milk and he is warm to
touch. His eyes appear a bit sunken, head appears to be asymmetric and ears
are symmetrical. He appears to be breathing faster than normal and uses
accessory muscles apparently. Skin color is slightly cyanotic and he is able to
move his arms and legs and is able to stand with support.

REVIEW OF SYSTEMS
Warm to touch with a body temperature of
Skin
38.5°C, no lesions were noted and skin color is
slightly cyanotic

His ears a symmetrical with clear tympanic

membranes and clear bilateral canals. His nose
is located at the midline of the face with no
ENT/ Mouth
nasal septal deviation. A little bit of nasal flaring
is noted. Pharyngeal mucosa is pink and moist.
His mouth is a bit dry and cracked. His
oropharynges are pink and moist, no erythema
noted, no tonsillar enlargement noted
Eyes are normal, pupils equally round and
Eyes
reactive to light.

Chest appears to be normal with respiratory rate

of 34bpm. Appears to be breathing a bit faster
Respiratory System
than normal, use of accessory muscles is
 apparent.
Heart rate is around 100bpm with regular
Cardiovascular System
rhythm. Heart sounds audible with clear S1 and
S2 sounds. No murmur, rubs and gallops noted

Abdomen is a little bulging, soft and non-tender

Gastrointestinal
with 40 bowel sounds heard per minute.

Able to move his arms and legs and is able to

stand with support.
Musculoskeletal

Conscious and irritable but a bit sleepy.

Mental Status