PHYSICAL EXAMINATION

General Survey:
During the physical examination, the patient's height is 56cm and her weight is 4kg. When examined, the
skin color was seen fair/pallor, and there were no bruises but rashes are still present on the patient's skin.
The eyeballs are sunken, and the lips and oral mucosa are dry.

Anthropometric Measurement
Vital Signs
The patient’s vital signs were stable with a heart rate of 156 beats/min, a body temperature of 36.6 °C,
respiratory rate of 46 breath/min. Other vital signs include oxygen saturation of 98%, and blood pressure of
80/50 mmHg.

Body Position / Alignment:

The patient is a 1 month old infant who cannot stand or walk without support. Most of the time the patient is
cuddled into supine position.

Mental Acuity:
The eyes of the patient during physical examination was able to spontaneously follow the light with brisk
pupil reaction; the motor response demonstrated normal spontaneous movement; and the patient
demonstrated coos, cries, and smile for the verbal response.

Sensory / Motor Restrictions:

The patient has no sensory and motor restrictions.

Emotional Status:
The patient can expresses her feelings only by crying, whether the patient needs to change diaper, in pain,
hungry, and discomfort.

Medically Imposed Restrictions:

There are no restrictions ordered for the patient.

Other Health Related Patterns:

According to the patient’s mother, aside from the fever and rashes present during the admission, there are no
other health related problems reported.

Environment:
The room of the patient in the hospital is adequately with good room temperature, not too cold and hot. The
lighting in the room was slightly inadequate due to lights distribution.

Safety:
The safety of the patient was not violated during her admission in the hospital.

Activities of Daily Living:

The patient in her age of 1 month old, cannot perform any activities of daily living.
PHYSICAL EXAMINATION FINDINGS:

Head/Skull:
The patient upon admission has a bulging of anterior fontanelle. Other than that, there are no reported
bruise, lesions, and abnormalities present.

Eyes/Vision:
The patient’s eyes and vision during the examination demonstrated equal and round pupils, both are
accommodating and reactive to light.

Ears/Hearing:
The ears of the patient upon examination has no obstruction and discharge; there is also no problem in
hearing of the patient.

Nose, Mouth and Throat:

There are no discharge and obstruction on the patient’s nose, mouth and throat during the examination.

Neck and Lymph Nodes:

Upon palpation to the patient, there are no palpable swollen lymph nodes.

Thorax (Chest and Lungs):

a. Anterior
b. Posterior

Heart and Cardiovascular System:

The patient’s heart rate upon admission was slightly elevated of 190 beats/min crying. There are no family
history about any cardiovascular problems.

Abdomen:
The patient has a soft abdomen and there are no masses palpated upon examination.

Neurological:
The patient was oriented as demonstrated by smiling, cooing, and crying. The eyes spontaneously followed
the light and showed spontaneous movement.

Musculoskeletal:
The patient has no signs of swelling and tenderness.

Genitalia:
There were no abnormalities and discharge on the genitalia of the patient.

Extremities:
The patient has good pulses and there are no signs of swelling and tenderness on the extremities of the
patient.