Ate Rob and Lady.. naka-KJ po yung total number of rash per part of the body..

Physical Examination

Height – 127cm
Weight – 23kg
BMI – 14.2

Ideal Height: 117cm – 146cm

Ideal Weight: 22kg – 40kg

Vital Signs:
• Temperature – 37.0oC
• Blood Pressure – 90/60 mmHg
• Respiratory Rate – 23 bpm
• Pulse Rate – 120 bpm

General Appearance:
Patient was seen comfortably lying down on bed, conscious and coherent, with mother sitting at
bedside. Patient had coordinated movement, no odor problems and answered some of the
examiner’s questions.

Regional Examination:

SKIN
I:
Skin color is light brown in color
Presence of Maculopapular rash all throughout
Absence of edema

PA:
Presence of maculopapular rash
Absence of edema
Skin is dry and warm to touch
Good skin turgor
Absence other masses and nodules

NAILS:
I:
Clean and kept short
Nail bed color is pale pink

PA:
-Smooth in texture.
-Capillary refill about 2-3 seconds

HAIR
I:
Straight and Black in color
Evenly distributed
Absence of face
No infestation of lice

HEAD AND FACE

I:
Normocephalic with frontal, parietal and occipital prominences
Upright and still
Slightly asymmetrical facial features
Hair is thick and black in color and has some presence of flakes
Even distribution of hair
Presence of maculopapular rashes along the ear and face
PA:
Smooth contour
Absence of nodules and masses

EYES
I:
PERRLA
Anicteric sclera
Pinkish upper and lower conjunctiva
Eyebrows are symmetrically aligned
Eyelashes are equally distributed and curled outward
Eyelids are puffy, has presence of maculopapular rash
Cornea is transparent and appears shiny and smooth

PA:
-Absence of edema, masses and nodules
-No tenderness noted
-Visual fields: client can see objects in periphery on both eyes
-Extra ocular movement test: able to follow six directions of gaze on both eyes
-Visual acuity test: able to read newsprint

EARS
I:
Presence of maculopapular rash on surrounding skin
Colour same as surrounding skin
Symmetrical
No presence of cerumen or any discharges.
Absence of masses
Hearing Acuity test: ask people to hear words
Weber's test: bone conduction is greater than air conduction

PA:
-No tenderness noted

NOSE
I:
Located at the midline.
Same color as surrounding skin
No swelling or inflammation.
No presence of exudates and mucus secretions.

PA:
No tenderness noted

MOUTH AND PHARYNX

I:
Lips are pale pink, symmetrical; lip margin is well defined, smooth but quite dry
Able to purse lips
No ulcers
Moist and pinkish gums and buccal mucosa
No bleeding, swelling and inflammation of gums
Uvula positioned midline of soft palate
Tongue midline without deviation, moves freely
Slightly red, hypertrophic tonsils
No presence of exudates
Presence of dental caries at left and right molars
NECK
I:
Located at midline
Able to move without difficulty
Presence of maculopapular rashes along the neck and back of the neck.

PA:
No palpable lymph nodes
No tenderness noted

SPINE
I:
Presence of maculopapular rash at the back
Straight
No signs of bulging or deviations.

PA:
-No presence of lumps or masses.

THORAX AND LUNGS

I:
Chest contour is symmetrical
Spontaneous and non-labored breathing
Presence of maculopapular rashes over the chest

PA:
Symmetrical chest excursions
No deformities, masses and lumps found
No tenderness in the areas palpated

PER:
-Symmetrical resonant sounds heard

A:
With presence of fine crackles in the upper zone of the anterior chest during expiration

CARDIOVASCULAR/HEART
I:
-No visible pulsation.
-No exaggerated lifts and thrills in the area.
-No distended and bulging veins

PA:
-No presence of lumps and masses.

A:
-Cardiac rate and rhythm normal
-Absence of heart murmurs and bruits

ABDOMEN
I:
Flat contour
Presence of maculopapular rashes over the abdomen
No prominent pulsations
No presence of any distention or any bulging.
Umbilicus is located at the midline with no presence of discharges

PER:
Tympanitic over the abdomen

PA:
Absence of tenderness

A:
Audible bowel sounds

EXTREMITIES
I:
With ongoing IVF of D5 0.3% NaCl 1L at right metacarpal vein, intact and infusing well

PA:
No swelling or any nodules
Smooth and moist skin
Warm to touch
No muscle tenderness

GENITALS – client refused to do the assessment

RECTUM AND ANUS – client refused to do the assessment

NEUROLOGIC EXAM
I:
a. LANGUAGE
Doesn’t have any problems regarding speech
Can point common things and respond to verbal instruction

b. ORIENTATION
Patient was able to tell where she is, and who she is with.

c. MEMORY
Patient was able to recall some scenarios and things that she has experienced and seen
liked the interviewer’s name, what she ate last night for dinner and last lesson she learned
in Math class

d. ATTENTION SPAN
Attention span is fair.
She is able to recite the alphabet and count 1-10 and backwards.
Patient was also able to do simple mathematical equations (addition and subtraction).

e. LEVEL OF CONSCIOUSNESS
Patient is conscious, and coherent.

f. CRANIAL NERVES
All cranial nerves are in good condition.

g. REFLEXES
All reflexes are active.

h. MOTOR FUNCTION
These weren’t assessed as the patient was tired and wanted to rest already.

i. SENSORY FUNCTION
Patient is able to distinguish light and pain sensation, 1-2 point stimulus, recognize items
objects by touching, and positioning.