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Head to Toe Assessment

I- APPEARANCE & MENTAL STATUS Patient Diamante, years old, appears to be weak, and yellowish skin color is noticeable. (mao ra ni akong na observe ju, he3. paki add nalang

sa katong ingon ni Cyril nga mura daw way klaru ka storya. Wa ko kabalo ato. Thanks.)
II- VITAL SIGNS

Blood Pressure mmHg Respiratory Rate - cpm

Temperature Pulse Rate - bpm

III SKIN Patients skin is yellowish in color, and is slightly dry. Poor skin turgor is noted. And spots are observed in patients skin. IV HAIR Patients hair is evenly distributed, and slightly short, just above the shoulders. No infection and infestations. V NAILS Patients fingernails and toenails are yellowish in color. 180 degree angle in curvature. Capillary refill test is less than 2 seconds. VI SKULL & FACE Patients skull is round. No signs of mass upon palpation. (Ju, pls nalang ko

add ani. Gi tuyok2 ra man ni Glenn iya sentence.)


VII EYE STRUCTURE & VISUAL ACUITY Patients sclera is yellowish in color. Patients hair eyebrows are evenly distributed, symmetrically aligned, and equal in movement. No tenderness over the lacrimal gland. Pupils are black in color, equally round and reactive to light and accommodation. VIII EARS & HEARING Patients ears skin color is the same as the facial skin which is also yellowish (tama ni?). Auricle aligned with the outer canthus of the eyes. Not tender and pinna recoils after it is folded. No discharges. And patient ca hear the normal tone of a voice. IX NOSE & SINUSES Patients nose is symmetric, uniform in color with the facial skin, and no discharges. No tenderness and lesions, nodules, and mass. X MOUTH & OROPHARYNX

Patients outer lips are reddish in color, and are slightly dry and inner lips are moist. Tongue is in the central position of the tongue, moist, and no presence of nodules. Able to roll the tongue, and move from side to side. No dentures. XI NECK Patients neck muscle is equal in size and has no masses or tenderness. Coordinated movements in moving the head. Lymph nodes are not palpable. XII THORAX & LUNGS Full chest expansion was observed. No abnormal breathing sound upon auscultation. Patients spine is vertically aligned. XIII HEART & CENTRALO VESSELS Carotid artery has full pulsation. And jugular vein is not visible. XIV BREAST & AXILLAE Patients breast is yellowish in color, nipples has no discharges. No tenderness, masses, or nodules noted. XV ABDOMEN Patients abdomen is yellowish in color. Jackson Pratt is attached to the incision site in the abdomen with a bloody red-colored fluid. No masses upon palpation. XVI MUSCULOSKELETAL SYSTEM Patients muscle is equal in size in both side of the body. No muscle tendons and tremors. And no deformities. XVII NEUROLOGIC SYSTEM

(Ju, wa ko kabaw diri, wa ko naka talk sa pt personally.)