Demographic Data Name Address Age Sex Date of Birth Place of Birth Nationality Religion Civil Status Occupation Lumasac, Francis Llanita Brgy. Pingit, Baler, Aurora 21 years old Male February 26, 1985 Baler, Aurora Filipino Roman Catholic Single Construction Worker Father Occupation Domingo Lumasac Deceased Mother Occupation Clarita Llanita Housekeeper Physical Assessment & General Appearance Weight Height MEASUREMENTS Level of Consciousness Body Build Posture & Gait Overall hygiene & Grooming 57 kg 171 cm FINDINGS Spontaneous, oriented Medium Erectposture, active purposeful stride Good
Head to Toe Assessment BODY PART TECHNIQUE USED FINDINGS INTERPRETATION HEAD Skull proportional to the size of the body, round, with prominences in the frontal area anteriorly & the occipital area posteriorly, symmetrical in all planes, gently curved Scalp/ Hair scalp is white, clean, free from masses, lumps, nits, dandruff & lesions, with no areas of tenderness upon palpation; hair is black, evenly distributed & covers the whole scalp, thick & shiny Face oblong shaped, smooth & no involuntary muscle movements Eyes/ Vision eyes are parallel & evenly placed, nonprotruding, with scant amount of secretions, both eyes black & clear; sclera is white & clear; eyebrows are black,
thick, can raise both symmetrically & without difficulty, evenly distributed & parallel with each other; eyelashes are evenly distributed & turned outward; upper eyelids cover a small portion of the iris, cornea & the sclera when the eyes are open, when the eyes are closed the lids meet completely, symmetrical & the color is the same as the surrounding skin; lid margins are clear, without scaling or secretions; lower palpebral conjunctiva are shiny, moist, transparent & salmon pink in color; iris are proportional to the size of the eye, round & symmetrical; pupils are from pinpoint to almost the size of the iris, round, constricts with increasing light & accommodation; able to move eyes in full range of direction
Ears/ Hearing ears are parallel, proportional to the size of the head, bean-shaped, helix is in line with the outer canthus of the eye, skin is the same color as the surrounding area & clean; ear canal is pinkish, clean, with scant amount of cerumen & a few cilia; able to hear whisper spoken 2 feet away; 2 piercing are found in left ear and 1 piercing in right ear Nose nose is in midline, patent; internal nares are clean, dark pink with few cilia Mouth/ Lips lips are dark pink, lip margin is welldefined, smooth & moist; gums are dark pink, smooth, moist, no swelling, no retraction, no discharge; 32 teeth are present, aligned, with no dental caries; tongue is pinkish, slightly rough on top, smooth along
the lateral margins, moist, shiny & freely movable; cheeks are pinkish, moist & smooth; frenulum is in midline, straight & thin; soft palate is pinkish, smooth & moist; hard palate is slightly pinkish; uvula is at the center, symmetrical & freely movable NECK proportional to the size of the body & head, symmetrical & straight, no palpable lumps, masses or areas of tenderness THORAX & LUNGS percussion auscultation chest contour is spine is straight, no lumps, no masses, no tender areas, with clear breath sounds; a circular scar is found in his right upper abdomen HEART percussion auscultation no abnormal pulsations, pulsations are palpable & visible in apical area BREAST dark pink nipples, no cracks & discharges,
uniform in skin color, smooth & intact, no lumps, masses & tenderness ABDOMEN auscultation percussion abdominal skin is unblemished, no scars, color is uniform with the body color, abdomen is rounded with symmetric movements caused by respiration; umbilicus is concave UPPER EXTREMITIES with visible veins, fine hair evenly distributed, warm, dry & elastic upon palpation, with area of tenderness on the left arm; palms are pinkish, warm, soft & elastic; nails are transparent, smooth & convex with light pink nail beds & white translucent tips; 5 fingers in each hand; both shoulders, arms, elbows, hands & wrists can be moved in different range of motion with relative ease; left wrist with tattoo; scars on
the left arm LOWER EXTREMITIES skin is smooth, fine hair is evenly distributed, absence of varicose veins, muscles length 5 toes in each foot, sole & dorsal surface is smooth with pink nail beds & white translucent tips; right leg, knee, ankle, & toe can be moved in different range of motion with relative ease; scar on both patellar; scar on right sural; with external fixator on left crural. Deviated