Physical Examination Sample Pediatric

The patient is alert and oriented x3 and in slight distress secondary to pain. Patient is asleep but easily arousable. Patient who is reliable and old cpmc chart.

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96 cm 65th percentile bmi.

Physical examination sample pediatric. Weight 3 41 kg 10 25 ile height 54 cm 50 ile head circumference 37 5cm 50 ile general. No visible lesions or rashes. Physical exam format 1. 98 on room air bp.

To understand how the general approach to the physical examination of the child will be different compared to that of an adult patient and will vary according to the age of the patient. Subheadings in all caps and flush left to the margin. In order to assimilate the information most easily it is suggested that you read through the whole section before examining your first patient to get a general idea of the scope of the pediatric evaluation. The patient is a x year old well developed well nourished male female in no acute distress.

History and physical examination h p examples the links below are to actual h ps written by unc students during their inpatient clerkship rotations. Appears lethargic and ill. Assessment can be called the base or foundation of the nursing process. This is the 3rd cpmc admission for this 83 year old woman with a long history of hypertension who presented with the chief complaint of substernal toothache like chest pain of 12 hours.

With a weak or incorrect assessment nurses can create an incorrect nursing diagnosis and plans therefore creating wrong interventions and evaluation. 103 2of oral last tylenol dose was 4 hours ago. Pupils equal round and reactive to light and accommodation. 17 9 85th percentile general.

16 5 kg 90th percentile height. Example of a complete history and physical write up patient name. Patient is a well developed well nourished infant in no apparent distress. Nursing assessment is an important step of the whole nursing process.

Temp 37 8 rectal pulse 156 respiratory rate 45 bp 86 47 spo2 98 on room air growth parameters. The students have granted permission to have these h ps posted on the website as examples. This exam includes detailed examination of the reflex responses as well as the functioning of each of the cranial nerves. The practitioner in the health care setting assesses the neurologic status of the child by doing a complete neurologic exam.

To observe and demonstrate physical findings unique to the pediatric population and. Physical exam the following outline for the pediatric history and physical examination is comprehensive and detailed. Sclerae conjunctivae and fundi are clear bilaterally.