Physical Assessment General Appearance The patient has a small body frame.

He is well groomed and has no body odor. No physical deformity observed. He is always on side lying position. The patient height is 64.5 cm and weigh of 8.9 kg. His head circumference is 43 cm, chest circumference is 48 cm and abdominal circumference is 47 cm. his vital signs: cardiac rate: 133 bpm, respiratory rate: 43 cpm and body temperature of 36. 3 degree celcius. Mental Status The patient is conscious but irritable and always crying. Skin The patient color is light brown, the moisture is dry, warm temperature and the texture is smooth and soft to touched. No skin lesions observed and has no edema. Skin turgor is elastic and mobile. Nail Nail plate shape is convex approximately 160, smooth and thin. Nail bed color is pink. Upon performing blanched test, capillary refill within 3 seconds. Head and Face The head shape is round and symmetrical. Hair condition is evenly distributed, fine and black in color. The face shape is round, symmetrical and soft to touched. There are no lesions and the scalp is not tender upon palpation. Eye The eye condition is straight normal, eyebrows are thin. The color of the sclera is white. Bulbar conjunctiva is reddish because of crying. Lacrimal apparatus is moist. Pupils are equally in size, black and round. Ears

The ears is light brown same with the face, symmetric in size and pinna recoils when folded. The patient is response to normal voice. Nose The color of the nose is same with the face. No nasal flaring observed. Septum is in midline. The patient nose are both patent. Nasal cavity is moist. Mouth and Oropharynx Lips color is pink and moist. Neck The patient neck can move voluntarily without assistance. Movements are flexion and extension. Breast and Axilla Symmetrical in size, contour is flat and the skin surface is smooth. Chest and Lungs Chest color is same with the skin tone light brown. For lungs, respiratory rhythm is normal or regular. Respiratory pattern is regular. Upon auscultation, absent of bronchial sound and breath sound is normal. Abdomen Skin integrity is in normal racial tone with surgical incision in his left upper quadrant. The stool color is yellowish and soft. Bowel sound was heard without friction rub. Upper Extremities The upper extremities can move independently and lift without difficulty. No lesions observed.

Lower extremities Can move independently and present of IV line in his left foot. Male Genitalia The patient has indwelling catheter. Urine color is yellow. Anus The anus was not assessed because the patient looks irritability.