Vital signs Physical Examination on Admission:

General: awake, alert, ectomorph, well looking, well nourished, well hydrated, ambulatory without support,

Vital Signs: BP: 100/60mmHg CR 102 bpm regular, RR 20 cpm regular, Temp 37.1C

Anthropometrics: Ht: 109 cm (z-score= below 0); Wt: 18.1kg(z-score= below 0), BMI =15.23 (z-score= above 0)

Skin: warm, moist skin, good skin turgor, (-) flushed skin, (-) petechiae

Head: normocephalic, no palpable masses, no lesions, no facies, no facial asymmetry

Eyes: eyelashes not matted, no ptosis, no chemosis, pink palpebral conjunctiva, anicteric sclera, clear cornea, pupils
2-3 mm equally reactive to light,

Ears: no deformities, no aural discharge, non-hyperemic external auditory canal, tympanic membrane intact

Nose: nasal septum midline, no alar flaring, turbinates not congested, (-) discharge

Mouth: moist lips and buccal mucosa, midline uvula and tongue, (-) tongue fasciculations, tonsils not enlarged, non-
hyperemic posterior pharyngeal wall, (-) lip and oral lesions, (-) dental carries

Neck: supple neck, thyroid not enlarged, no cervical lymphadenopathy

Lungs: symmetrical chest expansion, no retractions, equal vocal fremiti, resonant lung fields, clear breath sounds

Heart: adynamic precordium, apex beat at the 4th LICS MCL, no heaves, no thrills, no lifts, no murmurs

Abdomen: Globular abdomen, no visible peristalsis, normoactive bowel sounds, dull on right upper quadrant and
upper half of right lower quadrant, the rest are tympanitic; Liver span at midclavicular line: 5 cm, smooth liver edge;
non-tender

Genitourinary: no phimosis, testes descended,

Extremities: pulses full and equal on all extremities, no cyanosis, no edema, no contractures or limitation of
movement, no clubbing of nails, bilaterally pronated feet

Neurological Exam:

Mental Status: awake, alert, conscious, coherent, oriented to time, person and place

Cranial Nerves:

CN I intact able to identify coffee

CN II pupils 2-3 mm equally reactive to light

Visual acuity 20/50 OD, OS

CN III, IV, VI full and equal external ocular movement

CN V V1-V3 able to pinpoint sensation

CN VII no facial asymmetry

CN VIII gross hearing intact

CN IX, X uvula midline, (+) gag reflex, able to swallow

CN XI sternocleidomastoid and upper trapezius 4/5

CN XII no tongue atrophy, tongue midline

Motor: shoulder abductors, biceps and triceps 4/5, Wrist extensors 3+/5

Trunk extensors 3/5, abdominals 2/5

Hip flexors 3+/5, Knee flexors 2+/5, Knee extensors 3/5, Ankle dorsiflexors 3+/5, ankle plantarflexors 3/5

Waddling gait, hip hiking, decreased knee flexion, foot pronated on stance phase.

Sensory: intact touch, pain and temperature sensation on upper/lower extremities, abdomen and chest

Cerebellum: (-) intention tremors, (-) dysdiadochokinesia, (-) overshooting

Meningeal signs: (-) nuchal rigidity, (-) Brudzinski sign, (-) Kernigs sign

Deep Tendon Reflexes: Biceps, triceps, patellar, ankle +1

(-) Babinski

Vital signs Physical Examination on Admission:

General: awake, alert, ectomorph, well looking, well nourished, well hydrated, ambulatory without support,

Vital Signs: BP: 100/60mmHg CR 102 bpm regular, RR 20 cpm regular, Temp 37.1C

Anthropometrics: Ht: 109 cm (z-score= below 0); Wt: 18.1kg(z-score= below 0), BMI =15.23 (z-score= above 0)

Skin: warm, moist skin, good skin turgor, (-) flushed skin, (-) petechiae
Head: normocephalic, no palpable masses, no lesions, no facies, no facial asymmetry

Eyes: eyelashes not matted, no ptosis, no chemosis, pink palpebral conjunctiva, anicteric sclera, clear cornea, pupils
2-3 mm equally reactive to light,

Ears: no deformities, no aural discharge, non-hyperemic external auditory canal, tympanic membrane intact

Nose: nasal septum midline, no alar flaring, turbinates not congested, (-) discharge

Mouth: moist lips and buccal mucosa, midline uvula and tongue, (-) tongue fasciculations, tonsils not enlarged, non-
hyperemic posterior pharyngeal wall, (-) lip and oral lesions, (-) dental carries

Neck: supple neck, thyroid not enlarged, no cervical lymphadenopathy

Lungs: symmetrical chest expansion, no retractions, equal vocal fremiti, resonant lung fields, clear breath sounds

Heart: adynamic precordium, apex beat at the 4th LICS MCL, no heaves, no thrills, no lifts, no murmurs

Abdomen: Globular abdomen, no visible peristalsis, normoactive bowel sounds, dull on right upper quadrant and
upper half of right lower quadrant, the rest are tympanitic; Liver span at midclavicular line: 5 cm, smooth liver edge;
non-tender

Genitourinary: no phimosis, testes descended,

Extremities: pulses full and equal on all extremities, no cyanosis, no edema, no contractures or limitation of
movement, no clubbing of nails, bilaterally pronated feet

Neurological Exam:

CN III, IV, VI full and equal external ocular movement

CN V V1-V3 able to pinpoint sensation

CN VII no facial asymmetry

CN VIII gross hearing intact

CN IX, X uvula midline, (+) gag reflex, able to swallow

CN XI sternocleidomastoid and upper trapezius 4/5

CN XII no tongue atrophy, tongue midline

Motor: shoulder abductors, biceps and triceps 4/5, Wrist extensors 3+/5

Trunk extensors 3/5, abdominals 2/5

Hip flexors 3+/5, Knee flexors 2+/5, Knee extensors 3/5, Ankle dorsiflexors 3+/5, ankle plantarflexors 3/5
Waddling gait, hip hiking, decreased knee flexion, foot pronated on stance phase.

Sensory: intact touch, pain and temperature sensation on upper/lower extremities, abdomen and chest

Cerebellum: (-) intention tremors, (-) dysdiadochokinesia, (-) overshooting

Meningeal signs: (-) nuchal rigidity, (-) Brudzinski sign, (-) Kernigs sign

Deep Tendon Reflexes: Biceps, triceps, patellar, ankle +1

(-) Babinski