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PHYSICAL EXAMINATION AND REVIEW OF SYSTEM GENERAL APPEARANCE 1. Appearance 2. Body fat 3. Dress, Grooming, Personal Hygiene 4.

Apparent age vs. Stated age 5. Mood and manner 6. Facial expressions 7. Speech 8. Distress 9. Body and Breath odor NORMAL FINDINGS - the pt exhibit body symmetry, no obvious deformity and well appearance; position is erect and the limbs and trunk appear proportion to height - the body should be evenly distributed; the height is appropriate to weight - has a normal gait and movement is smooth and effortless -no apparent odor and has fresh breathe -the pt s clean and dry; clothing choice is appropriate to the weather -the mood is cooperative and pleasant -pt respond to question and commands easily; speech is clear with normal pitch, rate, volume and understandable -pt appears awake and alert; facial expressions is appropriate to the happening in the environment and changes naturally ACTUAL ASSESSMENT Patient is sitting on side of the bed during assessment. Attached to oxygen at 4 L/min via nasal cannula. Patient appears weak, thin, and restless, in respiratory distress. Nasal grunting, use of accessory muscle, nasal flaring with chest retraction were observable. With evident productive cough. Chief Complain of Difficulty of breathing brought about by the copious secretion. The patient is not well-groomed and with foul odor. The mood is responsive, cooperative, expressive and pleasant. He responds to question and commands easily. Speech is clear with low pitch, rate volume but understandable. Facial expressions are appropriate to what is happening in the environment and changes naturally. Patient weighs 43.5 kilograms, standing 146 centimeters.

VITAL SIGNS 1. Temperature 2. Pulse rate 3. Respiratory rate 4. Blood pressure

NORMAL FINDINGS Temp= 35.4 37.4 C (axilla) PR= 60 100 bpm RR= 15 20 cpm BP= 120/80 mmHg

ACTUAL ASSESMENT Temp= 37.5 OC PR= 82 bpm RR= 28 cpm BP= 120/100 mmHg

SKIN INSPECTION 1. Color 2. Bleeding, Ecchymosis, Vascularity 3. Lesions PALPATION 1. Moisture 2. Temperature 3. Texture 4. Turgor 5. Edema, Lesions

NORMAL FINDINGS -uniform whitish-pink or brown depending on the race -there is no areas of increased vascularity, ecchymosis or bleeding -no skin lesions except freckles, birthmarks or nevi w/c may be flat or elevated -skin is dry with a minimum of perspiration; moisture vary from one body area to another

ACTUAL ASSESMENT The skin is uniformly brown with areas of increased vascularity, ecchymosis or bleeding and no presence of lesions. The skin is dry and has a minimum perspiration. The skin feels warm and the hands are slightly cooler that the rest of the body. Skin is nontender and feels smooth upon palpation.

In testing the turgor of the skin, when it is -surface temp. is warm and equal bilaterally; hands and feet may released, it goes back to its original contour be slightly cooler than the rest of the body slowly (about 4-5secs.). There is no edema or any other skin abnormalities. -skin surfaces should be non tender -skin feel smooth, even and firm except significance hair growth(certain roughness is normal) -when the skin is released it should return to its original contour rapidly -no edema and lesions

HAIR INSPECTION 1. Color 2. Distribution 3. Lesions PALPATION 1. Texture

NORMAL FINDINGS hair varies from black to pale blond -the body is covered with vellus hair and area like eyebrows with terminal hair -the scalp is pale white to pink with no lesion, seborrhea -hair may feel thin, straight, coarse or think or curly

ACTUAL ASSESSMENT During inspection, hair color is black. Hair is not equally distributed throughout the head. One of the obvious assessments to the patient is the decrease in hair concentration because he is undergoing chemotherapy and one of its side effects is hair loss which can lead to baldness. Patient reported that she experienced hair fall as the side effects of her chemotherapy treatment. There is no presence of nits and seborrhea.

NAILS INSPECTION 1. Color (pinch) 2. Shape and configuration (diamondshaped) PALPATION 1. Texture

NORMAL FINDINGS -Nails have pink cast with a normal capillary of 2 3 secs. -surface should be smooth, and slightly rounded or flat with the presence of the diamond shape when put together -nail base is firm

ACTUAL ASSESSMENT Patient has complete number of fingers in the hand and feet. Nails are long and dirty. Nail cast is brown all over and the capillary refill is 3 seconds which is not in normal range. The nail surface is rough and nails are slightly round. When the patient was asked to do the carpal tunnel, the presence of the diamond shape was observed. Upon palpation, the nails feel firm. .

MUSCULOSKELETAL NORMAL FINDINGS INSPECTION: 1. Muscle size and shape 2. Joint contour and periarticular tissue PALPATION: 1. Muscle tone 2. Joints ROM: rotation, external rotation, abduction, adduction, hyperextension) 7. Knees (flexion, extension, TEST FOR 1. Muscle strength -muscle contour will be affected by the increase of activity patterns of the individual -joint contour should be somewhat in flat extension and smooth in flexion -on palpation, muscle should feel smooth, firm and even; there should be no pain -when a major joint are palpated they should feel smooth, strong and firm --Body height and weight should be appropriate for age and gender -in standing the torso and head are upright. The head is midline and appendicular to the horizontal line of the shoulder and pelvis; shoulders and hips are level with symmetry of the scapula and iliac crest -walking is initiated in one smooth, rhythmic fashion; the foot is lifted 2.5 to 5 c, off the floor and propelled 30-45 cm forward - As heels strikes the floor, the body weight is lifted onto one ball of the foot to another. -normal muscle strength allows complete voluntary range of joint motion against both gravity and moderate in full resistance -muscle strength is equal bilaterally no involuntary muscle movement

ACTUAL ASSESSMENT Patient is ambulatory but has limited movement brought about by generalized weakness and easy fatigability as a consequence of shortness of breath and difficulty of breathing. No outward indications of discomforts. Limbs, torso and pelvis are symmetrical. Reported pain during exertion and presence of chest retractions. Extremities are proportion. During muscle contraction, the muscle increase in size. Joint contour is flat on smooth round flexion. No erythematic, edema, bruits, nodules and any deformities in the skin. Upon palpation, muscle is smooth, firm and clients reports no pain. During muscle contraction, significant overall increases in muscle firmness. Joint fells smooth, strong and firm with edema, tenderness and warm to touch. Range of motion is normal; muscle strength allows complete range of motion against a moderate resistance. Muscle strength is not equal bilaterally with any involuntary movements. No crepitus and elbows are same height and symmetrical in appearance. The thenar eminence is round. Knees are aligned to each other. No pain in the plantar fasia.

THORAX AND LUNGS


INSPECTION 1. Shape of thorax 2. Symmetry of chest wall 3. Presence of superficial veins 4. Costal angle (<90) 5. Angle of the ribs (45) 6. Intercostal spaces 7. Muscle respiration 8. Respirations 9. Sputum PALPATION 1. Pulsation 2. Masses 3. Muscle tenderness 4. Crepitus 5. Thoracic expansion (tape measure) 6. Tactile fremitus (blue moon) 7. Tracheal position Anterior PERCUSSION 1. Thorax - ICS 2. Diaphragmatic excursion - Anterior AUSCULTATION 1. Breath sound 2. Adventitious breath sounds 3. Voice sound 4. ICS

NORMAL FINDINGS
-thorax is slightly elliptical in shape. -shoulders and scapula is at the same height bilaterally and no masses -dilated superficial veins are not seen -costal angle is <90 during exhalation and at rest and widens slightly during inhalation. -ribs articulate at a 45 angle with the sternum - Absence of retractions and of bulging of the ICS. -no accessory muscles used in normal breathing -RR is 12 to 20bpm -small amount of odorless sputum which is light yellow or clear in color -no pulsations, masses, thoracic tenderness and crepitus is present -during thoracic expansion the distance of the thumbs is 3 to 5 cm -normal fremitus is felt as a buzzing on the ulnar aspect of the hand -the trachea is midline in suprasternal notch -lung tissue produces a resonant sound and rib sounds are flat -diaphragmatic excursion is 3-5 cm -bronchial, bronchovesicular and vesicular normal breath sounds were heard

ACTUAL FINDINGS
The thorax is bony and elliptical in shape. No dilated superficial blood vessels. The scapula is the same bilaterally. Ribs articulate at 45 degree with the sternum and there is no bulging in the intercostals spaces. The patient has a RR of 28 cpm. The breathing pattern has pain in exertion and irregular. The inspiration and expiration requires and symmetrical. Symmetrical lung expansion. No tenderness and retractions noted The patient breaths through his mouth brought about by the copious secretion which obstructs the airway canal. No pulsations, masses and thoracic tenderness. The tactile fremitus is felt bilaterally and equal. The trachea is in the midline of the supersternal notch. Upon percussion, the lung sound is resonant. Ribs are flat. The breath sound is all normal. With crackles sound on mid to base on the right and basal on both lung on all regions. Patient reported rusty sputum, thick, gray and sometimes green in color.