Thorax

For the assessment of the thorax, stethoscope, skin marker and centimeter ruler are the
equipment needed, patient was asked to remove his gown it was done with privacy and
patient was very cooperative. Upon inspection patients chest was normal, it is
symmetrical, its shape is oval and overall elliptical. The spinal alignment was normal, no
bulges, tenderness and lesions noted. The patient breathes effortlessly no signs of
respiratory distress. The chest skin turgor was good, it returned back easily. Upon
examining of the chest excursion patients lung expand symmetrically, patient was
instructed to say 99 while palpating for the tactile fremitus and it was bilaterally
symmetrical and low pitched. Upon percussion patient thorax produces a resonant
sound, it was long, loud and low pitched, the diaphragmatic excursion measures 5cm
which is normal to men and it was slightly elevated on the right side because of the
stomach. Upon auscultation bronchial sound was heard anteriorly over the trachea,
vesicular sound was heard at the base of the lung, and bronchovesicular sound heard
between the scapula and lateral to the sternum. No adventitious breath sounds noted.
Heart
For the assessment of the heart, the stethoscope was used. Aortic, pulmonic,tricuspid
and apical sounds was heard. S3 and S4 extra sounds was noted it is normal to elderly
patients. Upon palpation of the different pulses. All of the pulses was strong except for
the dorsalis pedis and posterior tibia which are weak, it is maybe because of different
factors such as the positioning of the patient. Homans test was done to determine calf
tenderness but it was negative.
Breast
Upon inspection of the breast it was noted that its size and shape were equal, no
masses, dimpling, redness and edema noted. The breast was not tender and the nipple
was normal, it is brown in color with hairs around the areola. Also no discharges noted.

Abdomen
For the assessment of the abdomen, tape measure, skin marker and stethoscope was
used. Upon inspection of the abdomen, lesions, scars, striae were not noted. The skin is
intact, no masses, no visible pulsation and no visible peristaltic movement. The
abdomen was globular it was not distended and tender. The patient was noted with
bladder distention as evidenced by guarding behavior on the area. Upon auscultation
the bowel sound was normoactive it occurred every 10 sec with 5 sec duration. Bruit
sound was not audible and friction rub was absent. Upon percussion on patients
abdomen was present tympanic over the stomach and dullness was over the liver and
spleen. The liver measures 7cm mid clavicular line and 5cm mid sternal line. The
bladder was palpable and no ascites noted.
Genito-Urinary System
The patient refuses to show his genitals but one of our members was able to assessed
the area because he helped the patient wear his gown. The patients genitalia is well
developed with meatus at the midline, no tenderness and lesions noted. No discharges
and other abnormalities noted.
Muscle
For the assessment of the muscle we used inspection with light palpation and we asked
the patient to perform actions to determine muscle strength. When palpated, examined,
and tested patients muscles were equal in size and capable of performing maneuvers
to determine muscle strength except for the ankles, and knees that are weaker and
painful according to the patient.
Bones
Upon palpation of the different bones, it was noted that they are symmetrical in length
and no deformities and no tenderness. No history of fractures and other bone related
diseases.
Joints

The interphalangeal, metacarpophalangeal, wrist joints were symmetrical no redness

and tenderness noted. The elbow joint has a little redness. The ankles and knees were
swelling but the other joints were fine and capable of moving full range, except for the
left wrist joint which had a IVF in his metacarpal vein.
Neurological Assessment
Upon assessment of the patients mental status, he was able to speak spontaneously,
with ease and good pronunciation. He was able to use compound complex sentences.
When asked he was asked he could determine the current time, current location and
person accompanying him. He doesnt have a good memory as evidenced by inability to
recall his grandmother and grandfathers name. He was overall oriented and very
attentive.
Gordons Functional Health Pattern
Health Perception- Health Management
According to the patients verbalization, his general health has been manageable, He
said he doesnt experienced any discomfort aside from the mentioned above. He
generally drinks a lot of alcohol, twice in a week. He used to smoke but quit in this year
due to hospitalization. It has been 48 years since he started to smoke. He cant recall
any accidents encountered, and was totally healthy before the discovery of his current
disease.
Nutritional-Metabolic Pattern
The patient eats three times a day but with little poor appetite due to fear in elimination.
He doesnt take any food supplements. He consumes 6-10 glasses a day. For the past
years his height and weight was not greatly affected, he have no problems about taking
solid or liquid foods and he have no diet restrictions. He has no skin problems and
wounds heal well. He undergone 4 tooth extraction and had tooth discoloration. The oral
mucosa is moist, pinkish and no lesions noted. With a height of 57 feet and weight of
78 kg, the patient is considered normal.

Elimination Pattern
The patient said that he defecates twice a day in scanty amount, he doesnt take any
laxatives and experiences no discomfort in defecating. He verbalizes discomfort in
micturating and complains about bladder distention. He was not noted of any foul body
odor and doesnt perspire excessively. As observed, he has a catheter attached to a
urine bag, with a reddish content.
Activity Exercise Pattern
Sleep-Rest
He sleeps for an average of 5-8 hours after 9:00 pm, He said that he has no discomfort
while sleeping and as he woke up he is capable of doing activities of daily living but with
restrictions due to catheter and IVF attached.
Cognitive-Perceptual Pattern
Upon examination of the patients hearing ability, it was obvious that he has a little
difficulty in hearing words. He doesnt wear any eyeglasses, and never been to an
ophthalmologist. He is a kinesthetic person, it means he learn things by manipulating
them. He experiences discomfort in urinating as mentioned above but was able to
manage it.