Review of System GENERAL: The patient is coherent, weak and not in cardiorespiratory distress SKIN: warm to touch, and

with maculo-papular rash HEART: Normal rate regular rhythm, (-) murmur, Normal PR () EXTREMETIES:Full and equal pulses Vital Signs: Blood Pressure 120/70 mmHg Pulse Rate 84 bpm Respiratory Rate 19 cpm Temperature 38.2 C

AREA OF ASSESSMENT Head Size, Shape & Symmetry

Cephalo-caudal Assessment
Rounded (normocephalic) *symmetric with frontal, parietal and occipital prominences Smooth, uniform in consistency, absence of nodules and mass Inspection & Palpation Rounded (normocephalic) *symmetric with frontal, parietal and occipital prominences Smooth, uniform in consistency, absence of nodules and mass

NORMAL FINDINGS

METHOD OF ASSESSMENT

ACTUAL FINDINGS

INTERPRETATION

Normal Normal

Hair Color Texture Distribution

Black - brown Silky; smooth presence of hair Thin straight; evenly distributed

Inspection & Palpation

Brown- black Silky; smooth presence of hair Thin straight; evenly distributed

Normal Normal Normal

Scalp

No presence of lesions and no sign of infestation

No presence of lesions and no sign of infestation

Normal

AREA OF ASSESSMENT Face

NORMAL FINDINGS Symmetrical

METHOD OF ASSESSMENT Inspection

ACTUAL FINDINGS Symmetrical

INTERPRETATION

Normal

Eyes Eyebrows *Hair distribution and alignment Eyelashes *Evenness, distribution and direction of curl

Hair evenly distributed, skin intact, eyebrows symmetrically aligned Equally distributed, Curled slightly outward

Inspection Inspection

Hair evenly distributed, skin intact, eyebrows symmetrically aligned Equally distributed, Curled slightly outward

Normal Normal

AREA OF ASSESSMENT

NORMAL FINDINGS

METHOD OF ASSESSMENT

ACTUAL FINDINGS

INTERPRETATION

Eyeballs Eyelids *Surface characteristics

(-) Sunken eyeballs Skin intact, No discharge; no discoloration Pupil equally round and of the same size and black in color Pupil constricted when accommodated with light Bulbar Conjunctiva is clear with tiny capillaries visible, Palpebral conjunctiva is pink; no discharge

Inspection Inspection

(-) Sunken eyeballs Skin intact, No discharge; no discoloration Pupil equally round and of the same size and black in color Pupil constricted when accommodated with light Bulbar Conjunctiva is clear with tiny capillaries visible, Palpebral conjunctiva is pink; no discharge

Normal Normal

( PERLLA) *PER*/ Color *RLA*

Inspection

Normal Normal

Conjunctiva

Normal

AREA OF ASSESSMENT
Sclera Lacrimal gland, Nasolacrimal duct.

NORMAL FINDINGS
Anicteric sclera No edema, No Tenderness and tearing.

METHOD OF ASSESSMENT
Inspection Inspection & palpation

ACTUAL FINDINGS
Red sclera No edema, No Tenderness and tearing.

INTERPRETATION
Abnormal Normal

Ears Color; symmetry of size and position

Color same as facial skin; symmetrical; Auricle aligned with outer about 10 above ventricle

Inspection & Palpation

Color same as facial skin; symmetrical; Auricle aligned with outer about 10 above ventricle

Normal

Texture: elasticity and areas of tenderness

No discharge; No lesion; Tympanic membrane intact and pearly grey in color Mobile, firm, no tenderness, pinna recoils after it is folded

Normal No discharge; No lesion; Tympanic membrane intact and pearly grey in color Mobile, firm, no tenderness, pinna recoils after it is folded

AREA OF ASSESSMENT
Nose Septum Turbinates

NORMAL FINDINGS

METHOD OF ASSESSMENT

ACTUAL FINDINGS

INTERPRETATION

(-) nasal discharge/mucus secretion; Patent nostrils Intact and in midline Pinkish, moist and intact (-) nasal flaring

Inspection

(-) nasal discharge/mucus secretion; Patent nostrils Intact and in midline Pinkish, moist and intact (-) nasal flaring

Nares

Inspection

Mouth Lips; Symmetry and color

Symmetry of contour; Uniform pink color, moist White teeth and pinkish gums Pinkish in color; Moves freely; (-) presence of sore

Inspection

Symmetry of contour; Uniform pink color, moist White teeth and pinkish gums Pinkish in color; Moves freely; (-)presence of sores Inflamed

Normal

Normal

Teeth and Gums Tongue

Inspection

Normal

Tonsils

Not inflamed

Abnormal

AREA OF ASSESSMENT Cervical/ neck

Thyroid gland

NORMAL FINDINGS Symmetrical, flexible, full range of motion, with out lumps, tenderness or pain (-) jugular vein distention

METHOD OF ASSESSMENT Inspection & Palpation

Inspection/ palpation

ACTUAL FINDINGS Symmetrical, flexible, full range of motion, with out lumps, tenderness or pain (-) jugular vein distention

INTERPRETATIO N normal

Normal

Skin Color

Fair; No deviation Smooth Skin; without any lesions and infestations

Inspection

Fair but with red spots With confluent bumps because of macula papular rash

Abnormal

Texture

Palpation & Inspection

Abnormal

AREA OF ASSESSMENT Skin turgor

NORMAL FINDINGS Elastic and full; skin springs back immediately when pinched

METHOD OF ASSESSMENT Inspection/Palpat ion Palpation

ACTUAL FINDINGS Elastic and full; skin springs back immediately when pinched

INTERPRETATIO N Normal

Nail Color
Shape and texture

Pinkish Smooth, convex in curvature, long Prompt return of pink or usual colour

Inspection Inspection and Palpitation

Pinkish Smooth, convex in curvature, long Prompt return of pink or usual colour

Normal Normal

Capillary refill

Performed blanched test

Normal

AREA OF ASSESSMENT Thorax Physical appearance / Color

NORMAL FINDINGS Light to deep brown symmetrical chest wall with no wounds/lesions

METHOD OF ASSESSMENT Inspection

ACTUAL FINDINGS With maculo popular rash

INTERPRETATION abnormal

Breath sound

(No adventitious sound heard upon auscultation

Auscultation

(No adventitious sound heard upon auscultation

Normal

Chest expansion

Symmetrical Chest wall intact; no tenderness

Inspection and Palpitation

Symmetrical Chest wall intact; no tenderness

Normal

AREA OF ASSESSMENT
Heart

NORMAL FINDINGS
NRRR (normal rate regular rhythm) (-) murmur Symmetrical/ Flat abdominal contour Audible bowel sounds Over the stomach and gas filled

METHOD OF ASSESSMENT
Auscultation

ACTUAL FINDINGS
NRRR (normal rate regular rhythm) (-) murmur Symmetrical/ Flat abdominal contour Audible bowel sounds Over the stomach and gas filled

INTERPRETATION
Normal

Abdomen contour

Inspection Auscultation Percussion

Normal

Normal

Upper Extremities

No lesion seen : (-) Edema; no tenderness: symmetrical

Inspection & Palpation

With macula popular rash

Abnormal

lower Extremities

No lesion seen : (-) Edema; no tenderness: symmetrical

Inspection & Palpation

No lesion seen : (-) Edema; no tenderness: symmetrical

Normal

Functional Health Pattern

Before Hospitalization

Hospitalization

Health Perception/ Health management

The relative stated that our patient used to eat Poor health status and foods that are high in fats. shows signs of weakness. But he knows that to maintain his health status he always eat right. The client eatwith her family thrice a day. He On a Hypoallergenic diet. eats all the foods that was serve to him. Patient experienced Loose He usually urinates 3-4 Bowel Movements (7-12x times a day and defecates per day) for a period of 3 once a day. days. Further decrease in He doesnt have time to physical activity due to exercise every day.

Nutritional-Metabolic

Elimination

Activity &Exercise

Cognitive-Perceptual

Patient is Lethargic and He has good eyesight and having difficulty no other sensory defects. communicating.

Sleep-Rest

He sleeps 6-7 hours a day, but sometimes hes Intermittent sleep and having a hard time been very lethargic. sleeping when hes thinking about problems in his life.

Self-Perception / Self Concept

His wife stated that the patient is comfortable with He looks weak. his self.
He seldom goes to church Still unable to go to because of his work church. everyday

Value-Belief