A.

Review of Systems & Physical Examination

Date of Examination: May 09, 2014 (7:00-9:00AM) Cavite Center for Mental Health
Initial V/S: BP= 110/80 RR = 16
PR = 100 T = 36.3

C
Upon the initial assessment of the patient, blood pressure of 110/80 which is normal. Patients
pulse rate is 100. Normal pulse rate ranges from 60bpm to 100bpm. Temperature is 36.3

C which
is below normal. Normal temperature is 37.5

C. Hypothermia might be a result of different

factors such as weather, cold water and clothing. According to Health Encyclopedia, normal
respiratory rate ranges from 12cpm to 16cpm.

GENERAL
APPEARANCE


NORMAL
FINDINGS


ACTUAL FINDINGS


CLINICAL
SIGNIFICANCE
1. Body built and Height
Weight
proportionality
Proportionate
Varies with lifestyle
Height: 149.86 cm
Weight: 57kg
BMI: 25.3; normal
weight. Patients body
is not very fat.
According to Basic Nutrition
and diet therapy, normal
weight is between18.5 to 27.
Patient has mesomorph type
of body built.
2. Posture and gait
Relaxed
Erect posture
Coordinated
movement
The patient stands erect
without abnormal
spinal curvature and
has coordinated body
movements. She can
walk straight.
Good posture and gait
indicates that the client has
no problem in terms of
balance. No spinal
abnormalities observed.
3. Over-all hygiene and
grooming
Clean
Neat
Patient is properly
groomed. Her clothes
are clean. Her nails are
cut.
Patient is able to perform
self care as evidenced by
patients ability to do
morning care independently.
4. Body and breath odor
Has no body odor or
minor odor
Patient has fishy
and bloody smell.
Prolong usage of
antipsychotic drugs can
cause patient to smell
bloody and fishy since
the medication circulates
in the body it can be
smelled through patients
breath and sweat. Foul
breath odor can be cause
by tooth decay
5. Obvious sign of
distress / illness
No signs of distress
noted
Healthy Appearance
The patient
displays
involuntary
movements like
mild tremors in the
Involuntary movements like
tremors, tongue rolling and
jerking are common in
patients with schizophrenia.
This is side effect of prolong
hands and oral
muscle. Tongue
rolling, arm
folding, blank
stares and jerking
were observed.
usage of neuroleptics.
Serious neurologic side
effects include extra
pyramidal side effects
(EPS) (acute dystonic
reactions, akathisia, and
parkinsonism),
tardive dyskinesia, seizures,
and neuroleptic malignant
syndrome
6. Attitude

Cooperative, able to
follow instructions


She constantly
maintains eye contact.
She is cooperative and
friendly. The patient
can be easily
distracted.
Maintaining eye contact
indicates that the patient is
interested about the topic
being discussed
7. Affect/mood;
appropriateness of
responses
Appropriate to
situation
The patient is
conscious, well-
oriented to time,
person, month and year
but not of the day. She
has a poor memory
when it comes to
names and some of her
past events.
Disorientation can be part of
patients mental health status
or condition since the patient
has disorganized thoughts.
8. Quantity and quality
of speech
Understandable
Moderate pace
Exhibits thought
association
Patient showed interest
with the interview by
answering every
question
spontaneously. She
speaks with normal
pace and her words are
clearly understandable.
Patients words were
understandable. She speaks
clearly but the content is
disorganized.
9. Relevance and
organization of
thoughts
Logical sequence
Makes sense
Has sense of reality
Not considered a
reliable informant since
she has disorganized
thoughts when
responding to the
queries of the student
nurses.
Since the patient is having
disorganized thoughts, the
information coming from her
is not reliable and might be
part of her hallucinations
only.




Physical Examination
Body Part Examined Normal Finding Actual Finding Clinical Significance
INTEGUMENTARY
SYSTEM

INSPECTION
Uniform in color; no
abrasions or any lesions

No edema

No abrasions or lesions

Moisture in skin folds
and the axillae

When pinched springs
back to previous state.
Fair complexion

With scars on her
forehead

dry skin

good skin turgor

Mosquito bites on her
both leg
According to patients
history, when she was
admitted she bragged
her head on the wall.
Scars on her head can
be the result of the
incident.dry skin
might indicate
deficient fluid intake.
Head,
Skull and Face
INSPECTION
Round or
normocephalic;
symmetrical facial
movements.

PALPATION
Smooth, absence of
nodules or masses

Head Circumference:
51cm
Normocephalic

Has oral muscle
tremors

Has a scar on her head
Tremor is an
unintentional,
rhythmic muscle
movement involving
to-and-fro movements
of one or more parts of
the body. It is the
most common of all
involuntary
movements and can
affect the hands, arms,
head, face, voice,
trunk, and legs. Most
tremors occur in the
hands. In some
people, tremor is a
symptom of a
neurological disorder
or appears as a side
effect of certain
drugs. The most
common form of
tremor, however,
occurs in otherwise
largely healthy
people. Although
tremor is not life-
threatening, it can be
embarrassing to some
people and make it
harder to perform
daily tasks.
Reference: National
Institute of Neurologic
disorders and Stroke
Hair INSPECTION
Even distribution of hair
resilient thick hair with
no signs of infections or
infestations.
Hair is not evenly
distributed

Clean

Short hair

Smooth

White hair is present
Presence of white hair
at her age

Unevenly distributed
resulted from patients
pulling of hair. Thus,
this is normal finding.
Eyebrow INSPECTION
Evenly distributed hair;
eyebrows symmetrically
aligned
Equally distributed
with minimal hair
Eyebrow symmetrically
aligned; equal
movement
Patient showed
equally distributed
with minimal hair,
Eyebrow
symmetrically aligned
and equal movement.
Eyes









INSPECTION
Lids close
symmetrically; shiny
smooth, pinkish
conjunctiva; no edema
or tenderness.
Approximately 15 to 20
blinks per minute;
bilateral blinking
Skin intact, no discharge
With 10/min
involuntary blinks,
bilateral blinking
Slow eye blinking rate
(unless any of these
could be considered
normal behavior in
any individual can be
considered as
behavioral sign of
depression.
Reference: http://depre
ssiond.com/depression
-symptoms-signs/
Eyelashes INSPECTION
Evenly distributed,
curled slightly outward
Equally distributed,
curled slightly outward
The eyelashes of the
patient are equally
distributed, curled and
slightly outward.
Eyelids INSPECTION
No discoloration, Lids
close symmetrically
Lids close
symmetrically
The eyelids are
symmetric and cover
the eyes when closed.
Ears and Hearing



INSPECTION
Color same as facial
skin

Auricle color same as
facial skin.

Aligned with outer
Ear color is same with
the face, aligned with
the outer cantus of the
eye. There is visible











Symmetrical; mobile,
firm and not tender;

No notable discharges

Normal voice tones
audible




canthus of eye about
10
o
from vertical

Pinna recoils after it is
folded and not tender

Visible dry cerumen on
both ears

Can hear soft voices
able to repeat words
dry cerumen inside
patients ears. She is
responsive and does
not have hearing
problem since she is
able to response with
normal voice.
Nose and Sinuses















INSPECTION
Symmetric straight

No discharge or flaring;
not tender, no lesions

Uniform in color

Air moves freely as the
patient breath through
the nares.

PALPATION
No tenderness in
maxillary and frontal
sinuses
Nose is smooth and
symmetric

Nasal septum intact and
in midline position

Can breathe freely
without obstructions









The nose is symmetric
and has no tenderness
note. Patient breathes
freely.









Mouth

INSPECTION
Uniform in pink color;
symmetrical lips.
Outer lips are
symmetrical, slightly
protruded chopped and
dry

With wound on the left
side of both lips

Buccal mucosa and
palate of the mouth
appears pinkish

With unpleasant breath
odor
The patient had mouth
odor in which she had
tooth decay and
improper hygienic
practices. Tooth
decay, or dental caries,
refers to the bacterial
destruction of tooth
enamel. These acids
actually succeed in
breaking down the
dental enamel, a
process known as
tooth decay. Decay
smells bad. Chopped
lips may be linked to
patient deficient fluid
intake. (Kozier, 2008)
Tongue In central position; pink
in color

Moves freely with no
tenderness

Smooth tongue base
with prominent veins

Uvula positioned in
midline of soft palate.

Gag reflex present
With tardive dyskinesia
that lasts approx. 1-3
sec.: tongue rolling

Able to purse lip
Smooth tongue base
with prominent base
Uvula positioned in
midline of the soft
palate
Gag reflex present
The patient manifests
one of the signs of
tardive dyskinesia
(involuntary
movements of the
tongue that occur with
patients treated with
long-term
dopaminergic
antagonist
medications) which is
unconsciously rolling
and protruding of the
tongue.
(emedicine.medscape.
com)
Teeth INSPECTION
32 adult teeth, smooth,
white, shiny tooth
enamel

No retraction of gums
Molar: 5 missing
Incisor: (right)
1missing
With 3 dental carries
(Molar)
Plaque or cavity is
formed by the normal
bacteria that live in
our mouths. As the
bacteria grow, they
produce a white film
around the area of the
teeth that border the
gums. This is plaque,
and it contains acid
produced by the
bacteria, which
damages the enamel
surface of the tooth
and causes decay.
(netdoctor.co.uk)
Neck




Lymph Nodes

Trachea
INSPECTION
Coordinated, smooth
movement with no
discomfort. Has equal
muscle strength
PALPATION
Not palpable
INSPECTION
Thyroid gland is not
visible
Gland ascends during
swallowing but not
visible
PALPATION
Coordinated smooth
movement with equal
strength Normal
hyperextension, flexion
and lateral rotation

Non-palpable lymph
nodes

Trachea is in central
placement, spaces are
equal in both sides.

Thyroid gland is
The patient showed
normal neck
movements which is
flexion, extension,
bending and rotation
but felt dizziness upon
doing this.
Thyroid gland; lobes are
small, smooth centrally
located painless and rise
freely with swallowing
AUSCULTATION
Absence of bruit
smooth and centrally
located
Upper Extremities INSPECTION
Muscle: equal size on
both sides of the body

No Contractures

Bones: no skeletal
deformities

PALPATION
Joints: no swelling,
tenderness, crepitation
or nodules
Firm, equal on both
sides

Range of Motion:
flexion and extension

With hand tremors


With smooth
coordinated movements

Smooth
The patient manifests
hand resting tremors
in which these tremors
are present when your
muscles are resting.
This may be caused by
dystonia (uncontrolled
or slow movement is a
problem with muscle
tone, usually in large
muscle groups) due to
drug side effects in
patients with
schizophrenia.
(nlm.nih.gov/medlinep
lus)
RESPIRATORY
SYSTEM
Thorax and Lungs


















INSPECTION
Posterior thorax:
Symmetry: spine
vertically aligned; spinal
column is straight, right
and left shoulders, hips
are the same in height.

Skin intact; uniform
temperature, no
tenderness and no
Presence of masses

AUSCULTATION
Vesicular and broncho-
vesicular breath sounds

Anterior thorax: Quite,
rhythmic, and effortless
respirations

PALPATION
No tenderness and no
presence of masses
Normal breath sound

Diaphragmatic
expansion: 3inches

Normal breath sound
indicates that patient
does not have crackles
or wheezing sound.
This means that there
is no accumulation in
the lungs.

Breast









Areola




Nipples


INSPECTION
Breast size, symmetry,
contour and shape.
Localized discoloration,
hyper pigmentation,
retraction or dimpling,
localized hyper vascular
areas, swelling or
edema.

Size, shape, symmetry,
color, surface
characteristics, mass or
lesions.

Size, shape, color,
position, discharge, and
lesions.
Symmetric









Light brown in color
Symmetric



Symmetric

Color of the areola
varies depending on
the race. Symmetric
breast is normal.

GASTROINTESTIN
AL SYSTEM
Abdomen










INSPECTION
Unblemished skin
Uniform in color
Flat, rounded or
scaphoid
Symmetric movement
caused by respiration
AUSCULTATION
Audible bowel sound
PALPATION
No tenderness and
masses, muscle guarding
Round
With audible bowel
sound
smooth
These are normal
findings.
Peristalsis, or
intestinal motility, is a
normal function of the
small and large
intestine. Bowel
sounds are the audible
passage of air and
fluid created by
peristalsis. (Potter &
Perry,2005)
Lower extremities INSPECTION
Muscle: equal in size of
the body
No contractures
No lesions, swelling and
Inflammation

Bones: No skeletal
deformities.

Joints: no Swelling,
tenderness, crepitation
or nodules and moves
freely
Firm, symmetric on
both sides

Flexible

With akathisia that lasts
approx. 10 sec.: jerking
With smooth
coordinated movements

Moves smoothly and
freely.
Akathisia is another
side effect of
antipsychotic
medications
characterized by
restless movements
and inability to stay
still. This usually
develops during
increased of drug
dosage.(Videbeck,200
8)