PHYSICAL ASSESSMENT

Height: 5 feet 3 inches

Weight: 171 lbs.

VITAL SIGNS:
ADMISSION DAY (February 10, 2009)

TIME: 7:53 PM

Temperature: 37.4°C

Pulse Rate: 105 beats per minute

Respiratory Rate: 25 breaths per minute

Blood Pressure: 150/90 mmHg

1st DUTY DAY (February 11, 2009)

TIME: 6 AM – 10PM

Temperature: 37.1 – 37.4 °C

Heart Rate: 95 - 108 beats per minute

Respiratory Rate: 26 – 28 breaths per minute

Blood Pressure: 140/90 – 160/100 mmHg

2nd DUTY DAY (February 12, 2009)

TIME: 6 AM – 10PM

Temperature: 36.1 – 37.1°C

Heart Rate: 96 - 98 beats per minute

Respiratory Rate: 25 - 28 breaths per minute

Blood Pressure: 140/80 – 150/100 mmHg

3rd DUTY DAY (February 13, 2009)

TIME: 6 AM – 10PM

Temperature: 36.5 – 37.4 °C

Heart Rate: 80 - 85 beats per minute

Respiratory Rate: 23 – 25 breaths per minute

Blood Pressure: 130/80 - 140/80 mmHg

NEUROLOGICAL ASSESSMENT

GENERAL APPEARANCE

The patient is lethargic, disoriented to time, place and person. On

sitting position with head of bed elevated. He has oxygen via nasal cannula
at 3 liters per minute. There is heplock at his right arm with Guage 18
needle. The Arteriovenous fistula is found at his Left arm. With indwelling
urinary catheter to drainage bag at right side of the bed. Body parts in the
upper extremities look equal bilaterally and are in relative proportion to each
other while bipedal edema noted on the lower extremities. He was wearing a
clean hospital gown. The patient has no unpleasant body odor.

Glasgow Coma Scale of 13

The patient’s eyes open to speech, obeys to command, and confused

verbal response

INTEGUMENTARY SYSTEM
SKIN

Brown in color

Warm to touch

Dry, scaly skin noted

Scalp hair is gray, wavy and unevenly distributed

No presence of seborrhea or lice noted

Scalp palpated without presence of lumps or masses

Finger and toe nails surface are normally curved, smooth and no
clubbing noted
 Pale with capillary refill of 4 seconds on all 4 extremities

Cold and clammy extremities

+3 pitting edema noted on lower extremities until middle half

of the lower legs

EENT

HEAD AND NECK

Head position is centered in the midline

Face is symmetrical

Temporal pulses palpable

No masses or lesions palpated

EYES
Eyebrows

Symmetrically aligned but hairs are unevenly distributed

Eyelashes

Unevenly distributed, thin and uncurled

Eyelids

Intact without redness and swelling

No periorbital edema

Bulbar and palpebral conjunctivae

Clear and pale

Sclera

Anicteric

Iris

Round regular shape and even coloration

Pupils

Equally round, briskly reactive to light and accommodation

 Approximately 3 mm in diameter

Poor vision of both eyes

Good blinking reflex

EARS

Auricles

Equal size bilaterally with no swelling or thickening upper part of

the ears is aligned with the outer canthus of the eyes

Skin color is consistent with the person’s facial skin color and
intact

No lumps or lesions palpated

No mass, lesions, scaling and discharges

Presence of light yellowish cerumen on both external cannal

Good hearing on both ears

NOSE
Midline and in proportion to other facial features

No deformity, inflammation, lesion and nasal flaring

Nasal mucosa is pale and dry.

Swelling, discharges and bleeding are not noted

Nasal septum

Intact and is in midline

Nasal cannula on both nares at 3L/ min oxygen

Good sense of smell on both nares

NECK
Color is the same with the rest of the body

No lesions noted
 No scars noted

Jugular veins distended

Trachea

Midline and nontender

Carotid pulse

graded as +4 which is bounding and strong upon

palpation

MOUTH AND THROAT

Lips

Pale in color, dry with cracking noted

No lesions noted

Symmetrical

Tongue

Pale in color and dry

Can move from side to side

Gums

Pale and dry

Teeth

Complete set of teeth, yellowish in color

Uvula

Midline

Foul breath noted

RESPIRATORY SYSTEM

Respiratory rate of 23 to 28 breaths per minute

Use of accessory muscles for breathing is noted

 Irregular with asymmetrical chest expansion

No sternal retraction noted

Masses and tenderness not noted upon chest palpation

Crackles heard upon auscultation of the Left lower lobe

Non- productive cough noted with complaints of

orthopnea

Oxygen is provided at 3 liters per minute via nasal

cannula

CARDIOVASCULAR SYSTEM

Blood Pressure:

150/90 mmHg upon admission

130/80 – 160/100 mmHg upon duty

Pulse Rate:

105 beats per minute upon admission

80 - 108 beats per minute

Bulging Left chest upon inspection

Vibrations noted upon palpation of the Left chest

Bounding and strong pulses upon palpation of the carotid

pulse and apical pulses graded as +4

Diminished pulses of the lower extremities due to edema

GASTROINTESTINAL SYSTEM
Color is the same with the rest of the body

Distended abdomen with ascites noted

Hypoactive bowel sounds of 3-4 per minute on all four

quadrants of the abdomen upon auscultation

(+) fluid wave test

Stool

Had not BM since admission

REPRODUCTIVE SYSTEM

Penile skin

Intact and appears wrinkled and dark in color

Urethral meatus is positioned at the tip of the penis

Pubic hair distribution is consistent with age at the base of the

penis

Scrotal skin

Darker in color than that of the rest of the body

Loose and asymmetric

Scrotum is free of nodules and masses

GENITO-URINARY SYSTEM

No lesion or inflammation around the penis and scrotum

Foley catheter inserted and attached to drainage bag secured at

right lower abdomen

Urine

Concentrated urine

Scanty and tea colored

Aromatic upon drainage

MIO
DATE INTAKE OUTPUT

FEB. 10, 2009 520 170

FEB. 11, 2009 820 110

FEB. 12, 2009 600 65

FEB. 13, 2009 580 20

MUSCULOSKELETAL SYSTEM

Upper and lower extremities

Color is the same with the rest of the body

Symmetrical size on both sides of the body

Presence of cold, pitting edema on the lower extremities

Decreased muscle strength on right and left upper

extremities with grade of 3/5 while muscle strength right
and left lower extremities graded as 4/5

Decreased ROM

Easy fatigability noted