Arenas, Abigail S.

4C-Group1

Chinese General Hospital College of Nursing and Liberal Arts

Adult Physical Assessment

Name: MLG Date Admitted: August 16, 2010 Unit/Bed No. Female Cha – Surgery
Bed 1

Age: 46 years old Sex: FemaleCivil Status: Married Nationality: Filipino Religion:
Catholic

Diagnosis: Cholecystitis (Cholelithiasis) and t/c Chronic PID

Operation (if any) : None

Chief Complaint: Abdominal Pain

History of Present Illness:

A case of 46 diagnosed of Cholelithiasis last 2009, advised for surgery but decided no to
undergo. Patient came in due to moderate abdominal pain.

1 day prior to admission patient had a sudden onset of abdominal pain guarded 8 out of
10 in severity, no radiation, driven to go at the Emergency Room of CHGMC, given pain
medication.

Few hours prior to admission there is recurrence of pain, radiating in the back, not
tolerable, patient also noticed greenish vaginal discharge with foul smelling odor required
consult consequently admitted.

History of Past Illness:

(+) Cholelithiasis 2008 with no medication

(-) HPN

(-) DM

(-) Asthma, allergy to foods and drugs

Family History:

Unremarkable

Social History:

The patient is a non- smoker and non-alcoholic beverage drinker

I. General Physical Assessment and Cranial Nerve Testing

Vital Signs T=37⁰ P=90 R=20 BP=110/70 Height= 4’11 Weight=59kg

Physical appearance/Posture/Body Movements/Hygiene/Nutritional Status:

The patient looks uneasy, has limited movement and stands slouchy. She can move
her hands and feet evenly and can stand freely. Patient doesn’t have foul odor. Patient
is overweight and consumed 100 % of meal served.

Level of Consciousness/Facial Expression/Mood and Affect/Speech and Gait

 Patient is conscious during physical assessment. She is cooperative and has a little
eye to eye contact. She can follow instruction appropriate to her situation. The patient
speaks slow and clearly.

SKIN:

The patient’s skin color is fair and even. She has no birthmarks but has moles on
her left forearm. There is no lesion noted. Veins are easily seen on her skin. The skin
is cold and soft with no edema. When I pinched her skin it returns back to less than
4 seconds which indicates good skin turgor.

HAIR:

Her head is normocephalic. The patient’s hair color is black to some white
strands, oily and was evenly distributed. She can cpntrol her head freely. Her scalp
is clean and has no lesions present.

EYES:

Her eyelids are symmetrical in shape. She has pink conjunctiva and she has
anicteric sclera. Mild opaque lenses and equally sized pupils are observed when
exposed to light. Pupils react briskly to light and accommodation.

EARS
She has symmetrical ears without any reports of pain or tenderness upon
palpation. There are no discharges observed upon inspection of the external canal.
Her gross hearing is symmetrical.

NOSE
Her nasolabial fold and septum are along the vertical midline of her face. Her
nasal mucosa is pinkish in color. There are no discharges noted upon inspection of
nostrils. Both nostrils are patent with symmetrical gross smelling. No pain or
tenderness is reported upon palpation of sinuses.

MOUTH
Her lips are colored pink to dark pink. Her mucosa is colored pink and is well
lubricated with saliva. The tongue is along the vertical midline of her face and she
has missing teeth which are replaced by false teeth. Her speech is intact.

PHARYNX
The uvula is along the vertical midline of her face and the mucosa is
observed to be pinkish. Tonsils are not inflamed.

NECK
The trachea is along the vertical midline of her face and there are no
observations of inflamed cervical lymph nodes. The thyroid gland is not enlarged.

CHEST AND LUNGS

Her breathing pattern is regular and she has symmetrical chest expansion.
No crackles are heard upon auscultation of both lung fields.

HEART
Her pericardial area is flat. Her heart sounds are distinct and regular upon
auscultation.

BREAST AND AXILLAE

Patient did not allow student nurse to assess her breasts thoroughly but was
open to answer questions verbally. Patient didn’t notice any lumps or inflamed
lymph nodes in her breast and axillae.
 ABDOMEN
The abdomen is soft, flabby, and non- tender. It is not enlarged. Positive pain
on the epigastric region radiation on the back and in four other quadrants.

BACK AND EXTREMITIES

Peripheral pulses are present and symmetrical when palpated. Nail beds are
pinkish. Range of Motion is active. Muscle tone on both sides on each extremity is
equally strong. The spine has an slightly impaired curvature. Chest Xray revealed
she has mild dextroscoliosis. Patient reports that she feels pain in her upper right
back when she checks papers in school for an extended period of time.

II. Significant Health Patterns:

a. Sleep

Hours: 6 to 8 hours

Bed time rituals: Bathing and Praying

b. Activity and Exercise

The patient does not exercise everyday.

c. Nutrition
Food Preferences: Patient eats all kinds of food but most often eats meat
than vegetables.

Amount: Patient consumed 100% of meal served.

Dietary Restriction: high fat, high cholesterol foods

d. Elimination

Bowel Pattern:

Color: Brown Frequency: 1-2x/week Consistency: Hard

Odor: Normal

Urinary Pattern:

Color: light yellow Frequency: 4x/day Consistency: Clear Odor:

Pungent

e. Work

Type: house wife/sedentary Hazards: None

f. Rest and Recreation

The patients rest and recreation is watching t.v. only.

III. Work-ups

a. Diagnostic Studies
 • UTZ of the Whole Abdomen and Appendix

Impression:

-thickened Gallbladder wall with multiple tiny lithiasis

-urinary sedements

-non-visualized appendix

-thickened endometrium

-non-dilated biliary tree

-no liver, pancreatic, splenic or renal pathology detected

• UTZ of the Pelvis (Transvaginal)

Impression:

-Thickened endometrial stripe with minimal endocavitary fluid. A POLYP is not

ruled out. Suggest follow-up on the proliferative phase of the next cycle.
Minimal non-specific fluid posterior cul de sac.

• Chest Xray

Impression:

-Pleural thickening/Minimal effusion, left costrophrenic sulcus. Mild

dextroscoliosis.

b. Laboratory

• CBC (8/16/10) Patient’s Value Normal Values

WBC 8.1

RBC 4.26

HGB 126

HCT 0.372

MCV 87.2

MCH 29.6

MCHC 340

RDW 12.8

DIFFERENTIAL COUNT

Bands 02

Segmenters 75

Lymphocytes 15

Monocytes 04
 Eosinophils 04

• Prothrombin Test (8/17/10)

PTT 14.8

Normal Control 14.5

Internal Normalized 1.02

Prothrombin Ratio 1.02

Activity 96.9 %

• Liver Profile Test (8/18/10) Descriptiom Patient’s Value

Cut off Normal Values

HBSAG non-reactive 0.23 1.0

ANTI HBS non-reactive 0.02 10 MIU/ML

ANTI HBC IGM non-reactive 0.13 1.2

HBEAG non-reactive 0.18 1.0

ANTI HBE non-reactive 2.002 1.0

ANTI HAV IGM non-reactive 0.15 1.2

• Kidney Function test (8/16/10) Patient’s Value

Female Normal Values

Creatinine 63 62-102 umol/L

ALAT (SGPT) 547 9-72 u/L

Alkaline Phospatase 186 32-92

Sodium 145 mmol/L

Potassium 3.90 mmol/L

• Urinalysis (8/16/10)

Color Light yellow

Transparency Clear

Reaction pH 6.0

SPGR 1.010

Microscopic Findings

Cells

Pus cells 0-1/HPF

 RBC 0-1/HPF

Squamous RARE

Amorphous urates RARE

Amorphous P04

Bacteria RARE

MUCUS THREADS:

Yeasts

Chemical test

Albumin (-)

Sugar (-)

• 8/19/10

Source of Specimen – Vaginal Discharge

Gram (+) cocci occurring singly and in pairs – few

Gram (-) bacilli few

Leukocytes – rare

No intra/extracellular gram (-) diplococcic seen