1. A physical examination and review of systems was conducted on Madam X, noting her general appearance of weakness, dry yellowish skin, and fatigue.
2. Specific findings included vital signs within normal limits except for tachycardia, crackles in the right lower lung on auscultation, and edema of the lower extremities.
3. The patient appeared older than her stated age and had difficulty with mobility and consciousness.
1. A physical examination and review of systems was conducted on Madam X, noting her general appearance of weakness, dry yellowish skin, and fatigue.
2. Specific findings included vital signs within normal limits except for tachycardia, crackles in the right lower lung on auscultation, and edema of the lower extremities.
3. The patient appeared older than her stated age and had difficulty with mobility and consciousness.
1. A physical examination and review of systems was conducted on Madam X, noting her general appearance of weakness, dry yellowish skin, and fatigue.
2. Specific findings included vital signs within normal limits except for tachycardia, crackles in the right lower lung on auscultation, and edema of the lower extremities.
3. The patient appeared older than her stated age and had difficulty with mobility and consciousness.
1. A physical examination and review of systems was conducted on Madam X, noting her general appearance of weakness, dry yellowish skin, and fatigue.
2. Specific findings included vital signs within normal limits except for tachycardia, crackles in the right lower lung on auscultation, and edema of the lower extremities.
3. The patient appeared older than her stated age and had difficulty with mobility and consciousness.
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Table 1
Physical Examination and Review of Systems of Madam X
Areas Examined Subjective Findings Objective Findings Problems
Identified
1. General Health Survey “ Kapoy ang akong Weak appearance Fatigue related to a. Physical development and body lawas og cge disease process Weight: 45 kg build koogkatulog’’ as verbalized by the Height: 5’2” patient Ectomorph
b. Gender and sexual development
PUT SOME SPACE Sexual development is ON every words appropriate for the gender and age
c. Apparent age as compared to
reported age Client appears older than stated chronological age
“Sixty five naiyangedad” as verbalized by the Dry, senile skin, slightly Disturbed body d. Skin condition and color patient’s daughter. yellowish skin image related to yellowing of the “gabitaynamanniako skin secondary to angpanit” as ascites verbalized by the patient e. Dress and hygiene No unusual odor noted, hair Self-care deficit looks greasy. due to limitation in physical “dli siya mag mobility related patrapokytugnawond to pain on post- awsiya, surgical incision peromusugotngailisa site. f. Posture and gait nlng”, as stated by Activity patient’s daughter Weak and lying flat on bed the intolerance whole shift. related to fatigue
“maglisod pa g. Level of consciousness xaoglihok”, as Confusion related observed by her lethargic and less responsive to portal systemic daughter. encephalopathy
“mutubagramanpuds iyaogstoryahonpero h. Behaviors, body movements, and dli mutumong”, as affect patient’s daughter Appropriate for the particular verbalized. situation
i. Facial expression Pain related to Appropriate for the particular enlargement of
situation liver related to
Pain upon movement ascites Facial grimacing Pain scale of 7 out of 10 j. Speech
Normal volume ,tone and
quantity
k. Vital Signs
Vital Signs:
T: 35.3- 36.6 C
BP: 130/80 – 140/90
mmHg
RR: 25-29 bpm
PR: 80-90 bpm
Weight: 45 kg
2. Integumentary System No lesion, no mass, Inspection:Dry and intact Disturbed body
absence of bruises, dressing in the epigastric image related to absence of rashes region, edema on both lower ascites and edema extremities, white striae on upper thighs
Palpation:Skin warm to touch,
swollen skin on lower extremeties
3. HEENT a. Head and face “Nilabad akong ulo” Symmetrical and round, no lesion, no mass As verbalized by the Ineffective tissue patient perfusion related to vasodilation Slightly yellowish sclera, “naa nay cataract c pupil equally reactive to light b. Eyes mama and accommodation. Body image saiyangwalanamata” disturbance as stated by the related to daughter yellowing of sclera No discharges noted, ears are c. Ears equal size and similar
No discharges, symmetrical d. Nose appearance, (+) nasal flaring ‘’wala man koge sip noted on og okay Ineffective rapodakongpanimah breathing pattern o’’ as verbalized by related to intra- the patient abdominal pressure in Inspection: diaphragm
e. Oral cavity Dry mucous membrane, dry
lips, normal tongue size
4. Neck Inspection: No problem
identified Symmetrical in appearance, no presence of extended veins
Palpitation:
No enlargement of thyroid glands, No stiffness
5. Respiratory System “muraglisodlng e Inspection: Limited lung Ineffective
ginhawagamay”, as expansion breathing pattern verbalized by patient related to Auscultation: Crackles are pulmonary RR: 25-29 bpm heard over right lower lung. nodule as seen in patient’s x-ray
RESULT OF XRAY
6. Cardiovascular System “Walaramankoygeba Inspection: No problem
tingasakitakongdugh identified No chest deformities, No an’’, as verbalized by visible pulsations the patient Auscultation: BP: 130/80- 140/90 mmHg No murmurs, no extra heart sounds, strong bounding PR: 80-90 bpm pulse,
7. Breast and Axilla Palpitation:No masses, No No problem
pain felt identified
Inspection:No discharges, Areola is color brown 8. Gastrointestinal System ‘’ Palpitation: tenderness felt Abdominal pain Sakitangakongtiyan before doing Jackson pratt related to “as verbalized by drainage (1800ml of fluid) presence of fluids patient secondary to Percussion: supine- dullness, ascites Bloated right lateral- tymphany
kosugod thirty nine elimination akongedad‘’ as patient’s reported. I AND O DURING SHIFT
Positive painful urination
10. Musculoskeletal System “Lisod kayo daw Inspection: No bony Inffective
itindog og ilakaw” as deformity intravascular verbalized by the perfusion related IVF of D5NSS in IV pump daughter to vasodilation hooked at right metacarpal vein at 100cc/hour
11. Lymphatic/Hematologic System Diagnostic test: Inspection: jaundice noted, Disturbed body No bleeding, edema on lower image related to RBC- 3.64 (NV: 4-6 extremities, no bruise and edema. x10 12/L) petechial noted Hematocrit- 0.32 (NV: 0.37- 0.47)
Hemoglobin- 102 (NV: 110-180 g/L)
WBC- 16.45 (NV: 5-
10x 10 9/L)
Blood type 0
12. Metabolic and Endocrine System Diagnostic Test: Inspection: Activity
intolerance Albumin- 27. 1 (NV: Feet, fingers, and hand size related to reduced 35-54 g/L) proportion to the body , No metabolic rate wounds noted Bilirubin 16.24 (16.24) Constipation Constipated related reduced “Wala siya kalibang metabolic rate sukad atong naadmit RESULT OF LIVER siya BIOPSY
