In Partial Fulfillment of the Final Requirements in

ADVANCED HEALTH ASSESSMENT

MSN 205

Submitted by:

MR. GAMAR AKALAL SUGALA

Offshore Student
Master of Science in Nursing
Major in Adult Health Nursing

Submitted to:

MR. ARNOLD M. MANIEBO, MSN, RN

Professor
Gradual School Programs
Saint Paul University Manila

1
 PAIN ASSESSMENT: ACUTE APPENDICITIS

Patient Name: Mr. A Date of Admission: 27 September 2019

Medical Record Number: 1093204 Nationality: Saudi
Chief Complaint: Patient complaining of right lower abdominal pain with P/S of 8/10.
History of Present Illness: 39-year old Saudi male, presented to ER complaining of pain on right iliac abdominal region started 2 days ago. Pain is sharp stabbing in nature, non radiating and
increases in severity from P/S 6/10 to 8/10 today. Aggravated by movement and not relieved by OTC analgesics. Nauseous, vomited three times today with loss of
appetite as verbalized by patient.
Past Medical History: No significant medical history noted except with left radial fracture due to vehicular accident 3 years ago.
Medication History: None remarkable.
Family History: Father with DM and HTN.
Social History: Lives alone in a rented apartment. No history of smoking. Sedentary lifestyle.
General Appearance: Patient looks ill, moaning, lying uncomfortably on fetal position, hand guarding on right lower abdomen.
Vital Signs: BP: 141/87 mmHg PR: 75 beats/min RR: 18 cycles/min T: 38.1 C O2 Sat: 98% at room air Pain: P/S of 8/10 sharp stabbing pain on right iliac region aggravated
by movement, not relieved by either rest or pain reliever.

Method of
Area Normal Findings Abnormal Findings Remarks
Assessment
Inspection Febrile due to body’s response to
Skin

Normal elasticity of the skin noted. Febrile, moist skin. T at 38.1C taken orally.
Palpation infection and inflammation.
Skull and face symmetrical. No signs of deformities, swelling or
Head &

Inspection
Face

tenderness noted. Non remarkable.

Palpation \

Scalp is clean. Black silky hair, equal in distribution. No signs of nits.

Normal vision. Peripheral vision normal.
No discharges noted.
HEENT

Inspection No signs of swelling or tenderness noted.

Equipment used:
Eyes

Palpation Sclera white and clear. Non remarkable.

Penlight
Palpebral conjunctiva pink.
Pupils are equal, round, reactive to light and accommodation.
Normal extra-ocular movement; eyes moves in conjugate fashion.

2
 Pinna symmetrical in shape and size.
No discharges noted. Weber’s Test and Rinne’s Test done for
Inspection Normal hearing acuity on both ears. lateralization and conduction findings.

Ears
Non remarkable.
Palpation External canal clear with minimal cerumen. Equipment used:
Normal sound lateralization and conduction noted. Tuning fork, Otoscope.
Sinuses non-tender.
No deviation noted. Nasal septum straight and not perforated.
Inspection Polyps not present. Equipment used:
Nose

Non remarkable.
Palpation No discharges noted. Otoscope
Airway patent.
Lips are moist and not cracking.
\

Pink buccal mucosa without any ulcerations. Gums non swelling, no

Mouth

Inspection bleeding noted. Equipment used:

Palpation Non remarkable.
Tongue midline. Penlight, tongue depressor.
Uvula midline.
Normal range of motion.
Muscular symmetry noted. Cervical and trapezius muscles normal
tone and strength.
Inspection Trachea midline.
Neck

Palpation Equipment used:

No jugular vein distension. Non remarkable.
Auscultation Stethoscope
Cervical lymph nodes non-palpable. Trachea midline.
Carotid bruit not noted.
\

Speech and voice normal.

No deformities nor tenderness noted.
Thorax symmetric. Symmetrical chest movement., Normal bilateral
air entry.
Inspection
Pulmonary

RR at 18 cycles per minute; O2 Sat 98% at room air Equipment used:

Palpation
Chest

No any deformities, inflammation nor tenderness noted. Non remarkable. Sphygmomanometer

Percussion Stethoscope
No discharges seen on nipple.
Auscultation 12-lead ECG
Fremitus equal throughout the lung fields.
Resonance noted over symmetrical areas of the lungs.
Vesicular breath sound auscultated over most of the lungs.

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 No bulges noted.

Cardiovascular
Apical pulse strong with regular rhythm at 75 beat/min.
S1 and S2 audible.
BP: 141/87 mmHg.
Peripheral pulsations strong with regular rhythm.
Norma Sinus Rhythm at 12-lead ECG.
Normal capillary refill.
Auscultation was done before
percussion and palpation to prevent
alteration of bowel sounds.
Nausea and vomiting 3 times as verbalized by patient.
Nausea, vomiting and pain due to the
Bowel sound at 4 bowel sounds per minute. distension and increased intraluminal
pressure of the appendix.
Distended abdomen. Generalized abdominal rigidity.
Peristalsis decreased due to disease
Inspection
Abdomen

Sharp stabbing right iliac region pain of 8/10, condition.

Auscultation
aggravated by movement. Non-radiating, not relieved Involuntary guarding and positive
Palpation
by OTC pain meds. McBurney’s Sign indicative of peritoneal
Percussion
Involuntary guarding noted. irritation/inflammation.
Inflammation of the psoas muscle
Positive McBurney’s sign. Rebound tenderness noted. increases abdominal pain with Psoas
Positive Psoas Sign. Sign Maneuver.

Equipment used:
Stethoscope
Normal range of motion on both upper and lower extremities.
Symmetrical muscle tone and strength on all extremities. Febrile due to body’s response to
Musculoskeletal

No edema, deformities nor tenderness noted on all extremities. infection and inflammation.
Inspection Skin febrile and moist. T at 38.1 C taken orally.
Strong, regular peripheral pulses noted. Surgical scar due to previous surgery.
Palpation Surgical scar on left anterolateral forearm.
Normal capillary refill less than 2 seconds. Equipment used:
Deep Tendon Reflex: Normo-reflexive at DTR ++. Neuro-hammer
Normal sensation noted on all extremities.
Genito-
urinary

Inspection No discharges noted from urethra.

Non remarkable.
Palpation No tenderness, lesions, nodules or masses noted.

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 GCS at 15
Alert, oriented to three spheres: person place and time.
Cerebellar Function Normal. Balance and coordination intact.
Motor Function: Normal symmetrical muscle tone and strength.
Sensory Function: Normal sensation observed all throughout.
Cranial Nerves
CN 1: Olfactory Nerve and
Not smell sensation.
CN 2: Optic Nerve GCS: 15
Normal visual acuity. Eye Response: 4
CN 3: Oculomotor Nerve, CN 4: Trochlear Nerve and CN 6: Verbal Response: 5
Abducens Nerve Motor Response: 6
Neurological

Normal extra-ocular movement; eyes moves in conjugate fashion.

Inspection CN 5: Trigeminal Nerve Non remarkable.
Palpation Facial muscle strength symmetrical. Facial sensation normal and Equipment used:
symmetrical. Penlight
Neuro-hammer
CN 7: Facial Nerve
Tuning Fork
Facial muscles symmetrical.
Cotton
CN 8: Vestibulocochlear Nerve Tongue Depressor
Symmetrical hearing noted.
Normal balance and equilibrium noted.
CN 9: Glossopharyngeal Nerve and CN 10: Vagus Nerve
Gag reflex present, no difficulty in swallowing.
Palate and uvula move symmetrically without deviation.
CN 11: Accessory Nerve
Symmetrical neck and shoulder muscle tone.
CN 12: Hypoglossal Nerve
Normal speech and articulation noted. Tongue symmetric and not
deviated.

5
 NUTRITIONAL ASSESSMENT: OBESITY WITH UNCONTROLLED TYPE 2 DM

Patient Name: Mr. B Date of Admission: 14 September 2019

Medical Record Number: 1075101 Nationality: Saudi
Chief Complaint: Patient complains of fatigue and dizziness that started a week ago.
History of Present Illness: A 52-year-old Saudi male came to ER, KAMC accompanied by wife, complaining of fatigue and dizziness. He was diagnosed with Type 2 Diabetes 5 years ago at Security
Force Hospital, Makkah and was given prescribed medications. Patient verbalized that the decrease of energy level and dizziness started last Friday 06 September 2019,
progressive in nature and usually happens particularly in the afternoons. Wife stated Mr. B is always thirsty with increase frequency and urge of voiding.
Past Medical History: Hypertension, Hypercholesterolemia and Osteoarthritis 3 years ago.
Medication History: Glyburide 2.5 mg daily; Atorvastatin 10 mg daily; Chromium Picolinate; Insulin; Lisinopril; Hydrochlorothiazide; Triamterene
Family History: DM and HTN
Social History: Government Employee. Lives with his family. No history of smoking. Sedentary lifestyle; no regular physical activities.
Nutritional History: Wife verbalized that husband has gained an enormous amount of weight since being placed on insulin 5 years ago. His weight has continued to increase over the years,
and presently at his highest weight at 95.4 Kg.
Although his previous doctor advised him to loose weight and do daily exercises to improve his health status, no further actions were taken. Accordingly, every time he tries
to cut down on eating, he has symptoms of shakiness, diaphoresis, and increased hunger. He complains that pain in his knees and ankles with P/S 3/10 makes it difficult to
do any exercises.
He does not follow any specific diet and claimed that his prescribed meds can take care of his condition. During the day, he often has three to five pieces of kubus (bread),
eight to ten pieces of fresh fruit at meals and as snacks and prefers chicken and meat with kabsa (rice) for lunch and dinner.
He stopped taking Diabeta because of dizziness, often accompanied by sweating and a feeling of mild agitation, in the late afternoon.
No known food allergies.
Height: 5’ 5” Weight: 95.4 Kg BMI: 34.9 (Obesity Class I category)
General Appearance: Patient is obese and looks weak with shortness of breath.
Vital Signs: BP: 160/88 mmHg PR: 89 beats/min RR: 20 cycles/min T: 37.1 C O2 Sat: 97% at room air RBS: 182 mg/dl Pain: Localized chronic pain on both knees 3/10
aggravated by long period of standing/walking.

Method of
Area Normal Findings Abnormal Findings Remarks
Assessment
Inspection Warm, moist skin. Normal elasticity of the skin noted.
Skin

Non-remarkable.
Palpation T: 37.1 C

6
 Skull and face symmetrical. No signs of deformities, swelling or

Head &
Inspection

Face
tenderness noted. Non-remarkable.
Palpation \

Scalp is clean. Black silky hair, equal in distribution. No signs of nits.

Peripheral vision normal.
No discharges noted. Corrective lenses
\

Inspection No signs of swelling or tenderness noted.

Wears corrective lenses. Equipment used:
Eyes

Palpation Sclera white and clear.

Penlight
Palpebral conjunctiva pink.
Pupils are equal, round, reactive to light and accommodation.
Normal extra-ocular movement; eyes moves in conjugate fashion.
Pinna symmetrical in shape and size.
No discharges noted. Weber’s Test and Rinne’s Test done for
Inspection Normal hearing acuity on both ears. lateralization and conduction findings.
Ears

Non-remarkable.
Palpation External canal clear with minimal cerumen. Equipment used:
Normal sound lateralization and conduction noted. Tuning fork, Otoscope.
HEENT

Sinuses non-tender.
No deviation noted. Nasal septum straight and not perforated.
Inspection Polyps not present. Equipment used:
Nose

Non remarkable.
Palpation No discharges noted. Otoscope
Airway patent.
Lips are moist and not cracking.
\

Pink buccal mucosa without any ulcerations. Gums non swelling, no Polydipsia due to hyperglycemia.
Mouth

Inspection bleeding noted.

Palpation Polydipsia. Equipment used:
Tongue midline. Penlight, tongue depressor.
Uvula midline.
Normal range of motion.
Muscular symmetry noted. Cervical and trapezius muscles normal
Inspection tone and strength.
Neck

Palpation Trachea midline. Equipment used:

Non-remarkable.
Auscultation No jugular vein distension. Carotid bruit not noted. Stethoscope
Cervical lymph nodes non-palpable. Trachea midline.
\

Speech and voice normal.

7
 No deformities nor tenderness noted.
Thorax symmetric. Symmetrical chest movement. Normal bilateral
air entry.
RR at 20 cycles per min; O2 Sat: 97% at room
Pulmonary No any deformities, inflammation nor tenderness noted.
Dyspnea on exertion associated with
Dyspnea on exertion noted. increase tissue oxygen demand due to
No discharges seen on nipple. obesity.
Inspection Fremitus equal throughout the lung fields.
Palpation
Chest

Resonance noted over symmetrical areas of the lungs. Hyperglycemia due to uncontrolled DM
Percussion
Auscultation Vesicular breath sound auscultated over most of the lungs. Equipment used:
No bulges noted. Sphygmomanometer
Cardiovascular

Apical pulse strong with regular rhythm at 89 beats/min. Stethoscope

S1 and S2 audible. BP: 160/88 mmHg. 12-lead ECG
Peripheral pulsations strong with regular rhythm. RBS: 182 mg/dl
Norma Sinus Rhythm at 12-lead ECG.
Normal capillary refill.
Auscultation was done before
percussion and palpation to prevent
alteration of bowel sounds.
Inspection Bowel sound at 10 bowel sounds per minute.
Abdomen

Auscultation Waist circumference taken at the level

No tenderness noted upon palpation on al regions. Waist Circumference: 101.6 cm of umbilicus with 101.6 cm, categorized
Palpation
Percussion Tympanic sound during percussion. as obese. (>88cm)

Equipment used:
Stethoscope
Decreased range of motion noted on both knees.
Normal range of motion on both upper extremities.
Muscle strength on both lower extremities of 4/5 noted
Symmetrical muscle tone and strength on both upper extremities.
Musculoskeletal

upon resistance. All abnormal findings indicative of

No edema, deformities nor tenderness noted on upper extremities. deterioration of the articular cartilage in
Inspection Chronic Localized pain with P/S of 3/10 aggravated by the knee joint.
Strong, regular peripheral pulses noted.
Palpation prolong walking or standing and relieved by rest.
Normal capillary refill less than 2 seconds.
Tenderness with minimal inflammation noted on both Equipment used:
Deep Tendon Reflex: Normo-reflexive at DTR ++. Neuro-hammer
knee joints upon palpation.
Normal sensation noted on all extremities.
Crepitation audible on left knee joint.

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Genito-
urinary
Inspection No discharges noted from urethra.
Polyuria; Increased urgency and frequency of voiding. Polyuria due to hyperglycemia
Palpation No tenderness, lesions, nodules or masses noted.

GCS at 15
Alert, oriented to three spheres: person place and time.
Cerebellar Function Normal. Balance and coordination intact.
Motor Function: Normal symmetrical muscle tone and strength on
both upper extremities.
Sensory Function: Normal sensation observed all throughout.
GCS: 15
Cranial Nerves Eye Response: 4
Verbal Response: 5
CN 1: Olfactory Nerve and
Motor Response: 6
Not smell sensation.
CN 3: Oculomotor Nerve, CN 4: Trochlear Nerve and CN 6: Motor Function:
Decreased ROM indicative of
Abducens Nerve Decreased range of motion with muscle strength of 4/5
deterioration of the articular cartilage in
Normal extra-ocular movement; eyes moves in conjugate fashion. noted on lower extremities upon resistance.
Neurological

the knee joint.

Inspection CN 5: Trigeminal Nerve
CN 2: Optic Nerve
Palpation Facial muscle strength symmetrical. Facial sensation normal and Slight muscle weakness due to pain
Patient can read newspaper with the use of corrective
symmetrical. when given resistance.
lenses.
CN 7: Facial Nerve
Facial muscles symmetrical.
Equipment used:
CN 8: Vestibulocochlear Nerve Penlight
Symmetrical hearing noted. Neuro-hammer
Normal balance and equilibrium noted. Tuning Fork
CN 9: Glossopharyngeal Nerve and CN 10: Vagus Nerve Cotton
Gag reflex present, no difficulty in swallowing. Tongue Depressor
Palate and uvula move symmetrically without deviation.
CN 11: Accessory Nerve
Symmetrical neck and shoulder muscle tone.
CN 12: Hypoglossal Nerve
Normal speech and articulation noted. Tongue symmetric and not
deviated.

9
 MENTAL HEALTH ASSESSMENT: OPIOID SUBSTANCE ABUSE DISORDER
WITH MODERATE OPIOID WITHDRAWAL

Patient Name: Mr. C Date of Admission: 18 September 2019

Medical Record Number: 1080001 Nationality: Saudi
Chief Complaint: Patient C complaining of chronic localized pain on left hip with P/S 9/10. Not relieved by rest nor prescribed pain meds and is aggravated by prolong standing.
History of Present Illness: A 35 year-old Saudi came to ER, KAMC complaining of bothering chronic pain since June 2018. He had a motor vehicular accident with displaced Left Femoral Neck Fracture
requiring Total Hip Arthroplasty under the care of KAMC Orthopedic Surgeon Dr. Alqarni. Patient was prescribed with Tramadol 50 mg QID. Undergone physiotherapy
sessions. A week ago, his prescription was changed to ibuprofen 800 mg TID, however patient claimed ineffective with no pain relief. He requested his Doctor to prescribe
him the previous medication but was not granted. He does not want to return to his doctor, “Mafi Faidah” (No benefit) since He doesn’t believe that I am still in pain” as
verbalized by the patient. Thus, patient visited the ER for tramadol prescription. Patient complains of localized chronic pain with P/S of 9/10 on left hip. Not relieved with
current medication or rest and aggravated by prolong walking. Patient is nauseous and had diarrhea this morning.
Past Medical History: No known medical history. Undergone Total Hip Arthroplasty last June 2018.
Medication History: Tramadol 50 mg QID, Ibuprofen 800 mg TID
Family History: Hypertension
Social History: Patient is a Police Officer, recently divorced and living alone. Smoker for 10 years. Skipped work today due to severe pain that affects his activities of daily living.

General Appearance: Patient with limping gait; using assistive device; cane. Patient seems anxious with flushed skin, restless, irritable and very talkative.
Vital Signs: BP: 135/78 mmHg PR: 92 beats/min RR: 17 cycles/min T: 37.0 C O2 Sat: 98% at room air Pain: Localized chronic pain on left hip P/S 9/10 aggravated by
prolong standing, not relieved by current pain meds.
Height: 5’ 8’ Weight: 80 kg BMI: 26.8 (Slightly overweight)) .

Method of
Area Normal Findings Abnormal Findings Remarks
Assessment

Inspection Normal elasticity of the skin noted. Sweating may be indicative of opioid
Skin

Sweating, warm skin noted. withdrawal.

Palpation T: 37.0 C

Skull and face symmetrical. No signs of deformities, swelling or Flushed skin may be indicative of opioid
Head &

Inspection
Face

tenderness noted. Flushed skin on face noted. withdrawal.

Palpation \

Scalp is clean. Black silky hair, equal in distribution. No signs of nits.

HEENT

Inspection Peripheral vision normal.

Equipment used:
Eyes

Palpation No signs of swelling or tenderness noted. Teary eyes.

Penlight
Sclera white and clear.
10
 Palpebral conjunctiva pink.
Pupils are equal, round, reactive to light and accommodation.
Normal extra-ocular movement; eyes moves in conjugate fashion.
Pinna symmetrical in shape and size.
No discharges noted. Weber’s Test and Rinne’s Test done for
Inspection Normal hearing acuity on both ears. lateralization and conduction findings.
Ears

Non remarkable.
Palpation External canal clear with minimal cerumen. Equipment used:
Normal sound lateralization and conduction noted. Tuning fork, Otoscope.
Sinuses non-tender.
No deviation noted. Nasal septum straight and not perforated. Stuffy nose may be indicative of opioid
Inspection Polyps not present. withdrawal.
Nose

Rhinorrhea; transparent watery discharges noted.

Palpation No discharges noted. Equipment used:
Airway patent. Otoscope
Lips are moist and not cracking.
\
Nausea may be indicative of opioid
Pink buccal mucosa without any ulcerations. Gums non swelling, no withdrawal.
Mouth

Inspection bleeding noted. Nauseous since yesterday.

Palpation Equipment used:
Tongue midline.
Penlight, tongue depressor.
Uvula midline.
Normal range of motion.
Muscular symmetry noted. Cervical and trapezius muscles normal
Inspection tone and strength.
Neck

Palpation Trachea midline. Equipment used:

Non-remarkable.
Auscultation No jugular vein distension. Carotid bruit not noted. Stethoscope
Cervical lymph nodes non-palpable. Trachea midline.
\

Speech and voice normal.

No deformities nor tenderness noted.
Thorax symmetric. Symmetrical chest movement. Normal bilateral
Inspection air entry.
Pulmonary

Palpation Anterior and posterior lung sounds clear bilaterally. No wheezing, Equipment used:
Chest

Percussion crackles or rhonchi noted. Sphygmomanometer

Auscultation RR at 17 cycles per min; O2 Sat: 98% at room Stethoscope
12-lead ECG
No any deformities, inflammation nor tenderness noted.
No discharges seen on nipple.
11
 Fremitus equal throughout the lung fields.
Resonance noted over symmetrical areas of the lungs.
Vesicular breath sound auscultated over most of the lungs.
No bulges noted.
Cardiovascular
Apical pulse strong with regular rhythm at 92 beats/min.
S1 and S2 audible.
BP: 135/78 mmHg.
Peripheral pulsations strong with regular rhythm.
Norma Sinus Rhythm at 12-lead ECG.
Normal capillary refill.
Auscultation was done before
percussion and palpation to prevent
Inspection alteration of bowel sounds.
Abdomen

Auscultation No tenderness noted upon palpation on al regions. Bowel sound at 18 bowel sounds per minute. Diarrhea may be indicative of opioid
Palpation Diarrhea in the morning as verbalized by patient. withdrawal.
Tympanic sound during percussion.
Percussion
Equipment used:
Stethoscope

Normal range of motion on both all extremities. Well healed scar over left later hip.
Symmetrical muscle tone and strength on both upper and lower Tremor may be indicative of opioid
Slight tremor noted on hands.
Musculoskeletal

extremities. withdrawal.
Inspection No edema, deformities nor tenderness noted on all extremities. Chronic Localized pain with P/S of 9/10 aggravated by Surgical scar from Total Hip
Palpation Strong, regular peripheral pulses noted. prolong walking and not relieved by current pain meds. Replacement Surgery done June 2018
Normal capillary refill less than 2 seconds. Bilateral feet with dry, cracking and peeling skin.
Equipment used:
Deep Tendon Reflex: Normo-reflexive at DTR ++. Patient verbalized sometimes itchy on the calcaneal
Neuro-hammer
Normal sensation noted on all extremities. part of the foot.
Genito-
urinary

Inspection No discharges noted from urethra.

Non-remarkable.
Palpation No tenderness, lesions, nodules or masses noted.

12
 GCS at 15
Alert, oriented to three spheres: person place and time.
Cerebellar Function Normal. Balance and coordination intact.
Motor Function: Normal symmetrical muscle tone and strength on
both upper extremities.
Sensory Function: Normal sensation observed all throughout.
Cranial Nerves
CN 1: Olfactory Nerve and GCS: 15
Not smell sensation. Eye Response: 4
CN 2: Optic Nerve. Verbal Response: 5
Normal visual acquits. Motor Response: 6

CN 3: Oculomotor Nerve, CN 4: Trochlear Nerve and CN 6:

Abducens Nerve Patient seems anxious, restless and irritable. Restless, Irritability maybe indicative of
Neurological

Normal extra-ocular movement; eyes moves in conjugate fashion. opioid withdrawal.

Inspection
CN 12: Hypoglossal Nerve
Palpation CN 5: Trigeminal Nerve
Normal articulation noted, however talks fast.
Facial muscle strength symmetrical. Facial sensation normal and
Talkative.
symmetrical. Equipment used:
CN 7: Facial Nerve Penlight
Facial muscles symmetrical. Neuro-hammer
Tuning Fork
CN 8: Vestibulocochlear Nerve Cotton
Symmetrical hearing noted. Tongue Depressor
Normal balance and equilibrium noted.
CN 9: Glossopharyngeal Nerve and CN 10: Vagus Nerve
Gag reflex present, no difficulty in swallowing.
Palate and uvula move symmetrically without deviation.
CN 11: Accessory Nerve
Symmetrical neck and shoulder muscle tone.
CN 12: Hypoglossal Nerve
Normal speech and articulation noted. Tongue symmetric and not
deviated.

13