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PA and DTR As Well As SOAPIE
PA and DTR As Well As SOAPIE
Name of Patient: Serenio, Olympio Lota Diagnosis: Post-gliotic seizure secondary to CVA Diabetes Mellitus, type 2 Essential Hypertension, stage I Hypokalemia
Hospital No.: 39096- 2011 Room No.: MM8 Physician: Dr. Honey Alcantara/ Dr. Dennis Daniel Roa
INSPECTION
PALPATION
PERCUSSION
AUSCULTATION
Hair
Scalp
White and gray, no scars noted, lighter skin color than complexion Lighter in color Without masses, than skin no pain felt, no complexion, lumps moist from perspiration, no scars, free from dandruff
Normal skull which looks smooth, no masses nontender, and depressions, no pain felt Flat shaft, brittle, moist from perspiration/ oily, thin
Forehead
No wounds/ scars, color is even which is light brown, lentigens (brown age spots) slightly noted
Face
Eyes
Eyebrows
No pain felt, without lesions and depressions, no masses, no pain felt, , temporal pulse= 61 bpm synchronized on both sides with normal strength, warm to touch Oval, , No masses, no symmetrical pain felt, no facial features, swelling dry skin, poor skin turgor, facial grimace and facial wrinkles noted In line with each other/ symmetrical, non-protruding Bilateral, No masses, no grayish and lumps, no white in color, nodules evenly distributed, symmetrically aligned, parallel
INSPECTION
PALPATION
PERCUSSION
AUSCULTATION
Eyelids
Evenly Active blink distributed, reflex, thin slightly curved outward, black, blink reflex= 15 times per minute UPPER LIDS: Involuntary
Symmetrical, when blinking Intact, able to open and close, pale pink in color, dry, drooping eyelids LOWER LIDS: Involuntary Symmetrical, when blinking intact, able to open and close, pale pink in color, dry white, absence of lesions, small veins are visible Not inflamed; pale pink in color, moist Transparent and glossy, teary looking, clear Equal in size of both eyes and brownish in color, appears flat with a regular shape Black, Equally round, reactive to light and accommodatio n Both eyes are well coordinated, it moves smoothly and symmetrically
Sclera
Conjunctivae
Cornea
Iris
Pupil
Muscle Function
Muscle Balance
Visual Acuity
Peripheral Vision
Nose
Frontal Sinus
and follows the 6 fields of gaze. Constricting during light reflex and simultaneously during consensual light reflex 20/20 (Normal Vision); Upon admission,, patient experienced blurring of vision and gradually returns to normal Able to see the stimulus at about 90 degrees temporally, 50 degrees superiorly, 70 degrees inferiorly, and 60 degrees nasally Found in the midline of the face with no lesions and no presence of discharges Evidence of swelling around the eyes and nose, gray during transilluminati on
Maxillary Sinus
Evidence of Slightly tender swelling around the eyes and nose, grayish color during transilluminati on
Dull sound
Mouth Lips Pallor, pale pink in color, cracked and dry Pale pink in color, no bleeding, smooth Yellowish, 27 teeth, 2 extracted, and dentures for molars noted, presence of dental plaques also noted Pink in color and is in the midline of the mouth. It moves freely and the dorsal and ventral surface is moist. Attached to the tongue, pink in color Pink in color, absence of lesions, blood vessels visible Slightly whitish Non-tender, no pain felt, soft, no lumps No pain felt
Gums
Teeth
Tongue
Frenulum
Sublingual
Hard Palate
Hard
Soft Palate
Uvula
Tonsils
in color and dome-shaped with ridges, no lesions, dry Light pink in Soft color, concave, no lesions, moist Hanging in the midline of soft palate, pink in color, slightly dry Pink, moist, No pain felt not inflamed Slightly slurred Bilaterally equal, without swelling, light brown in color consistent with the patients facial skin, no discharges, laterally aligned with the outer canthus of the eye, symmetrical, and pendulous Able to perceived the words and sounds equally in both ears Able to move the head in full range of motion without complaints or
Speech EARS
Auditory Acuity
Neck
Smooth, absence of lesions, no pain felt, carotid pulse= 61 bpm synchronized and strong pulse
Thyroid Gland
discomforts, able to move neck with full ROM: flexion= 45, hyperextension = 60, lateral abduction= 40, rotation=10 Not inflamed No pain felt during palpation Appears in Placed centrally midline in midline, spaces are equal on both sides, not deviated Moves up No enlargement, when masses and swallowing, no tenderness visible masses
Thorax Chest Anterior Lighter in color, equal rise and fall, breathing route is 18 cycles per minute, moist with perspiration Equal chest Resonance on Clear sounds on expansion, full lung area, flat both lobes of the symmetric on ribs lungs excursion, warm skin, axillary temperature= 37.8C Respiratory rate= 18 cycles per minute, bilateral symmetry Resonant Clear sounds on sound on both lobes of the intercostals lungs spaces, flat on ribs Dull Sound Apical pulse= 61 bpm Clear sounds on both lobes of the lungs
Lungs
Heart
Chest Posterior
Nonpalpable, heartbeats=61 bpm Spine vertically Warm to touch, Resonant align, no pain felt, full sound heard symmetrical and symmetric expansion
Abdomen
Color is the same with the body, flat, umbilicus in the midline and nonprotruding
Tympanic High pitched sound over the sound/ gurgles: 8 stomach, times/minute dullness over the liver and spleen
Liver Spleen Kidney Extremities Upper Even in color, hairy, slight age spots noted, numbness and difficulty moving left hand, with ongoing IVF #4 of PNSS 1L @ 20 gtts/min at the level of 150 cc infusing well @ right hand; unable to perform gross and fine motor skills at left hand Color is even, poor skin turgor, wrinkles, and unable to resist the force exerted on his left hand and was able to resist force
No pain felt, Dull sound lightly palpable Non palpable Dull sound Non palpable, no Dull sound pain
No pain felt, capillary refill less than 3 seconds, brachial and radial/ulnar pulse palpable, T= 37.8 degrees Celsius PR= 61 bpm
Muscle tone
Muscle strength
no pain felt, no lumps, nontender, warm and moist from perspiration. Patient has weak resistance to force exerted to him
exerted on the right hand Reflexes Biceps= flexion of the forearm Triceps= extension of the elbow Brachioradialis= supination and flexion of forearm Equal in size, brown in complexion, even skin tone, hairy legs No pain felt, popliteal/dorsalis pedis and tibal pulse palpable
Lower
Muscle Strength
Muscle tone
Weak resistance to force exerted on him Color is even, No pain felt, unable to non-tender, no move left leg, lumps, warm to symmetrical, touch age spots and wrinkles noted Patellar= extension of the knee Achilles= planter flexion of the feet Plantar= toes curved/plantar flexion of the toes Patient is confined to bed (nonambulatory) due to leftsided weakness. Gait
Reflexes
Gait
Balance
Coordination
was not assessed. Patient is confined to bed (n0nambulatory) due to leftsided weakness. Balance was not assessed. Patient is confined to bed. Coordination was not assessed.
Name of Patient: Serenio, Olympio Lota Diagnosis: Post-gliotic seizure secondary to CVA Diabetes Mellitus, type 2 Essential Hypertension, stage I Hypokalemia
Hospital No.: 39096- 2011 Room No.: MM8 Physician: Dr. Honey Alcantara/ Dr. Dennis Daniel Roa
DRUG THERAPEUTIC RECORD Drug/ Dose/ Classification/ Frequency/ Mechanism of Route Cction Indications/ Contraindications/Side Effects Principles of Care Treatment Evaluation
Metformin HCl
Classification: Antidiabetic
Indications:
1. Do
Medications or taken at
Mechanism of glucose with type 2 medication Action: Exact mechanism DM -As part without of consulting healthcare with provider. wherein 2.
is combination
Timing: 10 am 10 pm
dosage.
of glucose levels in glucose and Arrange for patients with type 2 ketone DM as transfer insulin therapy Contraindications: Swallow during periods of to
prescribed.
high stress.
do Use
IV if
this during
of
Nausea, vomiting, pregnancy. anorexia, heartburn, diarrhea Avoid and flatulence Hypersensitivity: -allergic using alcohol Increased risk of
skin while
the overdose. .
Report your fever, sore throat, unusual rash bruising, dark-urine, lightcolored stools, hypoor or
Indications: -Hpertension
Medications to taken at
ordered dose,
Dose:
Mechanism of -used cautiously to blood Action: Inhibits calcium influx cardiac patients other receiving pressure peripheral frequently during
feeling better.
effects obtained.
-Tell
the SL
Nitroglycrei n may be as
smooth muscle CNS: cells, decreasing myocardial contractility and thus -headache, fatigue, -Notify dizziness, headedness, paresthesia light- prescriber
taken
needed when
palpitations Gastrointestinal:
and -nausea, abdominal shortness of therapy pain Genitourinary: -sexual difficulties Musculoskeletal: -muscle pain -Alert: Dont confuse with Amiloride. breathing. during adjustment of amlodipine dosage, urge continued compliance.
Medications taken at
Mechanism of cerebral injury Action: Increases blood flow and oxygen Contraindications: -Cerebrovascular disease
meals.
-Should not -Observe be taken in closely the late monitor patients it neurologic or
cause status.
difficulty in sleeping. -Report physician for -Should be unusualities started within such 24 rashes as and
Increases
speed
of elevation
occurs.
taking drug.
-Contact physician immediatel y if allergic reaction such hives, rashes and chest tightness occurs. as
or into a Yport.
Phenytoin (Dilantin)
Indications:
-Tell patient
ordered dose,
Dose: 100 mg
pregnancy.
develops.
effects obtained.
derivative that dose probably stabilizes neuronal membranes and -to treat during neurosurgery
and solution for avoid driving and other -Dont give potentially IM unless hazardous activities that require mental alertness until drugs
seizures injection.
dosage adjustments
cell SA block, 2nd- and doses given CNS effects degree AV with or are known.
motor block, or Adam- after meals during Stokes syndrome may -Advise patient not to
those with hepatic adverse GI change dysfunction, hypotension -Elderly reactions. brands dosage -Stop drug forms once or
appears.
slurred -Dont stop dizziness, drug confusion, suddenly -Tell patient not to use
-periateritis, nodosa -Monitor EENT: -nystagmus, diplopia, vision Metabolic: -osteomalacia Hepatic: -toxic hepatitis blurred -Monitor CBC calcium drug
-Advise to
in blood.
the
importance
function. .
Glimepiride
Classification: -Medium
Indications: to
exercise
blood with insulin meal of the date and time. level in for patients day. lose -Make patient first understands that therapy relieves symptoms but does not the Desired effects sure obtained.
by diet and exercise responding alone level -Adjunct by and to diet in -Monitor with fasting to therapy.
exercise
conjunction
release insulin
of insulin
or glucose
cure disease.
the
functioning
pancreatic beta type 2 DM whose to cells and may hyperglycemia lead increased sensitivity peripheral tissues insulin. to Contraindications: determine
-Stress
the
may personal
-hypersensitivity to carry higher hygiene the drug -Pregnant elderly clients -breastfeeding patients -debilitated malnourished patients -When Side Effects: CNS: changing patient -Advise woman to risk of CV programs. or mortality than use of -Advise diet alone patient to carry
identificatio n at all
times.
-dizziness, asthenia,, headache EENT: -changes accommodation, Gastrointestinal: -nausea Hematologic: -leukopenia, hemolytic anemia Skin: -pruritus, erythema, urticaria, photosensitivity reactions Hepatic: -cholestatic jaundice
to before
not needed.
Dexamethas one
Classification: Corticosteroid
-Determine
Dose:
Mechanism of conditions
sensitive to abruptly
Action: Not defined. Decreases inflammation, mainly stabilizing leukocyte lysomal membranes; suppresses immune response; stimulates
Contraindications:
by -Hypersensitivity to results and patient the drug -recent MI less toxicity, take
with food or
-patients with GI give once- milk. ulcer, renal disease, daily hypertension, in dose the -Teach patient signs -Give dose the and
protein, ,and
muscle Side Effects: CNS: -euphoria, -Give injection IM weakness, joint pain,
carbohydrate metabolism.
hypertension,
edema, arrthymias, atrophy. thrombophlebitis, thromboembolism EENT: -cataracts, glaucoma -Always adjust lowest effective dose.
-Watch for exposure in depression pr psychotic episodes especially in dose therapy. infections (such as
occurs.