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Lesigues Rospe
Lesigues Rospe
SYSTEM
GENERAL ASSESSMENT
PHYSICAL EXAM
Upon Admission:
BP: 120/80 mmHg
HR: 69 bpm
RR: 16 cpm
T: 36 C
HEIGHT: 157.5 CM
WEIGHT: 72 kg
BMI: 29.02 - overweight
Upon assessment:
BP: 110/70 mmHg
HR: 70 bpm
RR: 16 cpm
T: 36.6 C
HEIGHT: 157.5
WEIGHT: 57 kg
BMI: 25.8 - overweight
MENTAL STATUS
EXAMINATION
SKIN, HAIR, NAILS
REVIEW OF SYSTEM
INSPECTION:
HEAD Normocephalic and
symmetrical. There is a
scar with stiches at the
back of his head that was
caused by fall.
PALPATION:
There are no nodules or
masses and depressions
when palpated.
NECK INSPECTION:
Head is positioned in the
center. Accessory neck
muscles are symmetrical.
Motion is soft and
controlled when turn to
sides and extending the
head backward.
PALPATION:
Trachea is located at
midline. Lymph nodes are
not palpable. There are no
swelling, enlargement and
tenderness in the lymph
nodes. Thyroid tissue
moves up when
swallowing.
INSPECTION:
EYES The upper lid margin is
between the upper margin
of the iris and the upper
margin of the pupil. The
lower lid margin rests on
the lower boarder of the
iris.
The upper and lower lids
close easily and meet
completely when closed.
The lower eyelid is upright
with no inward or outward
turning. Eyelashes are
evenly distributed and
curve outward along the lid
margins. There is redness
around the iris and pupils
are dilated. Cornea looks
February 5, 2016 at
OD.
Ocular Movement
was performed in
front of the patient
and observed the
right eye using a
penlight, Iris cannot
constrict
immediately when
directed by light.
Visual Acuity result
was 20/400
Visual field shows
that patient cannot
see the 4 corners of
the eye except the
central vision.
LEFT EYE:
Opthalmoscopic
examination was
performed and
showed cupping and
pallor of the Optic
Nerve. There was
NO RED REFLEX
NOTED.
Pupil is now nonreactive.
Laser Iridotomy was
performed last April
4, 2016 at OS.
Ocular Movement
was performed in
front of the patient
and observed the
right eye using a
penlight, Iris are
dilated with or
without light.
Visual Acuity result
was 20/600.
Visual field shows
that patient cannot
MOUTH INSPECTION:
Lips are smooth without
lesions or swelling.
Can talk clearly without
complains of difficulty,
Uvula is positioned in the
midline of the soft palate.
Patient is not using
dentures. Have complete
teeth and are aligned.
NOSE INSPECTION AND
PALPATION:
The nose appeared
symmetric, straight and
uniform in color. There was
no presence of discharge.
There were no tenderness
and lesions palpated.
SINUSES PALPATION:
Frontal and maxillary
sinuses are non-tender
when palpated.
PERCUSSION:
Sinuses are non-tender
when percussed.
BREAST
INSPECTION:
Areola is dark brown and
round. No edema.
AXILLA:
Presence of hair in the
axillary area.
THORAX AND LUNGS
GENERAL INSPECTION:
Client has evenly colored
skin tone without unusual
or prominent discoloration.
THORAX INSPECTION:
Scapulae are symmetric
and non-protruding,
shoulders and scapulae at
equal horizontal positions.
Do not experience any
cough.
PALPATION:
No tenderness, pain or
unusual sensation, skin
and subcutaneous tissue
and free of lesions and
masses.
PERCUSSION:
Resonance in the chest
area, cardiac dullness, liver
dullness, stomach tympany
was noted upon
percussion.
AUSCULTATE:
Normal breath sound upon
auscultation.
RR
NECK
PALPATION:
The apical impulse is
palpated in the mitral area.
No pulsation or vibration is
AUSCULTATE:
Bowel sounds gurgling
are present.
PERCUSSION:
Tympany is predominant in
all four quadrants. Dullness
is present upon percussing
the spleen area. Umbilicus
and surrounding area are
free of swelling bulges or
masses. Abdomen is nontender and soft.
PALPATION:
No palpable mass and no
abdominal pain present.
GENITOURINARY
Patients menstruation
started when she was 14
years old and menopaused
at 45 years old.
MUSCULOSKELETAL
GAIT
INSPECTION:
Evenly distributed weight.
Client can stand up and
walk without feeling pain.
developed.
CERVICAL, THORACIC
AND LUMBAR SPINE
INSPECTION AND
PALPATION
Non tender paravertebral
muscles.
ELBOWS
INSPECTION AND
PALPATION
Even and symmetrical, no
tenderness reported. Fill
ROM. Can flex, extend,
abduct, rotate, and shrug
shoulders against
resistance.
WRIST
INSPECTION AND
PALPATION
Wrists are symmetric
without redness or
swelling. Full ROM of wrist.