PATIENT’S PERSONAL PROFILE

Name: Patient X

Age: 79

Gender: Male

Address: Gucab,Echague,Isabela

Birth Place: Tuguegarao, Echague, Isabela

Birth date: September 13, 1941

Civil Status: Widowed

Occupation: Geodetic Engineer

Significant Other: Mrs. X

Date of Admission: September 13, 2019

Chief Complaint: Difficulty in Breathing

Admission Diagnosis: Pneumonia, both mid to lower lung fields.

Vital Signs: Date Taken: September 21 2019

Temperature:34.6°c

Pulse Rate: 63 beats per minute

Blood Pressure:

Respiration: 24 cycles per minute

 HISTORY OF PRESENT ILLNESS

Patient X aforementioned that he discontinued his ingestion of alcoholic

beverages long before he admitted to the hospital. Despite the diagnosis Patient X admits to

drinking acidic beverages (soft drinks). Though patient is attending regular checkups, after a

week of being diagnosed the patient has reported no further complications.

PAST ILLNESS

According to Patients X he used to drink alcoholic beverages coupled with meat

and junk foods, he claims to have stopped his intake of such food items. Rarely does patient x go

to checkups.
 PHYSICAL ASSESSMENT

Body Parts Techniques Normal Findings Actual Findings Analysis

HEAD/ Inspection: for The head is

size, shape, and symmetrical. Size
HAIR symmetry varies with age and
body stature.
Palpation: For
contour, masses, Male pattern hair
depression loss is common.

Hair is distributed
evenly and free
from lesions

Free from lice and

other parasites
EYES Inspection Both eyeballs are
symmetrical in size
and position

Both upper and

lower eyelids are
symmetrical

Conjunctiva is
normal and not
otherwise inflamed
of pale

SKIN Inspection Consistent skin

color (varies based
Palpation with age or
environmental
effects)

Uniform texture
throughout the skin

No feelings of
dryness, itching,
 tightness or
stinging

Lifts easily and

snaps back into
position

NOSE External/Internal The bridge is the

superior part of the
Inspection triangle.

Palpation The tip is the outer

corner of the
triangle.

Both nostrils are

clear of
obstructions

Nasal septum is
intact and not
deformed

MOUTH/ Inspection Gums

TOUNGE should look pink
and firm

Moist lips

Properly aligned
teeth, intact and
free from stains
NAILS Inspection Nails are
transparent,
Palpation smooth and
convex, with
surrounding cuticle
smooth, intact and
without
inflammation

In older adults
nails become more
brittle, dull, and
opaque and turn
yellow

When pinched
color should return
in less than a
second

HANDS Inspection No tiny red bumps

or blisters
Palpation
No unusual
sensations such as
numbing, itching
or a tingly
sensation

Fingers are
complete and show
no signs of trauma
or deformity
CHEST Inspection Normal

Palpation
ABDOMEN Inspection Abdomen is
symmetrical
Palpation
No respiratory
retractions

No masses or
nodules
LEGS AND Inspection There is no redness
EXTREMITI or swelling
ES Palpation
There are no
swelling or
inflammation of
the joints

Extremities should
be warm and
pulses palpable