PHYSICAL ASSESSMENT MANUSCRIPT

In Partial Fulfilment of the Requirement in NCM 207- RLE

PRECLINICAL ROTATION

Submitted to

Karen Sol I. Operario. RN, MN

Clinical Instructor

Submitted by:

John Andrew A. Padilla

BSN2D- GROUP 4
Biographical Data
Name of client: Patient X Age: 45 Gender: Male
Ward: San Pedro College ward, room 200 Bed no: 1
Home:Agan Homes Brgy.Samapo, Isulan,Sultan Kudarat
Birthday: February 5 Place of birth:Cotabato City
Nationality: Filipino Marital Status: Married Religion:Roman Catholic
Educational level: College Graduat Occupation: Self-employ

History of Present History

Pateint X 45 year old comes in with a diagnosis of type 2 diabetes . The patient
blood sugar is 250mg/dl and the patient is admitted to your ICU. The patient is on an
insulin gtt per protocol. The goal is to get the patient blood sugar at 70-200 per md order.
The patient is alert and oriented times 3 and patient expresses discomfort on the lower
limb by verbalizing “Legs feel a little off”. He states this is the fourth time he has come to
the hospital in the past year for high blood sugar. However, he states he has never been
in the ICU and says “well this must be pretty serious then”. The pt’s wife is with him and
states the patient does not manage his diabetes at home very well and eats whatever he
wants and goes several days without checking his blood sugar. She states she urges him
to but he does not comply. During your assessment you ask the patient about his
knowledge about diabetes. You find out that the patient does not know how to check his
blood sugar properly and interpret the results. In addition, the patient is not
knowledgeable about diet regimes and knows little about the consequences of
uncontrolled blood sugars. The patient states “I have always thought I can eat whatever
I want, when I want, and insulin coverage can be at my discretion”. The patient is shocked
at what you educate him about and says he wants to get serious about managing his
diabetes because he doesn’t want to “be in the ICU again”.

Past health history

The patient A.B he stopped smoking more than 10 years ago His blood pressure has
been measured at 150/70, 148/92, and 166/88 mmHg on separate occasions during the
past year at the local senior centre screening clinic. Although he was told that his blood
pressure was “up a little,” he was not aware of the need to keep his blood pressure
≤130/80 mmHg for both cardiovascular and renal health. Medical records indicate that he
has no surgeries or hospitalization, his immunizations are up to date, and in general, he
has remarkably healthy.

History form
History
Patient is diagnose with type 2 diabetes. He is admitted to the hospital with hyperglycaemia
problems. Patient already been in the hospital for 4 times this year and patient’s main cause
of this is due ignorance and stubbornness.
Past Health history
Hypertension

Family History: Both patient are diagnose with type 2 diabetes and grandparents generation
unknown medical history
Personal History: Patient has stop smoking for 10 years

Family health history

The patients parents are both are decease and had type 2 Diabetes. Even both
parents are diagnosed type 2 diabetes patient has limited knowledge on self-care and
patient believe that insulin will cover inadequate management practice of the patient.
Aside from that patient does not have any recollection grandparent’s medical history.
Genogram

Legend:

 box-male
 circle-female
 red color – diagnose with type 2 diabetes
 with x in siden- deceased

General survey

Patient is alert and oriented times 3. Patient is obese, endomorphic built with a
BMI of 32.6 kg/m2 with normal gait and posture. Patient is well groom, acetone breath
odour. Patient vital results are the following temp: axillary:36,Blood pressure: lying, right
arm 140/90 mmHg; sitting, right arm 154/96 mmHg; pulse: 88 bpm; respirations 20 per
minute, HR: 91 bpm Patient’s cooperative and patients mood is appropriate. Patient is
expressing discomfort and loss of sensation of the lower limbs
Skin, Nails and Hair

Patient’s skin shows nigrican acanthosis on the nape . Skin dry, warm to touch,
turgor is good, absence of both lesions and edema .Nails are clean and well groomed.
Hair is equally distributed, oily and fine, no presence of infestation

Head, Eyes, Ears, Nose, Throat (HEENT).

Scalp without lesions. Skull is normocepahlic and symmetrical. Conjunctiva pink,

sclera is icteric. Pupils round, regular, equally reactive to light and accommodation. Extra
ocular movements intact. Disc margins sharp, without haemorrhages or exudates, absent
of retinopathy. Nasal mucosa pink. No sinus tenderness. Oral mucosa pink. Dentition fair.
Caries present. Tongue midline, slight beefy redness. Pharynx without exudates. Neck.
Supple. Trachea midline. Thyroid are not enlarged, Lymph Nodes palpable but not
inflamed. No cervical, axillary, epitrochlear, or inguinal lymph nodes.

Thorax and Lungs.

Patient thorax is uniform in colour, edema and lesions are not present, shape is
normal and no deformities. Lungs sound are normal, no adventurous sound present

Cardiovascular.

JVP 6 cm above the left atrium. Carotid upstrokes brisk, without bruits. PMI
tapping, in the 5th ICS, 9 cm lateral to the midsternal line. II/VI harsh holosystolic murmur
at the apex, radiating to the axilla. No S3, S4, or other murmurs. no carotid bruits; femoral,
popliteal, and dorsalis pedis pulses 2+ bilaterally.

Abdomen.

Scaphoid, with active bowel sounds. Soft, nontender. No masses or

hepatosplenomegaly. Liver span 7 cm in right midclavicular line; edge smooth and
palpable at the RCM. No CVAT.

Genitourinary.

Circumcised male. No penile lesions. Testes descended bilaterally, smooth.

Rectal. Rectal vault without masses. Stool brown, negative for occult blood.
Neurological.

Diminished vibratory sense to the forefoot, absent ankle reflexes, monofilament

(5.07 Semmes-Weinstein) felt only above the ankle

Conclusion:

The patient patient is showing symptoms that are associated with type diabetes
which are acetone breath, nigrican acanthosis on the nape, minor sensory loss in the
lower limbs that may indicate diabetic neuropathy and relatively high blood pressure
.Hyperglycaemia per se can evoke nerve hypoxia, especially in sensory nerves, altering
their electrical stability (Schreiber, A. K., Nones, C. F., Reis, R. C., Chichorro, J. G., &
Cunha, J. M. (2015). With the indication that patient may have neuropathy patient must
do proper foot care or closely monitor if lesions will be present so that it will be treated
immediately. In addition patient must start monitoring both his hypertension and diabetes
because significantly increase the risk for coronary heart disease (Grossman, A.,
Grossman, E. Blood pressure control in type 2 diabetic patients. (2017). Even with that
patient’s status manageable no lesion and infections that may put the patient in a high
risk position. In the future, for patient to avoid such happening he used be educated and
follow through with practice.

Gordon’s functional
Health Perception and Management
Nutritional metabolic
Elimination-excretion patterns and
problems need to be evaluated
(constipation,incontinence,diarrhea
Activity exercise-whether one is able to
do daily activities normally without any
problem, self care activities
 Patient is not well educated on his
diagnosis, as well as management
 Patient has already stopped
smoking for ten years already
 Patient has good appetite as
verbalize “ That he eats whatever
he wants”
 Patient is obese with a BMI of
32.6kg/m2
 Patient does frequently urinate and
bowel defecation is regular with an
occasional constipation
 Aside for work patient does not
have any day-to-day activities
Sleep rest-do they have hypersomnia,  Patient didn’t express that he is
insomnia, do they have normal sleeping expressing sleep/rest discomfort
patterns
Cognitive-perceptual-assessment of  The patient is has minor sensory
neurological function is done to assess, loss in the lower limbs
check the person's ability to comprehend
information
Self perception/self concept  The patient is alert and oriented
times 3
Role relationship  Patient is married with 2 married
children
Sexuality reproductive  patient did not feel comfortable
expressing answer in this subject
matter
Coping-stress tolerance  patient feels anxious and distress
inside the ICU evidence as the
expressing that he doesn’t want to
“be in the ICU again”
Value-Belief Pattern  patient is baptise Roman catholic
but is not active

References:

 Mayo clinic. Type 2 diabetes. https://www.mayoclinic.org/diseases-

conditions/type-2-diabetes/symptoms-causes/syc-20351193. 2020
 World Health Organization. Diabetes. https://www.who.int/news-room/fact-
sheets/detail/diabetes. 8 June 2020
 Schreiber, A. K., Nones, C. F., Reis, R. C., Chichorro, J. G., & Cunha, J. M. (2015).
Diabetic neuropathic pain: Physiopathology and treatment. World journal of
diabetes, 6(3), 432–444. https://doi.org/10.4239/wjd.v6.i3.432
 Grossman, A., Grossman, E. Blood pressure control in type 2 diabetic patients.
Cardiovasc Diabetol 16, 3 (2017). https://doi.org/10.1186/s12933-016-0485-3