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Pa Nephrotic
Pa Nephrotic
PHYSICAL ASSESSMENT
Heart Rate 90-150 bpm 107 bpm Within the normal range
Measurements
Normal Findings Actual Findings Interpretation
88 cm Within the normal range
Height 86-100 cm
the normal weight for
The patient lost weight because of the
Weight a toddler is between 18 kg
disease itself, nephrotic syndrome.
22 and 31 pounds.
REVIEW OF SYSTEMS
General ☺Weight loss Fatigue Anorexia Night sweats
Chills Fever Weakness
The patient experienced fever due to cough and colds.
The patient experienced fatigue due to illness and lack of sleep.
The patient experienced weakness due to fatigue.
Skin Itch Rash Lesions Bruising
Bleeding Color change
NONE
Eyes Pain Discharge Itch Vision loss Diplopia
Excessive tearing Glasses/Contact lens Date of last exam ☺EDEMA
NONE
Ears Earaches ☺ Discharges Tinnitus Hearing loss
NONE
Nose Obstruction Discharges Epistaxis
NONE
Throat and Mouth Sore throats Bleeding gums Toothache Dentures
NONE
Neck and Head Swelling Dysphagia Hoarseness
NONE
Chest Cough Sputum: Amount and Character Hemoptysis
☺Wheeze Pain on respiration Dyspnea
The patient has abnormal breath sound because of Pulmonary Congestion
Cardiovascular Precordial pain Palpitation Dyspnea on exertion Orthopnea
Dyspnea Paroxysmal nocturnal Edema Heart murmur
Claudication Thrombophlebitis
NONE
Gastrointestinal Heartburn Nausea ☺ Vomiting Diarrhea Food intolerance
Excessive gas or indication Constipation Jaundice Bloating
Change in Bowel movement Melena Hemorrhoids Hernia
NONE
Genitourinary Heartburn Nausea ☺Vomiting Diarrhea Food intolerance
Excessive gas or indication Constipation Jaundice Bloating
Change in Bowel movement Melena Hemorrhoids Hernia
NONE
Extremities Joint pains Varicose veins Claudication Back pain
Edema Stiffness Deformities
NONE
Endocrine Hot flashes Hair loss Temperature intolerance
Polydipsia Goiter
NONE
Neurology Numbness Tingling Tremor Fainting
Headaches Muscle weakness Ataxia Seizure Unconsciousness
Paralysis/Paresis Memory loss Dizziness
None
PHYSICAL ASSESSMENT
Skin Uniform skin color, no jaundice, cyanosis
Skin intact
Skin warm and dry
Hair Hair is evenly distributed over scalp
Hair color black and thin
No lesions or pediculosis
Nails Color pink, well groomed ad convex, smooth and firm