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Comprehensive Health Assessment General Appearance:: Head
Comprehensive Health Assessment General Appearance:: Head
Comprehensive Health Assessment General Appearance:: Head
General Appearance:
Apparent age: The appearance is younger than her age
• General appearance: Looks well, No signs of distress, appears comfortable
• Grooming: Well groom/wearing clean clothes/neat
• Hygiene: My Patient is clean and has good hygiene
• Odors: My Patient has No bad odors
• Nutritional status: Overweight but manifest weight loss
• Level of consciousness: Conscious
• Speech: Normal speech/Normal Volume
• Affect: Normal
• Gait: Normal Gait
• Posture: Regular/Posture erect/Normal spinal curve
• Movements: Can flex, can move, can extend, Can Walk
• Gross deformities: No deformities
• Signs of distress: Appears Comfortable
Integumentary:
1. Inspect color and lesions throughout examination
My Patient’s skin color is fair, No lesions and No edema, My Patient has scar at
her left leg, and her skin is oily and no excessive dryness.
HEENT:
Head:
1. Inspect size, shape, symmetry, position, hair distribution, and lesions
The head of my Patient is rounded shape, symmetric nasolabial, the position is
center at her body and No lesions or scar.
Face:
1. Inspect symmetry of nasolabial folds and palpebral fissures
The face of My Patient is symmetrically aligned and symmetric nasolabial folds.
3. Test ROM
My Patient’s facial movement are symmetrical, and there is no dropping of
eyelids or mouth, No involuntary movements of my patient’s face.
4. Test facial sensation (CN V), facial expression, and ability to smile and frown (CN
VII)
Eyes:
1. Test visual acuity near/far with Snellen chart (CN II)
My Patient’s both eye visual have myopia or nearsightedness
2. Color vision
The color vision of My Patient is appropriate to the situation.
6. Cover/uncover test
My Patient can see the object clearly when she cover/uncover her one eye with
her arms when its near or far.
Ears:
1. Inspect/palpate external ear
My Patient’s external ear is distal contains hair follies and glands.
Mouth:
1. Inspect/palpate lips, oral mucosa, teeth and gingiva, tongue
My Patient lips is smooth and no excessively dryness her teeth is 32 and the
tongue of My patient is no discoloration
Neck:
1. Inspect, palpate, and auscultate thyroid
My patient has not visible on glands ascends during swallowing.
3. Measure JVP
The JVP measures 6cm which is in normal range
Anterior Thorax/Breast:
1. Inspect and palpate breast and lymph nodes with patient in various positions
The breast of My patient is even with the chest wall, the skin is uniform in color,
smooth and intact, No discoloration and hyper Pigmentation, No edema and
masses.
Anterior Thorax/Lungs:
1. Inspect AP: lateral ratio
My Patient has normal ches5 ratio which is 1:2
3. Percuss chest
The percussion notes resonate down to the sixty rib at the level of the
diaphragm, flat over areas of heavy muscles and bone heard, No dullness and
areas over lungs.
Anterior Thorax/Heart:
Inspect and palpate precordium for pulsations
The precordium of My Patient has no pulsations and no irregularities.
2. Note PMI
Noted PMI is the 4th or 5th intercostal space.
Upper Extremities:
Palpate brachial, radial, and ulnar pulses
MY Patient has normal brachial, radial, ulnar pulses are easily palpated and
equal in strength.
Abdomen:
Inspect size, shape, symmetry, and movements (respirations, pulsations, peristalsis)
My Patient has rounded abdomen and symmetrical movement caused by
respiration and not visible aortic pulsations.
5. Palpate abdominal organs (liver, spleen, kidneys), aorta, inguinal nodes, and femoral
Arteries
My Patient has no presence of tenderness, relaxed abdomen with smooth
consistent tension.
Extremities:
Inspect color, hair distribution, varicose veins
My Patient skin integrity is uniform in color the hair is evenly distributed and
has no varicose veins.
13. Inspect gait, toe and heel walking tandem walk, deep knee bend
My Patient has upright posture and strength gait with opposing arm swing,
maintaining balance.
Female Genitalia/Rectum:
Inspect/palpate external and internal genitalia
My Patient genitalia/rectum shows kinky or curly pubic hair and skin is intact
and no lesions
Cotabato Medical Foundation College, Inc.
Quezon Ave. Poblacion 8, Midsayap, Cotabato
Tel: 064-229-8207
Male Genitalia/Rectum:
1. Inspect and palpate male genitalia
_____________________________________________________________________________________________
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2. Inspect and palpate rectum for masses, prostate
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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3. Test stool for occult blood
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_________________________________________________________________________________
Cotabato Medical Foundation College, Inc.
Quezon Ave. Poblacion 8, Midsayap, Cotabato
Tel: 064-229-8207
Secondary and tertiary levels: (Identify chief complaint and do symptom analysis)
Upper abdominal pain and sometimes a burning sensation in chest usually after eating which
becomes worst at night
2. Hospitalizations
My Patient said that she was hospitalized several times.
Surgeries
My Patient has no experience with surgeries.
4. Serious injuries
No Serious injuries
5. Chronic illnesses
No Chronic illnesses
6. Immunizations
My Patient said that she is already immunized, she has been vaccinated with covid vaccine last
month.
7. Allergies
My Patient has no allergies on skin or drugs.
8. Medications
She used to take medicine before but now she said that she already stop taking medicine because
she’s feeling well now.
9. Recent travel
No recent travel
2. Spouse
Her husband is high blood
3. Children
Patient’s children are all well and so far no problem with their health
______________________________________________________________________
4. Parents
____The patient’s parents are both hypertensive
5. Siblings
_____The patient has no siblings______________________________________________
6. Aunts/uncles
_____The patient’s aunts and uncles had high blood and some had diabetes_________
7. Grandparents
_____One of the grandparents is hypertensive____________________________________
3. HEENT
My patient said that she doesn’t have pain in her nose, mouth and eyes
4. Respiratory
My Patient has normal breathing and no any abnormalities in her respiratory.
5. Cardiovascular
___the patient has no chest pain, palpitations, murmurs and no noted weakness, does not feel
dizziness and hands and feet do not feel cold numb and cold
6. Breasts
No nodules and lumps were noted, no tenderness and the breasts are symmetrical in size, no
unusual redness _______________________________________________________
7. Gastrointestinal
There is no tenderness but GERD is being suspected as there is heartburn.
8. Genitourinary
The patient does not have painful urination, no backpain and urine is pale yellow in color
Cotabato Medical Foundation College, Inc.
Quezon Ave. Poblacion 8, Midsayap, Cotabato
Tel: 064-229-8207
9.Female/male reproductive
My Patient has normal and regular menstruation.
10. Musculoskeletal
Since I already assessed her musculoskeletal there has no abnormalities or deformities on her
bones or muscles and has no tenderness, swelling.
11. Neurological
My Patient seems oriented.
12. Lymphatic/hematological
___There is no visible lumps and nodes are accessible to palpitation but not large or firm enough
to be felt. No unusual bleeding and normal complete blood count_______________
Developmental (5 points):
Typical day
She said that she cleans the house every day and cooks for her family.
3. Nutritional pattern
___Usually skips breakfast and have her brunch at noontime and usually does not eat for dinner
4. Activity/exercise
The patient usually does household chores every morning which becomes her exercise everyday
6. Sleep/rest patterns
Usually has sleep disturbance when her acid reflux attacks, but usually sleeps at 10PM and
wakes up at 4 to 5AM in normal situation
9. Socioeconomic status
_____The patient belongs to the average income group of economic status
Stress/coping patterns
____The patient has a very positive outlook in life and handle problems and stresses smoothly,
she does not think or focus much on problems
Cotabato Medical Foundation College, Inc.
Quezon Ave. Poblacion 8, Midsayap, Cotabato
Tel: 064-229-8207
DRUG STUDY
Omeprazol Proton pump PRILOSEC Dosage: 40mg Gastric acid-pump Symptomatic Clostridium CNS: headache, Assess other
e inhibitor inhibitor: Suppresses gastroesopga eal reflux difficile infection dizziness, medications patient may
Frequency: OD gastric acid secretion disease (GERD) Inadequate Vitamin asthenia GI: be taking for
by specific inhibition without esophageal B12 low amount diarrhea, effectiveness and
Route: IVTT of the hydrogen- lesions Erosive of magnesium in abdominal pain, interactions (especially
esophagitis and the blood Liver nausea, vomiting, those dependent on
potassium ATPase
accompanying Problems constipatio n, cytochrome P450
enzyme system at
symptoms caused by Interstitial flatulence metabolism or those
the secretory surface Musculosk eletal:
GERD Maintenance Nephritis dependent on acid
of the gastric parietal back pain environment for
of healing erosive subacute cutaneous
cells; blocks the final Respirator y: absorption). Monitor
esophagitis lupus
step of acid cough, upper therapeutic effectiveness
Pathologic erythematosus
production hypersecretor y respiratory tract and adverse reactions at
Systemic Lupus
conditions eg infection Skin: beginning of therapy
Erythematosus
ZollingerEllison rash and periodically
Osteoporosis
syndrome Duodenal throughout therapy.
Broken Bone
ulcer (short term Assess GI system:
CYP2C19 Poor
treatment) bowel sounds every
Metabolizer
Helocobacter pylori 8hours, abdomen for
Hypersensitivity to
ibfection and duodenal pain and swelling,
drug or its
ulcer disease, to appetite loss.
components
eradicate H.pylori with
clarithromycin (dual
therapy) H.pylori
infection and duodenal
ulcer disease, to
eradicate H.pylori with
clarithromycin and
amoxicillin (triple
therapy) Short -term
treatment of active
benign ulcer
Cotabato Medical Foundation College, Inc.
Quezon Ave. Poblacion 8, Midsayap, Cotabato
Tel: 064-229-8207
Summary
An international consensus group has defined GERD as a condition that develops when reflux of
stomach contents causes troublesome symptoms with or without complications. Typical symptoms that
lead to the diagnosis of GERD are regurgitation and heartburn. As much as 16% of the US
population complains of regurgitation, and 6% report clinically troublesome heartburn. However,
while these symptoms are specific for the disease, they are insensitive markers of reflux. GERD
symptoms can worsen with lying recumbent, especially after meals.
Of note, dysphagia can be a symptom of uncomplicated GERD, but its presence warrants more
intensive examination and potential intervention, as it can be caused by strictures, rings, malignancy,
or esophageal dysmotility. Chest pain is another symptom often associated with GERD, but a cardiac
cause should be considered and ruled out before GERD is considered. Other symptoms of GERD
include dyspepsia, nausea, bloating, sore throat, globus sensation, and epigastric pain.
Reaction
Gastroesophageal reflux disease (GERD) is mainly a clinical diagnosis based on typical symptoms of
heartburn and acid regurgitation as manifested by my patient. Current guidelines indicate that
patients with typical symptoms should first try a proton pump inhibitor (PPI). If reflux symptoms
persist after 8 weeks on a PPI, endoscopy of the esophagus is recommended, with biopsies taken to
rule out eosinophilic esophagitis. The key point here is the diagnosis of GERD is mainly symptom-
based and often does not require endoscopic confirmation. Endoscopy is warranted in patients with
red-flag symptoms such as dysphagia, anemia, weight loss, bleeding, and recurrent vomiting. PPIs
are the first-line medical therapy. Histamine 2 receptor antagonists are mainly used to treat
breakthrough nocturnal symptoms. Endoscopic and surgical options exist but are pursued only if
medical therapy fails.
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