HEALTH ASSESSMENT

Name of Patient: Medrano, Allyson M. Age: 25 y/o Sex: Female

Civil Status: Not Indicated 
Impression/ Diagnosis:
Date of Admission: Sept. 26, 2021 Attending Physician: Dr. Mudanza
Room No.: 104                Date of Assessment: Sept. 26, 2021

I. HEALTH HISTORY

Chief Complaint: Pt, complained progressive dyspnea, generalized edema and left
lower chest pain with a non-productive cough.

Present health status: Upon admission, the patient was feeling very ill, afebrile,
intermittently she presented an obtunded state of consciousness. Aside from a diffuse
moderate edema and a livedoid skin discoloration, an erythematous rash is present
over the cheeks and nasal bridge was noted. 

Past health history: Patient has a history of inflammatory polyarthralgias involving

initially interphalangeal joints, evolving, at some time later, the knees and elbows
bilaterally. Later on she had symptoms of urethritis episode, associated with
unexplained anorexia and asthenia. 

Current Lifestyle: 

Psychosocial status:

Family history: Patients’ mother has a history of multiple sclerosis and siblings have
inflammatory bowel disease.

Gynecologic history (if applicable): NOT APPLICABLE

Menstrual History (Usual Cycle) Interval: Duration: Amount of Menstrual Flow:
Last Menstrual Period and LMP: EDD:  
Expected Date of Delivery
History of Dysmenorrhea? [ ] Yes [ ] No Gynecologic surgeries? [ ] No [ ] Yes; pls.
specify:
Obstetric history (if applicable):
Pregnancy Profile (GTPAL) Gravity:  Term:  Preterm:  Abortions:  Living
Children:   
Previous Pregnancies? [ ] No [ ] Yes; Please specify in chronological order)
Date Name of Child Type of Delivery Outcome

II. PHYSICAL EXAMINATION

A. PRELIMINARIES
 
VITAL SIGNS AND ANTHROPOMETRIC MEASUREMENTS
Blood pressure: 143/82 mmHg Height: N/A 
Heart rate:     144 bpm Weight: N/A
Pulse Rate:     144 bpm BMI: 
Temperature:     36.7 deg. centigrade [ ] within ideal body weight (IBW)
Respiratory Rate:  34 cpm [ ] less than IBW
Others: O2 Sat. 92% on room air [] more than IBW; specify:

GENERAL SURVEY:
Upon assessing, the patient was feeling very ill, afebrile, intermittently she
presented an obtunded state of consciousness. Aside from a diffuse moderate edema
and a livedoid skin discoloration, an erythematous rash over the cheeks and nasal
bridge was noted. Furthermore, the patient also had red blisters peppered on her
cheeks, and red, dry patches popped up on my arms, scalp, chest and back. Also the
patients o2 saturation is 92%, and it also presented that jugular venous pressure.

B. INTEGUMENT
SKIN 
Color: Upon admission, pt.’s skin is pale and there is livedoid discoloration found in the
patient’s body. Erythematous rash is also noted in the patient’s skin and nasal bridge.
Texture: Pt.’s skin texture is rough due to rashes.
Turgor: Skin turgor is poor, after pinching the pt.’s skin it turns to its original place about
2 seconds.
Scaling: There is scaling on the patient’s skin particularly on the area where livedoid is
present
Hair Distribution: There is a hair loss present; but not random patches falling out.
Hair Characteristics: Patient’s hair is thin.
Infestation: There is no patient of any lice or any foreign microorganisms in the
patient’s integument.
Comments: Erythematous rash over the cheeks. red blisters peppered on cheeks, and
red, dry patches popped up on arms, scalp, chest and back, Butterfly-shaped rash on
the cheeks. Patient is also sensitive to sunlight

STOMA [✔] not Applicable

[ ] clean dry [ ] redness [ ] chronic redness [ ] drainage [ ] chronic drainage [ ] prolapsed
Comments:

FINGERNAILS AND TOENAILS

[✔] color, chare, cleanliness good [✔] no problems or deviations assessed
[ ] irregularities in surface: 
[ ] inflammation around nails: 
[ ] fungal problem: 
Comments:
 C. HEAD AND NECK
HEAD & NECK
Head motion (describe): Patient’s head and neck are able to move and bend.
[ ]  asymmetric head position (describe):                      
[ ] shrugs shoulders [ ] unable to support head midline & erect
[✔] dull, puffy, yellow skin [ ] peritoneal edema   [ ] lymph node enlargement []
thyroid enlargement [ ] tracheal displacement 
Comments: Pt.’s head is able to move and bend, but there is a present of jugular
venous pressure.
NOSE & SINUSES
[ ] nasal drainage [ ] inflamed [ ] tender [ ] polyps/lesions [ ] edema
[ ]  altered nasal mucosa (describe):                                                                                  
[ ] absence of  frontal sinus glow [ ] right nostril occluded [ ] left nostril occluded
Comments: There’s no discharge and pt.’s nose is non-tender upon palpation. However,
an erythematous rash was noted in the pt.’s nasal bridge.

MOUTH & PHARYNX 

[ ] altered oral mucous membrane (describe):                                       
[ ] Inflammation (describe): [ ] hoarseness [ ] bruxism (grinds teeth)
[ ] loose teeth [ ]decay [ ] halitosis [ ] excessive salivation [ ] lips
dry, cracked [ ] lip fissures [ ] lip bleeding [ ] gums inflamed [ ] gums
bleed [ ]gum retraction [ ] thick tongue
[ ] tongue dry, cracked [ ] tongue fissures [ ] tongue bleeds

Inspected the following:

[✔] Inner oral mucosa [✔] buccal mucosa [✔] floor of mouth and tongue
[✔]hard palate [✔] soft palate 
Deviations (describe):                                                 
[ ]  lesions, vesicles (describe):                                                                                      
[ ] gag reflex absent [ ] gag reflex hyperactive [ ] poor  denture fit or not using [ ]
chewing problem  [ ] missing teeth 
Comments: Sores in the mouth

D. EYES AND EARS 

EYES
Visual acuity: Pt’s vision is 20/20
Visual fields/peripheral: 
Eye tracking present:[✔] up [✔] down [✔] right [✔] left [✔] corneal light reflex
aligned   [ ] light reflex misaligned   [ ]nystagmus 
External eye structure: Structures in the external eye are intact, no discharges, no
discoloration and no lesions found but eyes are swollen.  
Abnormalities (specify/describe): 
Blink reflex: Patient approximately blinks 15 to 20 involuntary blinks per minute. 
Pupil & Iris direct light response:  Patient’s eyes are able to react in light. Both eyes'
direct response is the change in pupil size in the eye to which the light is directed.
Pupil & Iris consensual light response: Patient’s reflexes are consensual and both
eyes are constricted equally. 
Ophthalmoscopic exam: 
Unable  to do  ophthalmoscope exam due to:
Comments: The patient’s conjunctiva and EOM are normal. Pupils are equal, round,
and reactive to light. No scleral icterus but his eyes are swollen and puffy.
 
EARS 
External ear structures: Patient’s ear contains hair follicles and glands. Dry cerumen
with no lesions. 
External ear structure abnormalities:
Other abnormalities (describe):                                                                                       
[ ] cone of light visualized [ ] cone of light not visualized
[ ] tympanic membrane inspected [ ] excessive cerumen
[ ] Unable to examine [ ] Simple hearing acuity test:

Comments:  The patient’s ear is in normal size, symmetrical, and the color is the same
as the facial skin. Also, the Tympanic membrane clear, canals clear bilaterally. Patient
is sensitive to loud noises.

E. CARDIOPULMONARY
HEART & VASCULAR
Auscultated heart sounds: heart sounds were found to be diminished                              
Apical pulse (rate & rhythm): 144 bpm 
Jugular venous  distention: [ ✔]  present [] absent 
Capillary refill: [✔] > 1 second [ ] < 2 seconds
[✔] PMI palpable – 5th intercostal space medial to left midclavicular line [ ] PMI not
palpable
[✔] edema (describe): Diffuse moderate edema.                                                        
Blood Pressure: 143/82 mmHg MAP: 102 mmHg
[✔] Pulse Deficit: 0 Peripheral Pulses: 144 bpm
Comments: (+) tachycardia (144 bpm), heart sounds were found to be diminished

THORAX & LUNGS

Inspected: [✔] posterior thorax [✔] lateral thorax [✔] anterior thorax
Thorax deviations: [ ] scoliosis [ ] lordosis [ ]barrel chest     
[ ] intercostal bulging
[ ] Others:
Auscultated breath sounds: Diffuse coarse crackles were noted on both lungs
[ ] vesicular sounds at periphery
[ ] bronchovesicular sounds between  scapulae or  1st  – 2nd  intercostal space lateral
to sternum
[ ] bronchial sounds over trachea
Adventitious sounds: [ ]  wheezes   [✔] crackles [ ] rhonchi
Location: 
[ ] clear with cough  [ ] Other: 
Respiratory distress: 
[ ] nasal  flaring [ ] use of  accessory muscles, specify:
[ ] SOB [ ] Intercostal retraction 
Respiratory Rate: 34 cpm Oxygen  Saturation: 92% [ ] apnea, 

Comments: diffuse coarse crackles were noted on both lungs, with depressed vocal
transmission in the right basal thorax, chest pain when breathing deeply

F. GASTROINTESTINAL
 
ABDOMEN
Bowel Sounds:[✔] Present in all quadrants,  counts per minute: 15 per minute []
absent:         [ ] hypoactive [ ] hyperactive [] tympanic
Abdomen:   [ ] flat [] distended          [ ] soft   [ ] firm    
   [] rounded [ ] obese [ ] asymmetry [ ] pain
   [ ] rebound tenderness [ ] umbilical hernia:
[ ] Others:                                                            
[ ] gastrostomy [ ] jejunostomy      [ ] large intestine transverse ostomy []
large intestine sigmoid ostomy
[ ] mass: 
Abdominal Skin Characteristics: Abdominal skin is fair in color.
Comments: Pt.’s abdomen is round and distended and there is a presence of sores in
the mouth. Abdominal examination revealed moderate hepatomegaly and ascites.

G. GENITOURINARY (GYNECOLOGICAL & BREASTS)

BREASTS: NOT APPLICABLE Deviations assessed in: [ ] size [ ] symmetrical

[ ] contour [ ] shape
      [ ] skin color [ ] texture [ ] venous pattern 
Nipple deviations: [ ] retraction [ ] discharge [ ] bleeding [ ] nodules
     [ ] edema [ ] ulcerations
Breast self-exam (if applicable): [ ] independent [ ] unable to complete
         [ ] needs instructions to complete        
Comments:

GENITO-URINARY & GYNECOLOGIC: NOT APPLICABLE

External genitalia inspected: [ ] excoriations [ ] rash [ ] lesions [ ] vesicles
[ ] inflammation [ ] bright red color [ ] swelling [ ] bulging [ ] discharge 
[ ] inguinal hernia [ ] tight scrotal skin [ ] large scrotum [ ] phimosis
[ ] displaced meatus  
Testicular self-exam (if applicable): [ ] independent  
[ ] needs instructions to complete   [ ] unable to complete
Comments:
OBSTETRIC ASSESSMENT (NOT APPLICABLE)
Estimated Fundal Height: Estimated AOG (based on FH measurement):           
Age of  Gestation (AOG): 
Fetal Presentation & Attitude Fetal Line: Fetal Position:
O Cephalic O Longitudinal O Occiput posterior O Occiput
[ ] Vertex [ ] Sinciput O Transverse O ROP     anterior
[ ] Brow [ ] Face [ ] Chin O Oblique O ROT O LOA
O Shoulder O ROA O LOT
[ ] Complete [ ] Footling [ ] Frank O LOP
O Breech
[ ] Arm [ ] Shoulder [ ] Trunk
O Compound; specify: 

Uterine Contraction: Fetal Station and Engagement:

Strength [ ] -3
O Mild [ ] -2
O Moderate [ ] -1
O Severe []0
[ ] +1
Duration: [ ] +2
Interval: [ ] +3  
Frequency:
Comments:
 

H. MUSCULOSKELETAL

[ ] Gait abnormalities:                                       

[ ] Posture abnormalities:                                                        
[ ] Impaired weight bearing stance: 
[ ] Bilateral symmetry: 
[ ] Asymmetry:
[ ] Bilateral alignment: 
[ ] Misalignment:
[ ] Decreased ROM:                                  
[✔] Joint swelling [ ] stiffness [✔] tenderness  [✔] Heat:
[ ] Hypertonicity:
[ ] Hypotonicity:
Comments: There is a presence of diffuse moderate edema on extremities. (+) pain and
swelling on the joints of the patient. 

I. NEUROLOGIC SYSTEM

MENTAL & EMOTIONAL STATUS

[ ] alert [✔] aware of environment [✔] impaired consciousness   GCS score: 13/15
RLS score:  [✔] changed level of consciousness 
[ ] unchanged level of consciousness [ ] able to communicate
[✔] vocalizes sounds [ ] limited verbalization [ ] non-verbal  
[ ] change  in communication pattern [ ]unchanged communication
Communication device:
[ ] intellectual impairment unchanged  [ ] memory impairment unchanged  
[ ] general knowledge  deficit unchanged  [ ] abstract reasoning unchanged 
[ ] impaired association ability unchanged [ ] impaired judgment unchanged
[ ] changes in mental & emotional status (describe):
Comments: Presented an obtunded state of consciousness. Patient is sensitive to
sunlight or fluorescent light

CRANIAL NERVE (CN) FUNCTION

CN I- olfactory [✔] intact [ ] impaired [ ] unknown
CN's II-II-IV-V- optic, oculomotor, trochlear, abducens (see eye exam)
CN VI – trigeminal (facial sensory & jaw motor) [✔] intact [ ] impaired 
CN VII-Facial (symmetry in face expressions & taste)  [✔] intact [] impaired
CN VIII – Acoustic (see hearing exam)
CN IX- Glossopharyngeal (taste at  back of tongue) [✔] intact [ ] impaired
CN X Vagus (palate movement, "ah" and  vocal motor [✔] intact [ ] impaired
CN XI – Spinal Accessory (head motion & shrug) [✔] intact [ ] impaired
CN XII – Hypoglossal (tongue  position & motor) [✔] intact [ ] impaired

SUMMARY OF SIGNIFICANT FINDINGS (Narrative):

Patient X, a 25-year old female, came into hospital due to progressive dyspnea,
generalized edema and left lower chest pain with a non-productive cough. Prior to
admission, she reported she couldn’t lift her arms above her head due to persistent
fatigue. Patient symptoms further developed an odd sensitivity to certain stimuli such as
odor, loud noises and bright lights, she also experienced nausea and debilitating
headaches. As it goes by, patient X continues to experience joint pain and swelling, and
then developed into red blisters peppered on her cheeks, and red, dry patches popped
up on her arms, scalp, chest and back. Lately, she experienced fluid retention that went
way beyond the usual hormone fluctuations or indulgence in overly salty food. The
edema and discomfort persisted, hence, her doctor began to suspect the possibility of
autoimmune disease, lupus specifically. Her mother side has a history of multiple
sclerosis and sibling has inflammatory bowel disease.
Currently, patient X was feeling very ill, afebrile, intermittently she presented an
obtunded state of consciousness. Diffuse moderate edema grade 3+ was noted on the
extremities of the patient and a livedoid skin discoloration. An erythematous rash over
the cheeks and nasal bridge was noted. Upon taking vital signs from the patient, she is
tachycardic with the heart rate of 144 bpm, tachypneic with a RR of 34 cpm, blood
pressure is at 143/82 mmHg, peripheral oxygen saturation of 92% at room air and
raised jugular venous pressure. On auscultation, heart sounds were found to be
diminished and diffuse coarse crackles were noted on both lungs, with depressed vocal
transmission in the right basal thorax. Abdominal examination revealed moderate
hepatomegaly and ascites. Further, patient also reported pain and swelling of the joints,
pain scale is at 7/10. She’s also sensitive to sunlight and fluorescent light and she also
reported to experience pain when breathing deeply.

NURSING DIAGNOSES

1. Impaired skin integrity related to skin rashes secondary to lupus

2. Disturbed body image related to lupus as evidenced by general rashes, edema
and skin discoloration
3. Fatigue related to disease condition as evidence by lack of energy, restlessness,
and tiredness.

II.FOCUSED PHYSICAL ASSESSMENT [Should be completed on the 2nd and 3rd

day]
System Assessed: [✔] Integument   [✔] Head & Neck [✔] Eyes & Ears
[✔]Cardiopulmonary   [✔] Preliminaries   [✔] Gastrointestinal [✔]
Genitourinary/OB [✔] Musculoskeletal [✔] Neurologic

Inspection : Upon inspecting the overall health status of the patient shows that she is
having red blisters peppered on her cheeks, and red dry patches popped up on her
arms, scalp, chest and back, Butterfly-shaped rash on the cheeks are also present in
patient’s skin, and around her eyes are swollen. There is a presence of blood on the
patient’s mouth. The patient experienced hair loss.

Palpation : Upon palpation, the patient abdomen is distended and his lower legs and
feet are swollen due to edema and is graded as 3+. Jugular veins are distended.

Percussion : Percussion was not performed in the case.

Auscultation : On auscultation heart sounds were found to be diminished and diffuse
coarse crackles were noted on both lungs, with depressed vocal transmission in the
right basal thorax