VIII.

PHYSICAL ASSESSMENT
Date Performed: September 2, 2006 Assessment Pathophysiologic Basis

Significant others: the patient lives with his mother and younger sister supportive sisters Coping mechanism: a type of fight in coping problems; faces problems encountered and accepts reality of problem Religion: Roman Catholic; Joins bible studies when invited by his sister Primary Language: Speaks Gaddang more often than Ilocano Primary source of health care: they usually consult Veterans Regional Hospital only when condition gets complicated Financial resources r/t illness: Hospital expenses comes form his sister Occupation: Tricycle driver Educational attainment: High school Undergraduate General Appearance: the patient is thin with dark complexion; small in stature; with slightly yellowish sclera; sunken eyeballs; with dry skin; with distended abdomen; edema on lower extremities Affect: appropriate foe the situation Orientation: Oriented to time, place and events Memory: Immediate: able to remember name of Examiners Recent: able to recall procedure done to him (paracentesis) Speech: clear, normal tone and volume Non- verbal behavior: maintains eye contact when conversing; nods to affirmation; sits upright

STOOL:

- Frequency and Pattern: once or twice per shift; one (1) to two (2) times per day - Consistency: well-formed - Amount: moderate amount - color: ranges from yellow to brown

URINE: -quantity per voiding: within the shift, the pt urinates 1- 2 times at approximately 250 cc per voiding. -color: yellow-orange -clarity: -specific gravity: -lab analysis: ABDOMEN: -bowel sounds: the bowel sound is normoactive with 5 borborygmic sound per min in each quadrant. -contour and palpation: globular and distended; without tenderness upon palpation; with presence of fluid wave. - due to portal hypertension -with caput medusae -with ascites; abdominal girth measures 39 inches; - with mild pain at the site of puncture wound covered below the umbilicus - with bandage at the site of puncture; without discharge - toileting activity; ambulatory and can go to toilet without

assistance.

R
ambulatory

-Current Activity Level:

- ADLs: can groom, feed by himself, can communicate; can go to toilet without assistance. - sleeps 6 7 hours at night uninterrupted and takes naps 2 3 hours. - body frame: ectomorph - posture: stands and sits upright - coordination: with coordinated body movements; but use either of the hands to guard the abdomen - gait: shows no heaviness on the lower extremities when walking - balance: well-balanced on standing; with difficulty bending towards front or back; no dizziness noted - muscle strength and tone: Right ++ 5/5 ++ 5/5 Left 5/5++ 5/5++

Legend: + hypotonic/flaccid= No resistance ++ Normotonic = Slight resistance +++ Hypertonic = Immediately there is resistance ROM: full range of motion on legs and arms - Motor function: Fine: can hold and pen and write his name; can open bottle of water Gross: can flex and extend extremities; with limited hip flexion; can bend head on all sides - pain relief measures: communicates with relatives and examiners; sleeping; massage on the abdomen -

- Allergies/Reaction: Medication: none Foods: none Environment: none - Eyes: Pupils: PERRLA - Hearing Aid: no hearing aid; the patient is able to hear normal tone of voice and whispers - Skin: with scars on the right outer ankle; puncture wound below the umbilicus; dark spots on the upper extremities; slight jaundice noticeable on the abdomen, palms, soles and sclera - Mucous membrane: Oral cavity: moist

deposition of bilirubin on the skin

Activity Tolerance: no dizziness

or weakness when performing ADLs; with no shortness of breath when lying down. - Airway Clearance; patent, no adventitious sounds upon auscultation Nose: no secretions; no anatomical abnormality Mouth: no presence of masses or inflamed tonsils -Respirations: Rhythm: regular Position Assumed: sitting Accessory muscle used: none Rate: 20 cpm Depth: shallow -Skin, nails and lips: acyanotic

-capillary refill: 2-3 seconds -Pulse: Location: radial Rate:92 bpm Rhythm: regular Strength: bounding Location: apical Rate: 92 bpm Rhythm: regular Strength: audible -BP: 110/80 mmHg - Edema: both lower extremities; grade II Size: Right thigh: 15 inches Right leg: 13 1/2 inches Right foot: 9 1/2 inches Left thigh: 15 inches Left leg: 13 inches Left foot: 9 1/2 inches - Oxygen Therapy: none

N
diet: on high protein diet, - to prevent further development of ascites low fat, low salt as ordered fluid intake: 1 - 1.5 L per day as ordered IVF: none Height: 52 Weight: 52 kg Ability to chew and swallow: The patient can chew and has no difficulty in swallowing; with good appetite; able to feed himself. Vomiting: negative Gag reflex: intact