REVIEW OF SYSTEMS (PHYSICAL ASSESSMENT)

A. GENERAL SURVEY Mega Mind was lying flat on bed, lethargic with sunken fontanels, dry pale lips, and distended abdomen, febrile with her mother beside her. Hes wearing his usual clothes at home. With ongoing IVF # 2 D5NM 1L infusing well @ 50 micro gtts/min on Left metacarpal vein. With the following vital signs:

Date 10/07/11

Time 8:00am 11am 12nn 12:30 1:00pm 1:30pm

Temp

BP

RR

PR

Date

Time 9:25am 10:15

Temp BP RR PR 38.1 37.7 37.4 36.9 40.2 39.5 26 114

36.8 40.2 39.2 38.4

90/60

25

95

30

110

11am 12nn

37.4

1:40pm
37.2

2:00
10/08/11 8:00 am

37

27

110

THE INTUGEMENTARY SYSTEM: Patient skin was light brown. The skin was uniform on her extremities as well as with her chest and back. Skin was dry and warm to touch. When pinched back skin backs to its original state. His nails were not that pinkish but it had a capillary refill time of 2 seconds.

18

THE HEAD Patient head is normocephalic; Patients hair is fine, proportionately distributed on the head with no greasy scales on scalp noted. No presence of infestations noted. No tenderness

upon palpation of scalp noted. Able to smile and frown, face is symmetrical in contour, no masses palpated.

THE EYES AND VISION:

Hair in the eyebrows is evenly distributed. Eyebrows are symmetrical aligned. Eyelashes are curled and slightly outward. Bilateral blinking was noted. Patients eyes are positioned symmetrically. Patient can see clearly and reacts on moving objects. Patients eyes are not sunken, sclera is clear and moist.

THE EARS AND HEARING

Top of the ear is in lined with the imaginary line drawn from the outer cantus. Both ears are symmetrical to each other. No presence of any drainage and tenderness noted upon assessment. The pinna recoils after its folded. With good hearing noted

MOUTH AND TEETH Patients lips are intact and moist. Oral mucosa is moist and reddish in color. Absence of lesions noted. His lips able to pursue. Tongue is in the center and slightly pinkish. Can able to move her tongue freely, and has a good ability to swallow. Have 26 teeth with dental carries and yellowish in color

19

THROAT AND NECK: Able to hold her neck erect and at midline. Able to move neck from side to side without difficulty. No swelling or masses noted. Trachea is symmetrical and in midline position. Pulsation is felt in carotid artery. Lymph nodes are non- palpable. The neck of our patient can move easily without any discomfort, which includes right and left lateral, right and left rotation, flexion and hyperextension. Neck can properly support the head. No signs of enlargement, masses on the thyroid. Carotid pulse is palpable. No signs of swelling or enlargement of the lymph nodes. THE THORAX AND LUNGS Patient has a respiratory rate of 30 cpm. Chest rises upon inspiration and falls upon expiration. No tenderness lumps and nodules felt during palpation. Crackles heard upon auscultation. Non productive cough noted. THE ABDOMEN

Patient Abdomen is uniform in color. Abdomen is round and distended. Tenderness noted. Veins are not visible upon inspection.

THE MUSCULOSKETAL

The patient manifested good posture

Fingers, hands and wrist are straight.

Elbows are at the same height and symmetrical in appearance. Able to move arms and hands without pain. Able to grasp objects firmly. Legs and thighs are slightly curved No lesions or edema noted. Able to move legs and feet without any pain. Weakness was note

20

CARDIOVASCULAR SYSTEM Patients CR was 110 beats per minute which is normal. No murmur heard upon auscultation. There was no history of cardiopulmonary disease

GASTROINTESTINAL SYSTEM The abdomen was distended, soft and there was no palpable mass felt upon palpation. Hypoactive bowel sound heard upon auscultation. The patient vomited 3-5 times a day and defecated more than 6 times a day with watery stool.

GENITO- URINARY SYSTEM Patient voided 60 350 cc per shift as weighed and yellow in color.

ACTIVITIES OF DAILY LIVING: ELIMINATION: According to patients mother, her child defecates every day defecates watery ,yellowish to brownish color of stool.

SLEEP and REST: Patients take a nap for 20-30 minutes and take a sleep for 4-5 hours at night. He had a abnormal sleeping pattern during his hospitalization.

21

EXERCISE Before the hospitalization the mothers state that he was so active and have a long period of playing. During his hospitalization he play is limited and doesnt move to much because of the Intravenous attached to him.

HYGIENE: Before the hospitalization he take a bath early in the morning. And during his hospitalization he never take a bath but his mother clean him with a sponge bath.

22