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    Ada's Document

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    Vanessa Jane Catulin
    The patient presented with a weak general appearance and restlessness. Vital signs showed a temperature of 36.3°C and pulse of 71 bpm. On examination, the patient had unproportionate body build and weight loss compared to their age. Skin examination found scars from previous childhood illnesses. Breath sounds were adventitious. In summary, the patient appeared weak with abnormal vital signs and physical findings related to weight loss and prior illnesses.

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    Ada's Document

    Uploaded by

    Vanessa Jane Catulin
    42 views4 pages
    The patient presented with a weak general appearance and restlessness. Vital signs showed a temperature of 36.3°C and pulse of 71 bpm. On examination, the patient had unproportionate body build and weight loss compared to their age. Skin examination found scars from previous childhood illnesses. Breath sounds were adventitious. In summary, the patient appeared weak with abnormal vital signs and physical findings related to weight loss and prior illnesses.

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    The patient presented with a weak general appearance and restlessness. Vital signs showed a temperature of 36.3°C and pulse of 71 bpm. On examination, the patient had unproportionate body build and weight loss compared to their age. Skin examination found scars from previous childhood illnesses. Breath sounds were adventitious. In summary, the patient appeared weak with abnormal vital signs and physical findings related to weight loss and prior illnesses.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    42 views4 pages

    Ada's Document

    Uploaded by

    Vanessa Jane Catulin
    The patient presented with a weak general appearance and restlessness. Vital signs showed a temperature of 36.3°C and pulse of 71 bpm. On examination, the patient had unproportionate body build and weight loss compared to their age. Skin examination found scars from previous childhood illnesses. Breath sounds were adventitious. In summary, the patient appeared weak with abnormal vital signs and physical findings related to weight loss and prior illnesses.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 4

    PHYSICAL ARRANGEMENT

    Date: May 24 2009 Vital signs: Temperature:36.3°C


    General Appearance: Weak PR: 71bmp RR: 37

    AREAS ASSESSED METHODS USED NORMAL FINDING ACTUAL FINDINDS ANALYSIS

    GENERAL SURVEY
    -Body build Inspection Unproportionate to Unproportionate to -weight loss
    age age -Restlessness may be
    related pain felt
    -Posture and Gait Inspection Coordinated Restlessness -Normal
    movement
    -Hygiene and Inspection Clean Clean -Normal
    Grooming
    -Body odor Inspection None None -Patient may be not in the
    -Attitude/ mood Observation and Cooperative Attention difficult to mood related to illness
    Interview get

    SKIN
    -Color Inspection Light Brown Light Brown -Normal
    -Edema Inspection None None -Normal
    -Skin Lesions Inspection None Scars from previous -Immunization may not
    none childhood be effective
    -Skin Palpation Uniform 37.1°C Illness-chickenpox
    Temperature
    -Skin turgor Palpation Skin springs back to Uniform 36.5-37.5°C
    previous state Skin springs back to
    previous state
    HAIR
    -Evenness of Inspection Evenly distributed Evenly distributed hair -Normal
    growth Inspection hair in scalp in scalp -Normal for age
    -Thickness or Inspection Fine hair Fine hair -Good hygiene practices
    thinnest None None
    -Presence of Inspection -Normal for age
    inspections or No hair axillary and No hair in axillary and
    infestations pubic areas pubic
    -Amount of body
    hair

    SKULL and FACE


    -Size, shape and Inspection Rounded, symmetrical Rounded, symmetrical -No skull deformities
    symmetry Palpation No nodules, masses Normal -Normal
    -Nodules, masses and depressions
    and depressions Inspection None None -Normal
    -Eye edema and
    hollowness

    EYES
    -Eyebrows Inspection Evenly distributed Evenly distributed -Normal
    -Eyelashes Inspection Evenly distributed Evenly distributed -Normal
    -Pupils Inspection PERRLA PERRLA -Normal
    -Conjunctiva Inspection Pinkish Pinkish -Normal

    EARS
    -Color Inspection Uniform with skin Uniform with skin -Normal
    -Symmetry Inspection color color -Normal
    -Texture Palpation Symmetric Symmetric -Normal
    -Lesions Inspection Firm Firm -Normal
    None None

    NOSE Inspection No difficult of Evident nasal in -Difficulty in breathing


    breathing flaring

    MOUTH
    -Lips Inspection Symmetrical Symmetrical -Normal
    -Color Inspection Reddish pink Reddish Pink -Normal
    -Moisture Inspection according to race according to race -Normal
    -Gingiva Inspection Moist Moist -Normal
    Pinkish Pinkish

    THORAX
    -Symmetry Inspection Symmetrical Symmetrical -Normal
    -Texture Palpation No nodules or lesions No nodules or lesions -Normal
    -Breath sounds Auscultation Clear breath sounds Adventitious breath -retained secretions
    sounds

    ABDOMEN
    -Color Inspection Uniform with skin Uniform with skin -Normal
    -Contour Inspection color color -Normal
    -Respiratory Inspection Flat Flat -Normal
    movement Palpation Abdominal movement Abdominal movement
    -Texture Non tender Non tender

    UPPER
    EXTREMITIES Inspection Symmetrical Symmetrical -Normal
    -Symmetry Inspection Uniform with skin Uniform with skin -Normal
    -Color Palpation color color -Normal
    -Texture Smooth Smooth

    LOWER
    EXTREMITIES Inspection Symmetrical Symmetrical -Normal
    -Symmetry Inspection Uniform with skin Uniform with skin -Normal
    -Color color color

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