PATHOPHYSIOLOGY

Risk factors history of complicated peptide ulcer disease age (patient is 76 years old)

Peptic Ulcer Disease

associated with H pylori infection.

disruption of the mucous barrier

direct inflammatory effect on gastric and duodenal mucosa.

weakening and necrosis of the arterial wall

development of a pseudoaneurysm.

wall ruptures

hemorrhage.

Melena hematochezia Epigastric pain Heartburn Diffuse abdominal pain Dysphagia

GENERAL APPEARANCE

BODY PART EXAMINED

ACTUAL FINDINGS

NORMAL FINDINGS

INTERPRETATI ON/ ANALYSIS ABNORMAL

Posture, gait, standing, sitting, and walking

Difficulty of standing,

Relaxed, erect in posture, coordinated movement

Overall hygiene and grooming

Hair were properly comb

Clean and neat.

NORMAL

Body and breath odor

Has no body odor as well as bad breath

Has no body odor as well as bad breath

NORMAL

Signs of health and distress

Physically ill

Healthy appearance

ABNORMAL

Attitude

Cooperative

Cooperative

NORMAL

Mood and affect

Appropriate.

Understandable, moderate in pace

NORMAL

BODY PART

ACTUAL

NORMAL

ANALYSIS

Skull

Round skull with prominences in the frontal and occipital area

Proportional to the size NORMAL of the body, round weth prominences in the frontal area anteriorly and the occipital area posteriorly. NORMAL

Scalp

Hair

White, clean, free from masses, lumps, scars, nits, dandruff and lesion The color of his hair is black and evenly distributed

White, clean, free from masses, lumps, scars, nits, dandruff and lesion Shiny , free from split NORMAL ends and evenly distributed

NORMAL Face Presence of wrinkles were noted Oblong or oval or square or heart shaped, symmetrical, facial expression that is dependent on the mood or true feelings, smooth and free from wrinkles on involuntary muscle movements Wrinkles under the eyes of the client were due to aging process, because the patient is already 76years old.

ABNORMAL Eyes She was diagnosed with cataract last july of 2012 Parallel and evenly placed, symmetrical with scanty amount of secretions, both eyes are black and clear A normally clear lens allows light to pass through to the back of the eye, so that the patient can see welldefined images. Most cataracts are related to aging. As a cataract develops, the lens becomes cloudy . This blocks light from entering the eye. Without enough light, she cannot see as clearly.

A part of the lens becomes opaque light does not pass through easily and the patient's vision becomes blurry like looking through cloudy water or a fogged-up window. The more opaque (cloudier) the lens becomes, the worse the person's vision will be.

Eyebrows

Black, symmetrical and parallel with each other Parallel , proportionate and it is not a low set ears. Skin is the same color of the surrounding area Clean and pinkish

Black, symmetrical and parallel with each other

NORMAL NORMAL

Ears

Able to move eyes in full range of motion or able to move in all direction NORMAL Pinkish , clean, with scant amount of cerumen and few cilia

Ear canal

Hearing acuity

Able to hear spoken words properly Symmetric and straight

Able to hear whisper spoken 2 feet away Midline , symmetrical

NORMAL

Nose

NORMAL

Septum

Straight

Straight

NORMAL

MOUTH Lips Lips were not dry Pinkish, symmetrical, lip margin well defined, smooth and moist NORMAL

Gums

No swelling noted

Pinkish, smooth, moist, no swelling, no retraction, no discharge

NORMAL

NORMAL Teeth permanent teeth , well aligned free from caries or filling, no halitosis 32 permanent teeth , well aligned free from caries or filling, no halitosis Large, medium, red or pink, slightly rough on top, smooth along the lateral margins, moist and freely movable NORMAL

Tongue

Moist and freely movable

Tonsils

Non inflamed

Pinkish, Non inflamed , no exudates

NORMAL

Voice

Well modulated

No hoarseness and well modulated

NORMAL

Neck

Proportional to the size of the boy and head

Proportional to the size of the body and head ,

NORMAL

symmetrical, and straight

Thorax and Lungs

The chest contour is symmetrical and the chest as wide as deep . The spine is straight. Posteriorly the ribs tend to slope across and down . The ribs are prominent in a thin person . There is no bulging or retraction of the ICS during breathing. The chest wall moves symmetrically during respiration

The chest contour is symmetrical and the chest as wide as deep . The spine is straight. Posteriorly the ribs tend to slope across and down . The ribs are prominent in a thin person . There is no bulging or retraction of the ICS during breathing. The chest wall moves symmetrically during respiration.

NORMAL

UPPER EXTREMITIES

NORMAL

Arms

Skin color varies (pinkish,tan, dark brown), symmetrical, fine hair evenly distributed, presence / absence o visible veins

Skin color varies (pinkish,tan, dark brown), symmetrical, fine hair evenly distributed, presence / absence o visible veins

Palms and Dorsal surfaces

Warm and thick

Palms pinkish ( dorsal surface ) warm; malesthick ; females softer ; elastic

NORMAL

NORMAL Nails Nails are transparent ,smooth and convex with pink nailbeds and white translucent tips Nails are transparent ,smooth and convex with pink nailbeds and white translucent tips . Perform with relative ease. NORMAL

Hands and wrist

Perform with relative ease.

LOWER EXTREMITIES

Legs

absence of varicose veins , muscles symmetrical , length symmetrical

Skin color varies ( pinkish, tan, dark brown) skin is smooth , fine hair evenly distributed , absence of varicose veins , muscles symmetrical , length symmetrical.

NORMAL

Knees

Has the difficulty moving, patient is in pain Pain scale is 5/10

Perform with relative ease

ABNORMAL Pain that was experienced by the patient was due to arthritis. Most kinds of arthritis cause pain and swelling in joints.

Toes

Cant perform with ease Patient is in pain Both of her toes has a presence of gangrene

Performs with relative ease

ABNORMAL Pain that was experienced by the patient was due to arthritis. Most kinds of arthritis cause pain and swelling in joints.

Patient has a history of DM type I