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Review of General Health Status

System
s The patient is 42 years old, male, and is married, and had 4 children. The patient is wearing a blue
and white striped hospital gown on the first visit. The patient weighed 60 kgs(Feb. 2 ,2010) and on
Feb. 3,2010 58kgs, upon admission 63kgs, ascites present with the abdominal girth of 39 on the 1st
day and 38 on the 2nd day. Height is 5’5. He also had bipedal pitting edema grade 2, has icteric
sclerae and is jaundice all over. He is conversant and witty, is alert and oriented to time, place and
person. Is experiencing weight loss. He had no mobility problems but he needs assistance upon
dressing because of the IV line, he can consume a cup of rice,1 serving of any kind of viand and a
cup of water every meal. He considers his health not in good condition because of his illness.

Areas/Syste ROS Physical Assessment/Examination


ms
Inspection Palpation Percussion Auscultation
Skin:
Integument The patient had no • jaundice, • CRT- 3 sec.
ary skin diseases • caput medusa • Poor skin
present such turgor
• Cracked red
as rashes,
lips
sores, ulcers,
warts, or • Scaly
moles. There Nails:
are no skin • Pale,
tumors, (-)clubbing
masses, and Temperature:
bruises. Hairs Feb. 2,2010
are evenly 10 pm-37.9
distributed. 2 am-37.8
Bathed daily 6 am-37.5
with special Feb. 3, 2010
skin care 10 pm- 38.4
preparation 2 am- 37.5
(applying of 6 am-37.3
lotion). Nails
are clean and
well trimmed.
Head The pt experiences Head:
hangover after • Symmetrical • No lumps and
drinking spree • Can move up tenderness
with his and down, left noted
companions. to right • Scalp freely
Two years ago without pain movable
had experience Face: without
collapse for 10 • Jaundice lesions or
minutes tenderness
because prior • Can do
at night they different facial
had drinking expressions
session with
• Evenly
his friends.
distributed
Hadn’t
hair
experience stiff
neck or head
trauma.

Eyes The patient is • Eyelashes and


already unable Eyebrows are
to read small well
letters. He distributed
does not wear • Icteric Sclerae
any eyeglasses • No lesions or
and did not go inflammation
for a check-up of eyelids
with an • Pupils equally
ophthalmologis reactive to
t. light
Ears The patient had no External Ear:
history of • Auricles are • No
hearing aligned with tenderness
disturbances. eyebrows. noted
Had not • No pain upon
experience any movement of
discharges or auricle and
pain. tragus
• No discharges
noted
External Canal:
• No redness,
swelling,and
discharges
noted

Nose and Experience colds if • No


Sinuses exposed to rain • Nasal cavities tenderness
sometimes are patent noted

Mouth and He had history of • Red, dry,


Pharynx alcoholism;eve cracked lips.
ry 15 days he • Dry buccal
always buy 1 mucosa,
long neck of intact, no
tanduay rhum prescence of
a day for 3-4 lesion.
days. He is • Gums appear
fond of eating very red but
meat as well as there are no
salty and fatty signs of
food. bleeding.
Neck No history of lumps • Freely moves • (-)pain
or swelling. -chin to chest • (-)masses
Had not -bends head • (-)enlargemen
experience stiff forward t of thyroid
neck and any and backward gland
limitation of -side to side
motion.
No history of lung • SOB when • chest • diaphrag • clear
Thorax and diseases, chest lying excursion matic breath
pain with Respiratory System =15 cm excursion sounds
Lungs/ breathing and Feb. 1, 2010 • vocal = 5cm on all
Respiratory wheezing or 2 am-26 cpm ( tactile) lung
noisy breathing. 6 am-31 cpm fremitus fields
Feb. 2, 2010 bilaterally
10 pm-30 cpm equal
2 am-34 cpm • no lumps
6am-30 cpm and
Feb. 3, 2010 masses
10 pm- 29 cpm noted
2 am- 30 cpm
No history of • JVD =3cm @ • PR : • BP
Cardiovascul cardiovascular 45 degrees Feb. 2, 2010 Feb. 2
diseases, no 2am=84 10pm=100/8
ar history of bpm 0
hypertension, 6am=93 2am=110/80
had normal BP bpm 6am=100/60
range 100/70- Feb. 3, 2010 Feb. 3
120/80 mmHg 10pm=98bp 10pm=110/7
since. m 0
2am=96bpm 2am=110/70
6am-90bpm 6am=100/70
Can consume • Veins are • (+) • Bowel
Abdomen four spoon full’s visible in shifting sounds
of rice and viand both right dullness cannot be
every meal and left • (+) fluid appreciat
before, and on upper wave test ed
admission can quadrant
consume 1 cup • Abdominal
of rice and 1 girth
serving of viand Feb 2, 2010
every meal. Had - Cm
experienced Feb 3, 2010
abdominal - Cm
pain(epigastric
area) 2 weeks
prior to
admission.
Defecates 2
times a day. 2
weeks prior to
admission the
client has stated
that he had
noticed that his