Review of General Health Status

Systems
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(Jan. ,2010) and on
Jan. ,2010 58?kgs, before the admission ____kgs, ascites present with the abdominal girth of 38 on
the 1st day and 37 on the 2nd day. 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.
Sleeping pattern disturbance???> , 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 viands and a cup of water every meal. As for the patient he stated that his condition

Areas/Syste ROS Physical Assessment/Examination

ms
Inspection Palpation Percussion Auscultation
Skin:
Integument The patient had no • jaundice, • CRT- 3 sec.
ary skin diseases Spider like • Poor skin
present such as blood vessels turgor
rashes, sores, in abdomen
ulcers, warts, or • Cracked red
moles. There are no lips
skin tumors, • Scaly
masses, and
bruises. Hairs are Nails:
evenly distributed. • Pale,
Bathed daily with (-)clubbing
special skin care
preparation Temperature:
(applying of lotion). Feb. 2,2010
Nails are clean and
 10 pm-37.9
well trimmed.
2 am-37.8

6 am-37.5
Feb. 3, 2010
10 pm- 38.4
2 am- 37.5
6 am-37.3

Head The pt experiences Head:

hangover after • Symmetrical • No lumps and
drinking spree with • Can move up tenderness
his companions. and down, left noted
Two years ago had to right • Scalp freely
experience collapse without pain movable
for 10 minutes without
because prior at Face: lesions or
night they had • Jaundice tenderness
drinking session
with his friends.
Hadn’t experience • Can do
stiff neck or head different facial
trauma. expressions
• Evenly
distributed
hair
Eyes The patient is • Eyelashes and
already unable to Eyebrows are
read small letters. well
He does not wear distributed
any eyeglasses and • Icteric Sclerae
did not go for a • No lesions or
check-up with an inflammation
ophthalmologist. of eyelids
• Pupils equally
reactive to
light

Ears The patient had no External Ear:

history of hearing • Auricles are • No
disturbances. Had aligned with tenderness
not experienced any eyebrows. noted
discharges or pain. • No pain upon
movement of
auricle and
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 The patient • Red, dry,

Pharynx experience cracked lips.
sorethroat last _____ • Dry buccal
associated with that mucosa,
is dysphagia. Had intact, no
his check-up and prescence of
was prescribed to lesion.
drink lincocin 500 • Gums appear
mg as stated by the very red but
patient upon there are no
drinking one tablet, signs of
he will be then bleeding.
relieved. Other than
that he had not
experience any
problems. He had
history of
alcoholism;every 15
days he always buy
1 long neck of
tanduay rhum a day
for 3-4 days. He is
fond of eating meat
as well as salty and
fatty food.

Neck No history of lumps • Freely moves • (-)pain

 -chin to chest • (-)masses
or swelling. Had not -bends head • (-)enlargemen
experience stiff forward t of thyroid
neck and any and backward gland
limitation of motion. -side to side
 No history of lung • SOB when • chest • diaphrag • clear
diseases, chest lying excursion matic breath
Thorax and pain with =15 cm excursion sounds
breathing and Respiratory System • vocal = 5cm on all
Lungs/
Respiratory wheezing or Feb. 1, 2010 lung
noisy breathing. ( tactile) fields
----------- 2 am-26 cpm fremitus
bilaterally
------------------------ 6 am-31 cpm equal

------------------------ Feb. 2, 2010 • no

10 pm-30 cpm
lumps
and
2 am-34 cpm masses
6am-30 cpm noted

Feb. 3, 2010

10 pm- 29 cpm

2 am- 30 cpm

No history of • JVD =3cm @ • PR : • BP

cardiovascular 45 degrees
Cardiovascul diseases, no Feb. 2, 2010 Feb. 2

ar history of 2am=84 10pm=100/8

hypertension, bpm 0
had normal BP
range 100/70- 6am=93 2am=110/80
120/80 mmHg bpm
since. 6am=100/60
Feb. 3, 2010
Feb. 3
10pm=98bp
10pm=110/7