PHYSICAL ASSESSMENT OF AN ADULT

HEALTH HISTORY

I. Biographical Data II. Chief Complaints

On and off high grade fever for 1 week, loose watery stool associated with vomiting several times noted 6 days prior to admission, epigastric pain and body malaise.

III. History of Present Illness

The patient actually lives in the rural area of Mabinay where their source of water for drinking is water pipe. They even dont boil the water unless it is raining. After drinking water from the pipe, the patient already experienced on and off high grade fever, loose watery stool associated with vomiting, epigastric pain, and body malaise. According to her, it is not just her who experienced this kind of symptoms but also some of her neighbors.

IV. Past Health History

CHILDHOOD ILLNESS: Cough, colds, fever, mumps, sore eyes, chicken pox ACCIDENTS/INJURIES: She doesnt experience any accidents except during her childhood days she stripped into the ground and got some wounds in her knees as claimed. SERIOUS OR CHRONIC DISEASE: none HOSPITALIZATIONS: It was his first time to be hospitalized OPERATIONS: None LAST EXAM DATE (DENTAL, VISION, HEARING, EKG, CHEST X-RAY): None IMMUNIZATIONS: BCG, DPT, Hep. B, Tetanus toxoid ALLERGIES: Verbalized she doesnt have any allergies. CURRENT MEDICATIONS: None HABITS AND LIFESTYLE: She doesnt smoke nor drink any alcoholic beverages. Exercise for her is doing household chores. RECENT TRAVEL: None

I.

GENERAL SURVEY State of awareness: She is aware of what is happening, cooperative, has sense of reality and can follow instructions. Obvious signs of distress, pain, anxiety: She is not in distress, no obvious sign of pain and anxiety since shes already cured and can go home. Gait and Posture: She walks purposefully. Body movements: Movements of the body are purposeful and congruent.

Hygiene and grooming: Shes neat and clean, and no foul odor. Speech: Her verbalizations are clear, understandable, moderate pace, and exhibits thought association. Mood and affect: Appropriate to the situation. II. VITAL SIGNS Temperature: 36.6C Pulse rate: 75 bpm, regular Heart rate: 76 bpm, regular Respiratory: 19 cpm, regular, no use of accessory muscles BP: 110/70 mmHg

III. RESPIRATORY SYSTEM HEALTH HISTORY: According to my patient, as far as she knows, her family doesnt have any history of asthma or any illnesses related to respiratory system such as cancer and tuberculosis. She experienced cough and colds many times from her childhood days up to the present. It will only occur once or twice in a year. The triggering factors were climate change and too much exposure to dust. She doesnt smoke but her husband does but not near to her, magpalayo man na siya usahay kung manigarilyo as verbalized by the patient. However, sometimes she can still whiff the smoke of the cigarette. If the patient is having cough, she drinks oregano. POSTERIOR CHEST: INSPECTION: The shape of her chest is oval with an anteroposterior diameter of half its transverse meaning the diameter is smaller at the top than the base. For the spinal alignment, it is vertically aligned, right and left shoulders and hips are at same height. There are some scar at the upper part of her chest due to her pimples. PALPATION: Skin is intact and temperature is uniform, not that warm nor cold. Chest wall is intact. Absence of tenderness and masses. During respiratory excursion, as the patient took a deep breath, my thumbs move apart an equal distance and at the same time, hence there is full and symmetric chest expansion. For vocal fremitus, there is bilateral symmetry. PERCUSSION: Resonance over the intercostal spaces. AUSCULTATION: Using the flat-disc diaphragm of the stethoscope, adventitious breath sounds were not noted. Vesicular is heard over the periphery of the lungs, broncho-vesicular is audible between the scapula and lateral to the sternum at the first and second intercostals spaces.

ANTERIOR CHEST: INSPECTION:

Her breathing pattern is quiet, regular, and effortless. PALPATION: The same with the posterior chest, skin is intact and temperature is uniform, not that warm nor cold. Chest wall is intact. Absence of tenderness and masses as I palpated the area. There is full and symmetric excursion. There is bilateral vocal fremitus and is decreased over breast tissue. PERCUSSION: Resonace over the intercostals spaces down to the sixth rib. Flat sound is noted over area of bone, and dull is noted where the liver is. AUSCULTATION: Adventitious breath sound is also not noted. Vesicular is heard over the periphery of the lungs, broncho-vesicular is audible between the scapula and lateral to the sternum at the first and second intercostals spaces, and bronchial is heard over the trachea. IV. CARDIOVASCULAR SYSTEM

HEALTH HISTORY: According to my patient, her father has hypertension and it really runs in the family. So far, she doesnt experience any signs and symptoms of hypertension. She doesnt have any diet restrictions and she eats what she wants. However, she has this little discipline in herself not to eat always fatty foods. According to her, stress is somewhat normal but too much of it will cause her sick. She deals with her problems appropriately such as talking to someone. BP: 110/70 mmHg During the inspection and palpation in the aortic, pulmonic, and tricuspid areas, there are no visible pulsations. Pulsations are not visible in the apical area. There is regular aortic, pulmonic, tricuspid, and apical pulsation. S1 is louder in the apical area, with a rate of 76 beats per minute. S2 is louder at the base of the heart. In the carotid artery, there are symmetric pulse volumes, palsations are full, and the quality is thrusting. The quality remains when the client breathes. Veins are not visible in the jugular veins.

V.

ABDOMEN

HEALTH HISTORY: The patient verbalized that she doesnt have any problems when it comes to her bowel movement although sometimes she experiences constipation depending on the food she eats and bowel movement is sometimes every other day. She also experienced LBM that was 2 years ago. She eats vegetables, fruits, and drinks a lot of water. She boils the water which comes from the pipe when it rains.

There are abrasions on her abdominal area due to her belt and she scratched it. She wore her belt tightly thinking that she will not be able to get gas pains as she traveled from Mabinay to Dumaguete. The abrasions are already dry.

The contour is flat, rounded, and symmetric. Liver or spleen enlargement is not evident. There is a symmetric movement which is caused by respiration. Bowel sounds are evident at 8 bowel sounds per minute. Liver is 6.8 cm at the right midclavicular. No tenderness noted during palpation. Border of the liver feels smooth.

COLLEGE OF NURSING SILLIMAN UNIVERSITY Dumaguete City

SUBMITTED TO: Asst. Prof. Corazon Ordonez

SUBMITTED BY: Ariane Paz C. Malahay