III.

BASELINE INFORMATION

Name : Mr. X Address : Nolin II Midsayap Birthday : April 20, 1948 Civil Status : Married Occupation : Farmer Religion : Roman Catholic Citizenship : Filipino Date of Admission : Feb. 28, 2011 Time of Admission : 3:05 pm Attending Physician : Dr. Madarang Chief Complaint : Swelling of the face Diagnosis : Chronic Renal Failure 2 Pulmonary Tuberculosis

IV. HISTORY OF PAST ILLNESS Two weeks prior to admission, the patient experienced swelling of the face. He also complained stabbing pain on his chest, and according to the intensity of pain it is 8 out of 10 and it radiates to his back and shoulders. The patient didnt experience any childhood diseases, being hospitalized or any operations. He doesnt have allergies to whatever kind of foods and medications as far as he knows, and any regular medical and dental check ups. On the maternal side of our patient they have heart disease and hypertension while on the paternal side they have kidney disease and asthma.

V. PHYSICAL ASSESSMENT GENERAL PHYSICAL SURVEY A. Appearance and Behavior

1. Age and Sex: 62 years old, Male

2. Body Built: Well-proportioned 3. Posture and Gait: Patient is weak and not able to walk without assistance

4. Hygiene and Grooming: Patient is neat but he is not able to take a bath. He has unshaven beard and the nails are short. 5. Dress: Patients clothes are properly worn and fit and fit and appropriate for the occasion and/or weather.
6. Odor of Body and Breath: Patient has minor odor.

7. Apparent state of health: The patient is weak. 8. Attitude: The patient is cooperative and interested. 9. Affects or Mood: The patients affect is appropriate to situation. 10.Speech: The patients speech is unclear and very slow. 11.Thought Process: The patients ideas are logical and with sense of reality. B. Vital Signs Temp : 37. 6 C RR : 20 bpm BP : 150/100 mmHg CR : 79 bpm PR : 72 bpm

C. Height and Weight Height : 5 ft and 5inches Weight : 61 kgs.

INTEGUMENTARY A. Skin The clients skin is brown in color with fair skin turgor. His skin was scaly, But there is no any lesions noted. B. Nails Nails are short but not well trimmed. Upon performing the capillary refill test, the color goes back to its original color after three seconds. Nails are short and straight across.

C. Head It is round and asymmetrical. His face was swelling. D. Eye The eye brows are evenly distributed, symmetrically aligned, equal movement, eyelashes equally distributed, curved slightly outward. Eyelids skin is intact, closes symmetrically, bilateral blinking, bulbar conjunctiva is clear. Sclera appears white and shiny.

Central Nervous System The patient is conscious and sometimes shows cooperation.

Musculoskeletal System Posture and body built is normal at his age. Both upper and lower extremities are able to extend and flex but he is not able to walk without assistance.

Circulatory System Point of maximal impulse is at the fifth intercostals space, it is auscultated three finger breaths below the left nipple. The cardiac rate is 79bpm. Rhythm is spontaneous bounding. His radical pulse rate is 72 bpm.

Respiratory System The respiratory rate is 22bpm. He can breath well in any position upon auscultation there were crackles breath sound noted at both right and left lungs.

Gastrointestinal System The abdomen is same color of the skin and the umbilicus is light brown in color and centrally located.

Genitourinary System

FOCUS ASSESSMENT During the interview and physical assessment, we have our focus on the respiratory system. The respiratory system is composed of the upper and lower respiratory tracts. Together the two tracts responsible for ventilation (movement of air in and out of the airways). Upon inspection, productive cough was observed with respiratory rate of 22 breaths per minute. Use of accessory muscles were observed with rounded thorax. Upon palpitation, symmetrical posterior and anterior thoracic expansion and increased fremitus felt over the chest. Upon auscultation, crackles breath sound were heard at both right and left lungs with respiratory rate of 22 breaths per minute.