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MRS. X
A 62 years old women was admitted to
the emergency room complaining of
cough and difficulty of breathing
which is the reason for her sleep
disturbances. She has a BP of 160/90
and RR of 24bmp upon checking her
vital signs. The physician ordered o2
cannula therapy and captopril
sublingual stat. She was diagnosed
with community acquired pneumonia
and hypertension
Studying this diseases where the patient
diagnosed will hopefully give us student
nurses or future nurses, together with
the rest of the health-care team, some
more information regarding the disease
and its proper management, and the
different nursing responsibilities
that should be taken into consideration
when faced with his kind of case.
• Biographic Data
– Name: Leonilla Racab Llantos
– Address: San Isidro, San Jorge Samar
– Age: 62 years old
– Sex: Female
– Mental Status: Alert, Conscious, Coherent
– Occupation: Farmer
– Religion: Roman Catholic
– Health Care Financing: Philhealth
– Usual Source of Medical Care: Philhealth and
children
– Status: Live in with Melano Arom G. Ros
• Chief of Complaint
– Cough for 3 days
– Fever
– Fatigue
– Dob
– Sleeping disturbances
• History of present illness
– When did the symptoms start?
• 3 days ago
– Onset of symptoms? Gradual/ Sudden
• Sudden
– How often does the problem occur
• Every night before going bed which causes sleep disturbances
– Exact location of the distress
• Chest
– Activity in which the client was involved that the
problem occurred
• Nag lalampaso
• Nag uma
• Nag lalaba
• Past Medical History
– Childhood Illness
• Fever, Cough, Colds (Common Childhood Illnesses)
– Childhood Immunization
• No immunization in her time
– Allergies
• None
– Accident or Injury
• None
– Hospitalization for serious illness
• Last hospitalization was September 27 because of
hypertension. 2 weeks from being admitted again
• Family History
– Fathers Name: Gregorio Llantos
– Mothers Name: Lolita Llantos
• HEMATOLOGY RESULTS
Result Normal
HCT 41.89g/L 40- 42 g/L
RBC 4.67g/L 4.7- 6.1 g/L
HEMOGLOBIN 14.11g/L 13- 17 g/L
WBC 8.82g/L 4.8- 10.8 g/L
LYMPHOCYTES 31.6% 19- 48%
PHYSICAL ASSESSMENT
FINDINGS
TEMPERATURE 37.3C
PR 119bpm
RR 24bpm
BP 160/90mmHg
I. The Skin Upon II. The Nails
inspection, the The nails of our patient
patient’s skin was were intact and well
warm to touch, trimmed. The patient
slightly moist and has pinkish nail beds
smooth. There was and is smooth in
no presence of texture. Her capillary
lesion. When we test refill time was 2
her skin for mobility seconds and has a
and turgor, skin convex curvature of
rapidly resumes its fingernail plate. No
original shape after lesions were noted
pinching. around her fingernails
and toenails.
III. The Head and Skull IV. The Hair
The Skull was Our patient has a
normocephalic and had short gray hair due to
symmetrical facial aging, slightly dry, and
features. There were no evenly distributed. No
deformities noted such as presence of infection
masses, bulges and or any infestations
tenderness upon
noted upon inspection
palpation. There was
symmetrical facial
at the back of the ears
expression when the group and along the hairline
asked the patient to raise in the neck. Hair on
her eyebrow, puff her the body was fine and
cheeks, smile and frown evenly distributed.
and close her eyes tightly
V. The Eyes VI. The Ears
Both eyes were symmetrical upon
inspection; it can follow the direction of
Symmetrical auricles on both
our finger when we test her visual ears were noted. Pinnas were in
acuity. The patient’s eyebrows were line with the outer canthus of
evenly distributed. It was symmetrically her eyes. There was no
aligned and has equal movement. tenderness noted upon
Eyelashes curled slightly outward. The palpation. Auricle had the same
eyelid on the other hand has no
discharges and discoloration. The sclera
color with the facial skin. Thus,
on both eyes was yellow and clear, irises it is firm and non tender. The
are black and round. Pupils are equally external canal of her ear has no
round, reactive to light and constrict discharges, inflammation nor
simultaneously with 2mm in size when impacted cerumen noted upon
passed by a light. The Conjunctivas are inspection. Ears were elastic
pinkish in color. There was no
and coils back to its original
tenderness noted upon palpation of the
lacrimal duct. The patient was able to shape after being folded.
see objects in periphery when we test Patient was able to hear and
her ocular eye movement. respond to a normal tone
VII. The Nose
No discharges noted upon VIII. The Mouth
inspection. Nasal flaring Lips are pail in color,
was noted upon early
monitoring of the vital dry lips; gums are
signs. Both nostrils are pinkish in color, tongue
present, and no tenderness
and masses or nodules is located in the
noted upon palpation. The midline, Uvula and
mucosa is pinkish with hair.
Thus, no tenderness on tonsils are not
sinuses noted upon inflamed and gag
palpation. There was good
patency on both nasal reflex is present.
cavities as the group
instructed the patient to
occlude of her nares and
breathe.
IX. The Neck X. The Thorax and Lungs
The thorax is symmetrical
The patient’s neck has no from posterior and lateral
evident masses, unusual views. There was no
swelling, or any pulsations. presence of masses or
Upon letting her neck move tenderness upon
such as flexing, extending, palpation. At the early vital
sign monitoring, the
right and left rotation, and respiratory rate of the
hyperextension, she was patient was 24 cycles per
able to move it easily minute, use of accessory
without pain or discomfort. muscles were noted.
The thyroid was not visible Increase tactile fremitus
noted upon percussion.
upon inspection and is There was presence of
smooth, without nodules crackles upon auscultation.
and masses Rapid shallow breathing
pattern was also noted.
XII. The Abdomen
XI. The Heart Upon inspection, there no
The heart sounds are distinct scars or lesions noted. There
and regular with the rate of are no evident signs of
119beats per minute. The infection of the umbilicus
point of maximal impulse is such as redness, pus
best heard at the left mid formation, discoloration or
clavicular line, 5th intercostal swelling. No abdominal
space distention noted.
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