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    Review of System

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    dhianne_garcia2001
    The physical exam document summarizes the exam of a female patient. She has dry skin, poor hygiene, and is overweight. Her vision is blurred and she has numbness in her right foot. Lung and heart exams are normal. She has a diabetic ulcer on her right foot.

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    Review of System

    Uploaded by

    dhianne_garcia2001
    172 views7 pages
    The physical exam document summarizes the exam of a female patient. She has dry skin, poor hygiene, and is overweight. Her vision is blurred and she has numbness in her right foot. Lung and heart exams are normal. She has a diabetic ulcer on her right foot.

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    The physical exam document summarizes the exam of a female patient. She has dry skin, poor hygiene, and is overweight. Her vision is blurred and she has numbness in her right foot. Lung and heart exams are normal. She has a diabetic ulcer on her right foot.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    172 views7 pages

    Review of System

    Uploaded by

    dhianne_garcia2001
    The physical exam document summarizes the exam of a female patient. She has dry skin, poor hygiene, and is overweight. Her vision is blurred and she has numbness in her right foot. Lung and heart exams are normal. She has a diabetic ulcer on her right foot.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    The patient reports blurred vision, insomnia, fatigue, body discomfort, numbness in the right foot, and increased appetite, thirst and urination.

    The patient reports blurred vision, insomnia, fatigue, body discomfort, numbness in the right foot, and increased appetite, thirst and urination.

    The physical examination revealed the patient's vital signs, weight loss, dry skin with poor turgor, diminished vision in the left eye, wax in the right ear, calluses on fingers and toes, and a diabetic ulcer in the right foot.

    I.

    REVIEW OF SYSTEM December 6, 2011

    Review of Systems (+) Blurred vision General Both eyes cannot recognize the object in about 10 feet, in reference with the distance vision test Right eye can see clearer than the left in about 14 inches, in reference with the near vision test. (+) Insomnia (+) Fatigue Musculoskelestal System (+) Body Malaise The patient stated that she is feeling body discomfort because of her condition. Naiinitan ako. Puro pawis

    likod ko.

    (+) Right Foot Numbness She stated that shes feeling numb at the right foot that occurs permanently and does not change throughout the day. According to her, Siguro kasi patay na yang paa ko. (+) pain in the wound area, 5/10 accordingly. Gastrointestinal System (+) increased appetite (+) increased thirst Urinary System (+)frequent urination

    IX.

    PHYSICAL EXAMINATION December 6, 2011 Methods Used Results Patient is conscious during the interview. She lies flat on bed. She responds quickly to questions. Her clothes are immaculate. Vital Signs: BP: 130/90 Temp (axilla): 36.5 PR: 81 HR: 89 RR: 22 Anthropometric Measurement: Weight prior hospitalization: 85 Weight during hospitalization: 72 Height: 168 cm BMI: 25.5- overweight CBG- 282

    General Survey

    Inspection

    Skin, Hair and Nail

    Inspection Palpation

    Skin is brown in color, dry and warm to touch. She has poor skin turgor. Hair is black, evenly distributed, dry in

    texture and not excessively oily. Reflects poor hygiene. Nail is long, untrimmed, pinkish in both upper and left lower extremities but pale in right lower foot, no clubbing noted but with calluses at the tip of fingers and toes. Capillary refill is >3 seconds Head and Neck Inspection Palpation Skull is round in shape, scalp without lesions, normocephalic, atraumatic (NC/AT) facial features and its movements are symmetrical Neck can flex, extend and move laterally (L and R) and, no thyroid enlargement (-) mass and lesions Eyes Inspection Eye lids symmetrically aligned Eyes with unequal shape, movement and hair distribution Pink conjunctiva, sclera white (-) discharge Pupils unequal, round but reactive to light and accommodation(OU) Diminished visual acuity left eye (OS)

    Ears

    Inspection

    Wax partially obscures right tympanic membrane Acuity good to whispered voice

    Nose

    Inspection

    Symmetrical in shape and color. Nasal hairs are evident when light is flashed through nasal passages Nose bridge straight and in midline Nasal mucosa is pink, with minimal discharge Symmetrical nares are patent

    Mouth

    Inspection

    Lips are symmetrical, moist and pink. Presence of 4 primary teeth ( 1st and 2nd lower and upper teeth), yellowish in color with few plaques on first and second molars Tongue is in midline, with thin whitish coating on top, able to move freely Mucous membranes pink and dry Uvula is well placed, tonsil not inflamed

    Thorax and Lungs

    Inspection

    Symmetrical: AP Transverse ratio is 1:2 22 cpm Breathing pattern is regular and with minimal effort

    Palpation

    Bilateral lung movement, diaphragm descend 4cm bilaterally Respiratory excursion w/in 3-6 cm

    Percussion Auscultation

    Lungs resonant No abnormal breath sounds Good S1 and S2 Normal heart rate is 60-100 bpm

    Abdomen

    Inspection

    No rashes and lesions, round and symmetrical, smooth. Not distended

    Auscultation

    Active bowel sounds

    Percussion Palpation

    No tenderness and masses

    Extremities Right foot wound

    Inspection

    Wound is pinkish in color with purulent drainage in minimal amount Equal and appropriate for body, symmetrical. Diabetic ulcer in right foot

    Palpation

    Dry, shiny skin

    Left foot is warmer than right, delayed capillary refill (>3 sec) Auscultation Calf in the left leg supple, nontender; Swelling in right foot Right Peripheral pulse faint but detectable= 1 Genitalia/ Rectal Inspection -not allowed-

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