P.A. (mangao)

8/6/2019 P.A. (mangao)

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PATIENT¶S INFORMATION

Name of Patient: Daryl Mangao

Age: 19 years old

Sex: Male

Diagnosis: Complicated UTI, Nephrolithiasis

INITIAL VITAL SIGNS

Temperature: 38.0oC

Pulse Rate: 98 bpm

Respiratory Rate: 27 cpm

Blood Pressure: 110/80 mmHg

Level of Consciousness: lethargic

PHYSICAL ASSESSMENT

Appearance and Mental Status

BODY PART TECHNIQUESUSED

ACTUAL FINDINGS INTERPRETATION

Body built, weight

and height

Inspection Not proportioned with

regards to age

Built, weight and height

are not proportioned

with the patient¶s age

due to the fact that the

patient have Down¶s

syndrome and Cerebral

PalsyPosture, Gait,

Standing, Sitting and

Walking

Inspection Bent posture and

uncoordinated body

movements

A person with Down¶s


Palsy have impairment

in physical growth and

exhibits limits in

8/6/2019 P.A. (mangao)


movement that cause

activity limitation

Hygiene, and

Grooming, Body and

Breath Odor

Inspection Unkempt, foul body

odor, foul breath

Since the patient had

been hospitalized for

almost 4 days,

exhibiting that kind of

condition, it¶s been

hard for the patient¶s

family to maintain

cleanliness and provide

daily hygiene care.

Attitude, Mood,

Speech and

Thoughts

Inspection Not cooperative and

unable to follow

instructions, have

communication

disorder, cognitive

impairment

A person with Down¶s


Palsy exhibits physical

and mental impairment.

Skin

BODY PART TECHNIQUESUSED


Skin Color,

Uniformity,

Inspection Brown and no

discoloration

It implies that there are

no evident signs of

hyperpigmentation or

hypopigmentation.

Skin Lesions,

Moisture

Inspection Presence of scar, dry

skin

The presence of skin

lesions or scar

indicated that patient isprone to accidents and

injury since the patient

has that special

condition. The dryness

of skin indicate that

8/6/2019 P.A. (mangao)


patient is prone to

dehydration.

Temperature Palpation Warm to touch Indicates fever

Hair

BODY PART TECHNIQUES

USED


Scalp Inspection Well distributed

throughout the scalp

The hair is well

distributed throughout

the scalp and no signs

of hair loss

Hair thickness or

thinness, texture,

and oiliness

Inspection Thick hair, oily The hair is oily due to

prohibited hair care

Infestation or

infection

Inspection There are minimal

signs of flaking

Signs of flaking is due

to prohibited hair care

or results from hair

products used as well

as the diet

Body Hair Inspection Variable and evenly

distributed

No indication of

hirsutism

Nails


USED


Fingernail shape,

texture, and color

Inspection Convex curvature,

smooth texture, brown

pigmentation

The nails are highly

oxygenated

Capillary Refill,

Tissues near nails

Inspection Intact skin, prompt

return of usual color

Indicate that there is

adequate circulation

8/6/2019 P.A. (mangao)


Skull and Face


USED


Skull size, shape,

and symmetry;

nodules, masses

Inspection

Palpation

Rounded, smooth, no

masses or lumps

Indicates that there are

no excessive growth of

hormones or increased

bone thickness,

trauma, sebaceous

cysts, local deformities

Facial Fractures and

Movements

Inspection Symmetric, no

involuntary facial

movements

No indication of hyper

or hypothryroidism

Eye Structure and Visual Acuity


USED


Eyebrows Inspection Intact skin, no hairloss,

hair are evenlydistributed, symmetric

Indicates good

circulation as there areno signs of hairloss,

symmetric eyebrow

shows no problem in

neural functions

Eyelashes and

Eyelids

Inspection

Palpation

Lids close

symmetrically, no

masses or lumps, no

discharge or discoloration

Indicates proper neural

functioning, negative

discharge indicates

absence of infection

8/6/2019 P.A. (mangao)


Pupils: color, shape,

symmetry, size,

reaction and

accommodation

Inspection Pupils are black,

symmetric, round;

Pupils illuminated

constricts, non-

illuminated constricts

There are no signs of

infection; indicates

proper functioning of

cranial nerve III

Occular Movements

and vision

Inspection Not coordinated,

cannot follow in

specific direction

Indicates that there is

neurologic impairment

Mouth


USED


Lips: color, shape,

texture, moisture

Inspection Dry and cracked

texture; symmetric, no

thrush

Dry and cracked texture

of the lips indicates

dehydration

Teeth Inspection Yellowish teeth Indicates poor oralhygiene

Tongue Inspection Dry Indicates fluid deficit

Lungs and Thorax


USED


Thorax: Alignment,

shape, symmetry

Palpation Symmetric, properly

aligned, skin intact, no

tenderness or

masses, full chest

expansion

No implication of kyphosis

or lordosis, inflamed

pleura

Breathing Pattern Inspection Quiet, rhythmic, No signs of atelectasis or

8/6/2019 P.A. (mangao)


easeful breathing pneumothorax

Lung sounds Auscultation No adventitious

sounds upon

auscultation

Indicate adequate

breathing pattern

Abdomen


USED


Liver Palpation Not palpable Liver is not enlarged or

inflamed

Bladder Palpation Not palpable Indicates absence of

urinary retention

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P.A. (mangao)