5.

Physical Examination (IPPA-Cephalocaudal Approach) As lifted from the chart Date of Admission: August 14, 2013 Chief Complaint: Fever Daily Vital Signs Date Temperature Axilla (C) Pulse rate (bpm) Respiratory Rate(cpm) Blood Pressure (mmHg) 90/60 mmhg 100/60 mmhg 25 bpm 18 bpm 96 bpm 96 bpm August 14 38.2C August 15 39.7C

Physical Examination: General : conscious, coherent Skin: (-) pallor, (-) cyanosis HEAD - HEENT: (-) colds Chest/Lung: CBS Rectum: (+) CVA tenderness Musculoskeletal: (-) weakness ADMITTING IMPRESSION: Acute Pyelonephritis

Review of systems: General: No at loss

Skin: (-) rash HEENT: (-) colds Musculoskeletal: (-) weakness, (-) edema Respiratory: (-) cough Cardiovascular: (-) chest pain GI: (-) LBM

Nurse-Patient Interaction Date: August 14, 2013 General Condition: Patient Kitkat is on a sitting position, awake, conscious and coherent. She appears weak but was able to move on her bed, and was able to ambulate. Upon receiving the patient, she has an ongoing IVF of PNSS 1L @ 200 cc level infusing well. Patient is currently experiencing dysuria, flank pain, and fever. T: 38.2 C/axilla PR: 96 bpm RR: 25 cpm BP: 90/60 mmHg SKULL AND FACE normocephalic shape skull with absence of nodules or masses upon palpation symmetrical facial features and facial movements was able to smile, frown, raise eyebrows, and puff her cheeks

HAIR AND SCALP hair is long, black and straight upon inspection evenly distributed with no lice and dandruff noted

SKIN AND NAILS warm and moist skin with absence of edema and nodules fair skin complexion no presence of lesions has short fingernails and toenails no presence of pallor

EYES AND VISION dark eyebrows are evenly distributed and symmetrically aligned with equal movements black pupil eyelashes are also equally distributed and curled slightly outward and upward eyelids close symmetrically with skin intact and no discharge or discoloration bulbar conjunctiva is transparent and sclera appears white without pale palpebral conjunctiva lacrimal ducts have no edema or tearing upon palpation cornea is transparent, shiny and smooth with visible details of iris pupils are equally round and reactive to light accommodation left and right eye can see clearly in the periphery when looking straight ahead and is able to read book-print at a given distance no discharges noted upon inspection

EARS AND HEARING no tenderness behind the ears auricles are same as the color of facial skin aligned with outer canthus of eyes

not tender and recoil after being folded left and right ear can hear clearly a normal voice tones

NOSE AND SINUSES symmetrical and straight no discharges or flaring has uniform color and not tender nasal septum is intact and in midline air moves freely on both nares as client breathes facial sinuses are not tender no lesions

MOUTH AND OROPHARYNX without dry and pale lips without dental caries tongue is at the center and pinkish in color with no lesions, no tenderness noted and moves freely

NECK muscles equal in size head centered can move her head smoothly and with no discomfort lymph nodes are not palpable trachea is in the midline of the neck thyroid gland is not visible upon inspection and ascends during swallowing upon palpation carotid artery and jugular veins are not distended or visible

THORAX AND LUNGS

chest symmetric volume no tenderness noted no masses noted full and symmetric chest expansion resonant sound upon percussion over the lungs breathing is rhythmic, quiet and effortless no adventitious breath sounds upon auscultation spine is vertically aligned

HEART normal heart rate irregular in rhythm peripheral pulses are symmetrical with that of the apical pulse

ABDOMEN uniform in color, flat, soft non-tender and no masses

UPPER EXTREMITIES and LOWER EXTREMITIES muscles are equal in size no contractures no tremors no bone deformities no tenderness palpated can sense sharp and blunt objects was able to adduct her arm, supine and prone her hands, shrug her shoulders against resistance, and flex and extend her arms

Date: August 15, 2013 General Condition: Patient Kitkat is on a sitting position, awake, conscious and coherent. Upon receiving the patient, she has an ongoing IVF of PNSS 1L x 32gtts/min @ 600 cc level infusing well through the metacarpal vein. She had increased in fluid intake but no output, she is slightly febrile, had a good skin turgor, and moist mucous membrane. T: 39.7C/axilla PR: 96 bpm RR: 18 cpm BP: 100/60 mmHg

SKULL AND FACE normocephalic shape skull with absence of nodules or masses upon palpation symmetrical facial features and facial movements was able to smile, frown, raise eyebrows, and puff her cheeks

HAIR AND SCALP hair is long, black and straight upon inspection evenly distributed with no lice and dandruff noted

SKIN AND NAILS cold and clammy skin with absence of edema and nodules fair skin complexion good skin turgor

no presence of lesions has short fingernails and toenails without presence of pallor

EYES AND VISION dark eyebrows are evenly distributed and symmetrically aligned with equal movements black pupil eyelashes are also equally distributed and curled slightly outward and upward eyelids close symmetrically with skin intact and no discharge or discoloration bulbar conjunctiva is transparent and sclera appears white without pale palpebral conjunctiva lacrimal ducts have no edema or tearing upon palpation cornea is transparent, shiny and smooth with visible details of iris pupils are equally round and reactive to light accommodation left and right eye can see clearly in the periphery when looking straight ahead and is able to read newsprint at a given distance no discharges noted upon inspection

EARS AND HEARING no tenderness behind the ears auricles are same as the color of facial skin aligned with outer canthus of eyes not tender and recoil after being folded left and right ear can hear clearly a normal voice tones

NOSE AND SINUSES symmetrical and straight no discharges or flaring has uniform color and not tender nasal septum is intact and in midline air moves freely on both nares as client breathes facial sinuses are not tender no lesions

MOUTH AND OROPHARYNX without dry and pale lips without dental caries tongue is at the center and pinkish in color with no lesions, no tenderness noted and moves freely

NECK muscles equal in size head centered can move her head smoothly and with no discomfort lymph nodes are not palpable trachea is in the midline of the neck thyroid gland is not visible upon inspection and ascends during swallowing upon palpation carotid artery and jugular veins are not distended or visible

THORAX AND LUNGS chest symmetric volume no tenderness noted no masses noted

full and symmetric chest expansion resonant sound upon percussion over the lungs breathing is rhythmic, quiet and effortless no adventitious breath sounds upon auscultation spine is vertically aligned

HEART presence of pulsation normal heart rate irregular in rhythm peripheral pulses are symmetrical with that of the apical pulse

ABDOMEN uniform in color, flat, soft non-tender and no masses

UPPER EXTREMITIES and LOWER EXTREMITIES muscles are equal in size no contractures no tremors no bone deformities no tenderness palpated can sense sharp and blunt objects was able to adduct her arm, supine and prone her hands, shrug her shoulders against resistance, and flex and extend her arms