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  • A. General Appearance: Pale Palpable Conjunctivae

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    Grae Taclob
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    The patient is a 25 kg, 5 foot tall male who is obtunded and unable to stand or walk. On physical examination, the patient has a blood pressure of 130/90, heart rate of 113 bpm, respiratory rate of 22, and temperature of 38 degrees Celsius. Examination of specific body systems found swelling and pain in the right knee, muscle weakness, inability to walk, constipation, nausea and vomiting, and pallor/cyanosis. The skin was noted to be brown, warm, slightly dry with fair turgor and redness around the right knee.

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    Physical Examination

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    The patient is a 25 kg, 5 foot tall male who is obtunded and unable to stand or walk. On physical examination, the patient has a blood pressure of 130/90, heart rate of 113 bpm, respiratory rate of 22, and temperature of 38 degrees Celsius. Examination of specific body systems found swelling and pain in the right knee, muscle weakness, inability to walk, constipation, nausea and vomiting, and pallor/cyanosis. The skin was noted to be brown, warm, slightly dry with fair turgor and redness around the right knee.

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    © All Rights Reserved
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    Segnala contenuti inappropriati
    10 visualizzazioni3 pagine

    A. General Appearance: Pale Palpable Conjunctivae

    Caricato da

    Grae Taclob
    The patient is a 25 kg, 5 foot tall male who is obtunded and unable to stand or walk. On physical examination, the patient has a blood pressure of 130/90, heart rate of 113 bpm, respiratory rate of 22, and temperature of 38 degrees Celsius. Examination of specific body systems found swelling and pain in the right knee, muscle weakness, inability to walk, constipation, nausea and vomiting, and pallor/cyanosis. The skin was noted to be brown, warm, slightly dry with fair turgor and redness around the right knee.

    Copyright:

    © All Rights Reserved
    Scarica in formato DOCX, PDF, TXT o leggi online su Scribd
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    di 3

    I.

    Physical Examination

    A. General Appearance

    Weight:

    25 kg

    Height:

    5 feet

    Level of Consciousness: Obtunded


    Body Build:

    Endomorphic

    Posture and Gait:

    Unable to stand and walk

    Overall Hygiene:

    Fair

    Awake, Alert, Coherent, (+) Pain @ Right Knee, pain scale of 8 out of 10 when
    moving Right Leg, in slight Respiratory Distress.
    Vital Signs: Bp = 130/90 ; HR = 113 bpm ; RR = 22 ; T = 38 C

    C. Head/Scalp/Hair

    Head is normocephalic (symmetrical and round)

    No palpable nodules or masses noted.

    Lesions are not noted.

    Has black hair.

    No presence of flakes, lice or lesions noted.

    D. Eye/Vision

    Anicteric sclerae with pupils round and black in color.

    Pale palpable conjunctivae

    Brisk reaction to light

    Blinking symmetrical

    Cornea is transparent , smooth and moist

    Both eyes move in a smooth, coordinated manner in all directions

    E. Ears/Hearing

    Size is normal and equal

    similar in color to face

    (-) discharges and swelling.

    Cerumen not noted.

    Skins smooth and without nodules

    No tenderness or pain when palpated

    F. Nose

    No discharges.

    Color is same as face, with smooth consistency

    Symmetrical appearance

    No changes in nares with respiration

    No nodules, masses, or pain reported on palpation

    G. Mouth/Speech

    Lips are slightly dry and slightly pale.

    No bleeding of gums noted.

    Lips and surrounding tissue is symmetrical

    No lesions, swelling, drooping

    H. Throat and Neck

    No distention of jugular vein noted.

    No inflammation of lymph nodes

    No stiffness

    I. Respiratory System

    Breathes normally and easily

    Equal chest expansion

    No crackles or abnormal lung sounds noted

    J. Circulatory/Cardiovascular System

    Swelling is noted on the Right knee

    There is fatigue upon arising from bed to sitting position

    K. Gastrointestinal System

    No abdominal pain noted.

    There are incidence of constipation

    (+) Nausea and vomiting

    L. Genitourinary System

    No difficulty in urination

    Urine is yellowish in color

    Fluid intake is approximately 800mL/day

    M. Musculoskeletal System

    Muscle weakness is noted


    Movements are weak. Unable to walk and cannot tolerate standing.

    Slightly weak handgrip and weak lower extremities

    Pain of Right Knee upon passive ROM

    N. Integumentary System

    Skin is brown in complexion, warm, and slightly dry with fair skin turgor.

    Redness of Right Knee and surrounding area

    Pallor/cyanosis is noted

    Swelling is noted on the Right knee

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