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DEMOGRAPHIC DATA

Name: Age: Civil Status: Natio alit!: P"!sicia i #c"arge: Room um%er: C"ie& com'lai ts: Diet: Ge eral im'ressio o& clie t duri g i itial co tact: Address: Sex: Educatio al Attai me t: Religio : Nurse Doi g P$A$: Admitted date a d time:

Histor! o& Prese t Ill ess:

Physical Assessment by Mr. Jonathan E. Salva

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H E A D , EYES, EARS, NOSE, THROAT


I$ Healt" Histor! Patient has known to have history of headaches during the past. This is due to his asthmatic condition, which could sometimes lead to headaches during the afternoon. Changing the position of the head does not affect the headache of the patient. Patient has had no history of any head injury. The vision is good as claimed and has not experienced blurring of vision ar any infection of the eyes.Patient has not also experienced pain in the eyes or around the eyes, redness or excessive tearing or watering. Has not been using glasses or contact lenses no history of eye examination. !urthermore, patient has good hearing as claimed has not experienced ear problems" infection, earaches, tinnitus and vertigo. Patient has no difficulty in understanding people as they talk and has not tried using hearing aids, as claimed. #ischarge from ear is brown in color and moist as claimed. $n addition, patient sometimes experience cough and colds, as claimed however, the patient cannot remember how long the cough" cold will usually last.. %astly, patient has experienced bleeding from the gums before, when the patient brushes teeth in a vigorous manner. II$ P"!sical Exami atio A$ E!es ($ I s'ectio a$ &yelids ' are bright, moist and clear %$ %acrimal #ucts ' have no swelling, nor excessive tearing or dryness of the eyes c$ Conjunctiva ' covers the anterior surface of the eye no swelling and nodules noted d$ (clera ' is white in color and it is vascular no nodules and swelling e$ Cornea ' has no opacities and no opacities in the lens that may be visible &$ $ris ' are fairly flat and forms a relatively open angle with the cornea g$ Pupils ' pupillary si)e changes in response to light and to the effort of focusing on a near object. *hen a light beam shining onto one retina, it causes pupillary
constriction in both that eye +the direct reaction to light, and the opposite eye +the consensual reaction,.*hen patient shifts ga)e from a far object to a near one, the pupils constrict.

)$ *isual Acuit! ' the patient can read printed material under ade-uate lighting +$ *isual ,ields ' as the patient looks straight, all objects in the periphery were normally seen -$ EOM ' both eyes move parallel to each other in each of the six direction of ga)e. +. foot away, .$ Ears
Physical Assessment by Mr. Jonathan E. Salva

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($ I s'ectio /Pal'atio a$ /uricles ' level with each other the upper point of attachment is in a straight line with the lateral canthus, or corner of the eye its position is almost vertical color is the same as that of the face, without moles, cysts, deformities, or nodules. no presence of redness or extreme pallor it is smooth, and without lesions. %$ 0astoid ' palpable without any presence of lesions and redness. c$ &xternal Canal ' curved and approximately 1 cm long it is lined with skin containing fine hairs d$ Tympanic ' pinkish gray in color )$ Auditor! Acuit! ' the patient sometimes asks the nurse to repeat the statement +although in this case, it is due to the nurse"me having a low voice upon assessment of auditory acuity, C$ Nose ($ I s'ectio a$ &xternal ' smooth and symmetric and the same color as the face no presence of swelling and deformities noted %$ $nternal +Turbinates 0eatus and (eptum, )$ Pal'atio a$ !rontal (inus ' not tender, no masses, or any underlying deviations %$ 0axillary (inus ' not tender, no masses, or any underlying deviations D$ Mout" ($ I s'ectio a$ %ips ' are pink in color, moist, symmetrical, and smooth no presence of pallor or cyanosis or cherry color. %$ 2uccal 0ucosa, 3ums, and Teeth ' no presence of teeth occlusion some teeth are smooth, white, and shiny but some has brown and black discolorations. 0ucous membrane is pinkish red, smooth, and moist but presence of lesions noted. c$ Palate ' hard palate is located anteriorly, whitish in color and dome in shape. (oft palate extends posteriorly toward the pharynx it is light pink in color and smooth no presence of bony growth between two palates. d$ Tongue ' no deviations, tremor, or limitation in movement when it protrudes, it lies midline it moves freely when patient is instructed to raise the tongue up and move it from side to side. )$ Se se o& Taste 0CN *II a d I1, ' patient can distinguish which food is sweet, sour, salty or bitter +assessment upon asking only, E$ P"ar! x

Physical Assessment by Mr. Jonathan E. Salva

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a$ 4vula ' rises centrally as the patient says 5ah6 %$ /nterior and posterior pillars ' are oval in shape, with foldings of tissue c$ Posterior pharynx ' behind the pillars and pharyngeal tissues are pink and smooth no presence of edema, ulceration, or inflammation ,$ Nec2 ($ I s'ectio a$ 0ovement ' no difficulty in moving to all directions was noted %$ 0asses ' no enlargement as noted c$ (ymmetry ' bilaterally asymmetrical because the left thyroid gland was already removed and the opposite side is enlarged. )$ Pal'atio o& 3!m'" Nodes ' lymph nodes +preauricular, postauricular, occipital, tinsillar, submental, superficial cervical, posterior cervical, deep cervical, and supraclavicular, are not easily palpable

ABDOMEN
I$ Healt" Histor! Patient has some known history of any abdominal problems such as indigestion and difficulty in defecation. 7ccasionally the patient will feel abdominal pain, if there is a fever. 8erbali)ed9 50usakit akoang tiyan:.pag naay hilanat .6 Patient will rate pain as ;<= in a scale of .<.> +. ? least painful, .> ? most painful,. Pain is sometimes associated with nausea. Patient likes has a good appetite, has no history of any food allergies. 4sual eating pattern includes9 2reakfast ? . cup rice, . piece egg, . piece meat"chori)o, %unch ? . cup rice, . viand, #inner . cup rice, . viand +snacks would include junk foods, and coke,, drinks milk. @o history of any severe urinary tract infection, viral hepatitis, abdominal surgery, maintenance medications. Play is the usual form of exercise for the patient. Page 4

Physical Assessment by Mr. Jonathan E. Salva

($ I s'ectio a$ @o presence of scars, appears flat. @o presence of bulges, or protuberance. (ymmetrical %$ 4mbilicus is located in the middle of abdomen. +midline at lateral line,. 4mbilicus is similar in skin tone to entire abdomen. c$ @o presence of rashes, striae or scars. d$ (kin appears to be paler than the general skin tone be< cause this skin is so seldom ex< posed to the natural elements. e$ (cattered Ane veins are not visible. )$ Auscultatio a$ = bowel sounds per minute. (ometimes have growling sounds. @o presence of bruits or rubs +$ Percussio a$ 3enerali)ed tympany predomi<nates over the abdomen because of air in the stomach andintestines. @ormal dullness is heard over the liver and spleen. @o presence of tenderness or pain upon percussion. %$ The liver border is in the midclavicular line and is = cm long. -$ Pal'atio 0O l! 3ig"t Pal'atio 4as Do e5 a$ There is no presence of tenderness or any involuntary guarding noted upon palpation of the abdomen %$ (pleen is non palpable c$ %iver was slightly palpable +only light palpation done, d$ Bidney was nonpalpable. @o pain upon palpation of the kidneys. @o C8/ tenderness. e$ 4mbilicus has no swelling or bruises

CARDIOVASCULAR SYSTEM
I$ Healt" Histor! Patient has history of asthmatic condition, with no history of hypertension or disorders of the cardiovascular system. &asily gets tired during strenuous activities. (ignificant others consider playing as the patientCs form of exercise. ($ I s'ectio a$ @o bulges of the precordium noted. /pical impulse not observed. @o other pulsations visible on the chest.

Physical Assessment by Mr. Jonathan E. Salva

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)$ Pal'atio a$ @o presence of thrills +weird vibrations caused by turbulence of blood moving through valves that are seen in the skin like a purring of cat, %$ @o pain upon palpation noted c$ @o heaving of ventricles are fely d$ /pical pulse was fely on the Dth intercostals space and at the midclavicular line, impulse is -uick and not<sharp +$ Percussio a$ %eft border does not extend beyond the midsternal line in the Eth, Dth, and ;th $C(. (ome minimal dullness noted upon percussion +more evident on the left side of the heart"left intercostals spaces, -$ Auscultatio a$ 4pon auscultation, two sounds were heard 5lub6 and 5dub6 %$ s. and s1 are almost e-ual in intensity. (ometimes s. becomes louder that s1. c$ Heart sounds are regular with rate ? F; beats per minute, strong pulses were heard d$ @o presence of sG, splinting, gallops +sE, noted

Physical Assessment by Mr. Jonathan E. Salva

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