pt who looks normal except that he is bald and had constipation he
was diagnosed with: AML - M3, post CTX, respiratory
failure, pulmonary hemorrhage, Atypical pneumonia the assessment
should be short in two lines and include :
skin, head, neck, eyes, ears, nose, mouth & throat, cheat
& lungs, heart & circulatory system, gastrointestinal
system, urinary/genital, musculoskeletal, neurologic
examination/reflexes
** this might help you write some of it but
briefly:
- I Want The Physical Assessment From Head To Toe For A Pt Who Looks Normal Except That He Is Bald And Had Constipation 1 (143.92 KiB) Viewed 17 times
- I Want The Physical Assessment From Head To Toe For A Pt Who Looks Normal Except That He Is Bald And Had Constipation 2 (194.94 KiB) Viewed 17 times
- I Want The Physical Assessment From Head To Toe For A Pt Who Looks Normal Except That He Is Bald And Had Constipation 3 (104.2 KiB) Viewed 17 times
- I Want The Physical Assessment From Head To Toe For A Pt Who Looks Normal Except That He Is Bald And Had Constipation 4 (159.7 KiB) Viewed 17 times
- I Want The Physical Assessment From Head To Toe For A Pt Who Looks Normal Except That He Is Bald And Had Constipation 5 (192.97 KiB) Viewed 17 times
Skin, Hair & Nails Skin: her skin elastic, is normal color (browen), moist and soft texture, it's color is normal pink with a little flushed face, and no bad odor from her skin, no has any lesions, massess, ecchymoses, petechiae and pruritus. no skin rashes ,no noscares on the skin ,no patches ,. The hair color is light browen and soft, Her hair is short fine and normal growth is a good distributor with no alopecia, No masses and her odor is good, Nails: normal color pink and clean but not well cut. Head & Neak : Head :symmetrical the size of her head to the body is normal for his age , no scares ,distributed hair, no lice. Face: she has symmetry facial organ .smooth and warm skin, unbroken ,with good muscles movement. No involuntary movement of focal muscles .in addition, it doesn't contain wart, wounds or scars. Neck : move its head in the four directions up, down, left, right, has a normal lymph nods :trachea is in the middle and with normal size ,equal bilaterally pulse protruding neck vein (98). Thyroid gland is difficult to palpate but thereis no any 5 enlargement. No any deviation ,masses ,or nodules when palpating neck structures. Eyes: Has normal and symmetry placement & are horizontally on imaginary line of eyes . normal color and movements of lids. The two eyes have the same size and distance from face outer ,good distribution and direction of hair of the eyelashes & eye browen..pupil react to light round (pupil equal round , reacts to light &accommodation {PERRLA}), moist and pink lid margins , no ulcers no redness , white sclera ,pink conjunctiva ,light eyelashes , and sure that's no medicinal glasses or lens because she is very young you can look in all directions & up and down , no discharge Ears: Symmetrical , extends slight forward from the skull , similar in size location and color ,equal hearing ability in both ears . no discharge , no lesions no bleeding or inflammation , good hygiene of ears, soft yellow waxy serum without odor. no abnormal opening and discharge ,normal external canal ,good hearing in both ears for example: she listen a voice of the game and drew attention
Diet and Nutrition : Eat according to appetite , if she is hungry, she sometimes eat, not all the time because she anxiety during stay in hospital . 9 No from any allergies to any type of food , she have normal diet but she heat eggs. Musculoskeletal system : Has symmetry of shoulder and hips. Doesn't have free movements of joints (especially in right hand )dislocation in Rt hand during labour. , mild mobility. has straight posture of back. doesn't have any extra fingers, unbroken of the body pt. Neurological system : She is oriented to sound , fully conscious , good behavior when she with her parents . alert , good sensory functioning ( vision , hearing , skin touch ) IV Therapy: Ringel lactiet (R/L) Site: (IV) Amount: 500cc Frequency :6/hrs. Significance for pt: rehydution Added medication : Zinazf (cefaroxim)750 mg *3 10 Medication & Drugs: Include generic and trade name prn
Abdomen: Has lax and soft abdomen , good peristalsis , & bowel movement(21 / min), and good stomach , no lesion or scars , clean umbilicus . no masses in the abdomen .not tender or distended . she have right nephrostome with right obstructive ureteric stone { the nephrostomy has been inserted on 1/9/2010.it is functioning. By using percussion : she have edema and flatulence because she suffering on hydroniphrosis and by using percussion I heard tympani sound over stomach & dullness at liver. 8 There is no bleeding the pt doesn't have any constipation or diarrhea and no N&V. Genitalia & Reproductive system: No examination (she's female ) Rectum & anus: she doesn't have any masses, swelling, lesions, abnormal discharge and disease. no presence of vaginal lesions, She has folys catheter 1 day post-op total output was 450 CC. She doesn't have any rectal bleeding, pain, cancer, polyps or inflammatory bowel diseases, after op she has a little constipation, put folys catheter one day post-op total output 450cc. Elimination: A:bowels: she bowel 1 time /day or 2day, no changes in bowel habits ,no indigestion and incontinence, bowel movement(21 / min), and on constipation and diarriah B:urination: pt her mouther said: she doesn't have pain, dysuria, anuria, hematuria, oliguria and polyuria urine normal color, no dysunia , no polyuria , no frequency ,good urine out put (450 cc) Diet and Nutrition : Eat according to appetite , if she is hungry , she sometimes eat, not all the time because she anxiety during stay in hospital . 9
Ears: Symmetrical ,extends slight forward from the skull , similar in size location and color ,equal hearing ability in both ears. no discharge , no lesions no bleeding or inflammation , good hygiene of ears , soft yellow waxy serum without odor . no abnormal opening and discharge ,normal external canal ,good hearing in both ears for example: she listen a voice of the game and drew attention. Nose & Sinuses: Is in the middle of the face, symmetrical appearance . both nostrils equal in size . nasal openings are pt. by inspection to the inner of the nose by the light , it is clean, no secretion. Nasal septum free from deviation , sinuses are invisible and painless by touching , same color as face, smooth skin . no swelling or tenderness. No rhinitis , no nasal deviation, no discharge and has stuffy nose 6 The pt can smell any things, he can smell odor of food during feeding, and her nose is straight without warping, no pain, no obstruction. Mouth & Pharynx: Soft and intact lips, pink in color . Complete hard &soft plate, normal size of tongue and it has rough texture , move freely , no cleft plate. good sucking, no ulceration in mouth, moist and smooth, a little speech because she's baby. There is no bleeding ,no swelling of gums, no increase in the secretion of saliva , no fungi in the mouth of the pt movement, has 22 teeth and can digest food properly she doesn't has any pain or tonsillitis. , Thorax & Lungs: Respiratory: The patient breathing deeply good and equal airway bilateral passage, breathing rate of 97% and by using stethoscope her RR is 18 times/min deep regular rhythm, no wheezing or any abnormal breath sounds or dyspnea, a little sputum, no presence of cough, is 22 , chest movement was rapid and significant, the lung is symmetry, lung sound is normal(S1-S2), no murmurs, no retractions and no wheezes. Cardiovascular System: according to auscultation by using stethoscope she has normal heart sound(s1&s2)( blub dub) & regular heart rate(RHR) I found apical pulse 67 b/m and