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Date of admission: 09/03/12 with ther diagnosis of Hypertensive Encephalopathy, Nephrotic Syndrome

Therr assessment was done on September 22, 2012 @ 11:00 AM in General Ward Soutn Philippines Medical Center


Patient Darna was received on bed, wearing shorts and sando, awake, coent, oriented to time and place with herplock @ ther right radial vein. Upon assessment, sher was experiencing heradacher with pain scale of 7. Sher was order with Low Salt diet and was ordered to increase oral fluid intake.

VITAL SIGNS Temperature: 37.3C Pulse rate: 78 bpm Respiratory rate: 22cpm Blood pressure: 130/100 mmHg Pain scale: 7

SKIN Darna has a fair complexion. Skin was smooth and warm to touch. It was slightly dry and

has good skin turgor. Scar was noted at ther left dorsal aspect of foot.


Head was in normocephalic without any deformities. It was hard, with frontal, parietal and occipital prominences. Scars were not observed. Scalp was clean and there was no presence of infestations such as lice or dandruff. Hair was short, black and thick, and was evenly distributed on her head. Foul odor was not noted. She has symmetrical facial features as well as facial movements. Moon face noted. Headache was noted upon assessment with Pain scale of 7.

EYES Eyebrows and eyelashes were free from flakes. The skin was intact. Scars and lesions were also not observed. The upper and lower lids closed easily and meet completely when it closes. Pupils were equally rounded and reactive to light and accommodation with pupil size of 2mm. Conjunctiva was pale. Eye movements were symmetric throughout six directions. The color of iris is dark brown. She can see clearly. Both eyes are coordinated with parallel alignment.

EARS Ears were symmetrical in size, shape and placement. Both ears were mobile, firm and non-tendered and were aligned with the outer cantus of the eyes. The pinna recoils after it was folded. Hearing was good on both ears. No foul-smelling discharges, lesions and

masses were noted. Slight presence of cerumen on both external canal were noted.

NOSE Nasal septum was in midline. Her mucosa was pinkish in color. No tenderness noted on the maxillary and frontal sinuses. There were no discharges observed. She was able to sniff through nostrils. She was able to distinguish the odor of alcohol when asked to smell it with her eyes closed.

MOUTH Lips were smooth and without lesions, cracks, or indication of dryness. They were pinkish in color. Oral mucosa was pinkish and do not have any masses or lesions. Her tongue was in midline, dark pink and no lesions. Teeth were white and complete. Her gums appeared moist and pinkish. Bleeding or lesions were not noted. She was able to masticate well. She was able to talk in a slow-harsh sound voice. PHARYNX The uvula was in midline. Tonsils were not inflamed. NECK The muscles on her neck were equal in size and head was on the center. Head movement was coordinated and smooth without any discomforts. Trachea was in midline. No enlargement of the lymph nodes was noted. Carotid pulse was palpable. CHERST AND LUNGS Her breathing pattern was regular and was in normal range of 22 cpm. Lung expansion

was symmetrical. No abnormal sounds noted during auscultation.

HEART Pulse rate was palpable within normal range with regular intervals between beats. Blood pressure was not in normal range: 130/100 mmHg. AXILLA No foul smelling odor was noticed. Presence of hair was not noted. ABDOMEN The abdomen was uniform in color. There were no signs of enlargement of the liver or spleen. Lesions, tenderness or any masses were not noted. Umbilicus and surrounding area were free from swelling, bulges or masses. GENITO-URINARY Inspection and assessment of the genito-urinary area was not done. She has no problem in voiding and can also defecate without pain.

BACK AND EXTREMITIES She has a complete set of fingers and toes. Clubbing of the digits was not noted. Peripheral pulse was palpable. Tremors were absent. Hands were pinkish in color as well as the nail beds with capillary refill of 2 seconds. Deformities, lesions and tenderness were not noted.