VII. Physical Assessment I.

General Survey Received lying on bed, awake with ongoing IVF of PNSS 1 L infusing well at right metacarpal vein in 30 gtts/min or 120 cc/hr. She has an order of DAT. Her level of consciousness was alert, coherent and oriented to time, place and person. She was calm throughout the assessment and did not appeared distress while interviewing her. She was able to convey her feelings and concerns without any hesitations. The patient was relaxed and has coordination whenever the client move. The patient was wearing a brown blouse and slacks. Ling has a bandana over her head to cover the side effects of chemotherapy, which is balding or alopecia. She was properly groomed; nails are properly and neatly trimmed. No body odor in relation to any activity, however halitosis was noted. The clients affect was appropriate to the situation. The quantity of speech is understandable but soft and slow and has a coherence of thoughts. The relevance or organization of her thoughts makes sense. II. Vital Signs and Anthropometric Measurement Temp. - 36.1 RR - 27 cpm PR - 83 bpm BP - 100/70 mmHg

III. Skin

Generally uniform, except in areas exposed to the sun. The skin was scaly, yet the skin turgor was normal. There were various interruptions in the lower extremities; multicolored or raised nevi. When pinched, the skin springs back to previews state. IV. Head The head was normocephalic and symmetric, with frontal, parietal, and occipital prominences; smooth skull contour. Smooth, uniform in consistency absence of nodules or masses, upon palpation. Symmetric facial movements. There was no hair, as side effects of chemotherapy. However, Ling always wear wig to hide her alopecia. No infection or infestation. V. Eyes The eyebrows are thinly distributed, skin was intact, symmetrically aligned, equal movement. The eyelashes was equally distributed; straight. The eyelids was intact, no discharges or discoloration. Lids close symmetrically. Patients eyes were symmetrical and moves in unison. She has thick black eyebrows. Normal blinking reflex was noted with straight thick lashes pointing outwards lashes. Pupils are brown, equally round and reactive to light and accommodation at 2 mm in diameter. Her periorbital region were sunken. Patient has normal eye movement. No edema or tenderness over lacrimal gland. No edema or tearing upon palpation and inspection of the lacrimal sac and nasolacrimal duct. Blinks whenever the cornea was touched. The color of the eyes was brown, equal in size (2mm), round. Iris was flat and round. Illuminated pupil constricts. When looking straight the client can see objects in the periphery. Both eyes coordinated, move in unison, with parallel alignment and able to read news print. VI. Ears The auricles has same color with the face and was aligned with the outer canthus

of the eyes. Upon palpation, the auricles was firm and not tender; pinna recoils after it was folded. No infestation, lesions, and discharges was seen. Was able to response in normal voice tones. Able to hear ticking in both ears. VIII. Nose The nose was symmetric and straight. No discharge or flaring was noted. Nose was uniform in color, not tender and no lesions was seen upon inspection. Air moves freely as the client breath through the nares. Has watery discharge. Nasal septum was intact and in the midline. Upon palpation of the maxillary and frontal sinuses no tenderness was present. IX. Mouth The outer lips was symmetric and darker in color. Scaling was noted. Client can pursed his lips. The inner lips and bucal mucosa is uniformly pink in color. It was moist and smooth. Complete teeth, however it was yellow and has dental carries. Gums was firm and smooth however it was red. No retraction of the gums. Only the hard and soft palate were seen. The tongue was white, moves freely, no tenderness and no swelling or ulceration. Gag reflex was present. X. Neck and Throat The muscle was equal in size and the head is in the center. The head movement was coordinated with no discomfort. Upon palpation of the entire neck, lymph nodes are not enlarged. The trachea was in the midline of the neck. The thyroid was not visible upon inspection and palpation. When the client swallowed, the gland ascends during swallowing but is not visible.

XI. Breasts At first, the Ling was hesitant to show her breast. But later on agreed on condition that her identity would not be revealed. The breast was not even, right breast appears to

be normal while left breast was bigger than the right, and has dimpling in the lower portion of the pectoris. Left breast has lump, and the texture of the skin is dissimilar to the right. It was scaly and brownish. XII. Back and Lungs The chest was symmetric, scoliosis was noted. The spinal column deviates to one side (left). The shoulders were not even. The skin was intact and has uniform in color. No tenderness or masses noted. Full and symmetric chest expansion. Upon percussion of the thorax, the notes resonate except over scapula. Upon auscultation, adventitious breath sound was heard, crackles. Upon palpation of the anterior chest the respiratory excursion was fully symmetric. The breathing pattern was normal. XIII. Heart and Peripheral Vascular System Patients apical pulse was at the rate of 83 bpm, which is within the normal range. Her heart sound is distinct and is audible upon auscultation. XIX. Abdomen The abdomen was not distended. The abdominal movement were symmetric upon respiration. Audible bowel sounds. No tenderness upon percussion. XX. Genito-urinary Client refused to show her private parts. XXI. Extremities Upper Limbs Patients shoulders and arms, as well as his elbows, are asymmetrical with a normal range of motion. No deformities. Her nails were properly trimmed. Lower Limbs Almost all of the nails were properly trimmed.