Arenas, Abigail S.

4C-Group1 Chinese General Hospital College of Nursing and Liberal Arts Adult Physical Assessment Name: MLG Bed 1 Date Admitted: August 16, 2010 Unit/Bed No. Female Cha – Surgery Nationality: Filipino Religion:

Age: 46 years old Sex: FemaleCivil Status: Married Catholic

Diagnosis: Cholecystitis (Cholelithiasis) and t/c Chronic PID Operation (if any) : None Chief Complaint: Abdominal Pain History of Present Illness: A case of 46 diagnosed of Cholelithiasis last 2009, advised for surgery but decided no to undergo. Patient came in due to moderate abdominal pain. 1 day prior to admission patient had a sudden onset of abdominal pain guarded 8 out of 10 in severity, no radiation, driven to go at the Emergency Room of CHGMC, given pain medication. Few hours prior to admission there is recurrence of pain, radiating in the back, not tolerable, patient also noticed greenish vaginal discharge with foul smelling odor required consult consequently admitted. History of Past Illness: (+) Cholelithiasis 2008 with no medication (-) HPN (-) DM (-) Asthma, allergy to foods and drugs Family History: Unremarkable Social History: The patient is a non- smoker and non-alcoholic beverage drinker I. General Physical Assessment and Cranial Nerve Testing

Vital Signs T=37⁰

P=90 R=20

BP=110/70

Height= 4’11 Weight=59kg

Physical appearance/Posture/Body Movements/Hygiene/Nutritional Status:

The patient looks uneasy, has limited movement and stands slouchy. She can move her hands and feet evenly and can stand freely. Patient doesn’t have foul odor. Patient is overweight and consumed 100 % of meal served.

Level of Consciousness/Facial Expression/Mood and Affect/Speech and Gait

PHARYNX The uvula is along the vertical midline of her face and the mucosa is observed to be pinkish. HAIR: Her head is normocephalic. Pupils react briskly to light and accommodation. She can cpntrol her head freely. HEART Her pericardial area is flat. There are no discharges noted upon inspection of nostrils. Mild opaque lenses and equally sized pupils are observed when exposed to light. EARS She has symmetrical ears without any reports of pain or tenderness upon palpation. Her heart sounds are distinct and regular upon auscultation. Her scalp is clean and has no lesions present. MOUTH Her lips are colored pink to dark pink. Both nostrils are patent with symmetrical gross smelling. There are no discharges observed upon inspection of the external canal. Patient didn’t notice any lumps or inflamed lymph nodes in her breast and axillae. CHEST AND LUNGS Her breathing pattern is regular and she has symmetrical chest expansion. The tongue is along the vertical midline of her face and she has missing teeth which are replaced by false teeth. There is no lesion noted. The patient speaks slow and clearly. She has no birthmarks but has moles on her left forearm. No crackles are heard upon auscultation of both lung fields. Veins are easily seen on her skin. She has pink conjunctiva and she has anicteric sclera. Her gross hearing is symmetrical. BREAST AND AXILLAE Patient did not allow student nurse to assess her breasts thoroughly but was open to answer questions verbally. EYES: Her eyelids are symmetrical in shape. Her mucosa is colored pink and is well lubricated with saliva. The patient’s hair color is black to some white strands. She can follow instruction appropriate to her situation. NECK The trachea is along the vertical midline of her face and there are no observations of inflamed cervical lymph nodes. . oily and was evenly distributed. No pain or tenderness is reported upon palpation of sinuses. The skin is cold and soft with no edema.Patient is conscious during physical assessment. Tonsils are not inflamed. She is cooperative and has a little eye to eye contact. SKIN: The patient’s skin color is fair and even. Her nasal mucosa is pinkish in color. NOSE Her nasolabial fold and septum are along the vertical midline of her face. When I pinched her skin it returns back to less than 4 seconds which indicates good skin turgor. Her speech is intact. The thyroid gland is not enlarged.

Rest and Recreation The patients rest and recreation is watching t. Activity and Exercise The patient does not exercise everyday. III. Range of Motion is active. Chest Xray revealed she has mild dextroscoliosis.tender. Significant Health Patterns: a. Work-ups a. Positive pain on the epigastric region radiation on the back and in four other quadrants. BACK AND EXTREMITIES Peripheral pulses are present and symmetrical when palpated.v. Patient reports that she feels pain in her upper right back when she checks papers in school for an extended period of time. II. flabby. Work Type: house wife/sedentary Hazards: None f.ABDOMEN The abdomen is soft. c. Sleep Hours: 6 to 8 hours Bed time rituals: Bathing and Praying b. Nutrition Food Preferences: Patient eats all kinds of food but most often eats meat than vegetables. Muscle tone on both sides on each extremity is equally strong. Diagnostic Studies . high cholesterol foods d. It is not enlarged. The spine has an slightly impaired curvature. Nail beds are pinkish. Amount: Patient consumed 100% of meal served. Dietary Restriction: high fat. only. Elimination Bowel Pattern: Color: Brown Frequency: 1-2x/week Odor: Normal Urinary Pattern: Color: light yellow Frequency: 4x/day Pungent Consistency: Clear Odor: Consistency: Hard e. and non.

effusion.1 4.6 340 12. • Chest Xray Impression: -Pleural thickening/Minimal dextroscoliosis.2 29. pancreatic. Minimal non-specific fluid posterior cul de sac. Laboratory • CBC (8/16/10) Patient’s Value 8. left costrophrenic sulcus. splenic or renal pathology detected • UTZ of the Pelvis (Transvaginal) Impression: -Thickened endometrial stripe with minimal endocavitary fluid.372 87. Suggest follow-up on the proliferative phase of the next cycle.26 126 0.• UTZ of the Whole Abdomen and Appendix Impression: -thickened Gallbladder wall with multiple tiny lithiasis -urinary sedements -non-visualized appendix -thickened endometrium -non-dilated biliary tree -no liver. Mild b. A POLYP is not ruled out.8 Normal Values WBC RBC HGB HCT MCV MCH MCHC RDW DIFFERENTIAL COUNT Bands Segmenters Lymphocytes Monocytes 02 75 15 04 .

9 % PTT Normal Control Internal Normalized Prothrombin Ratio Activity • Liver Profile Test (8/18/10) Descriptiom Cut off Normal Values non-reactive non-reactive non-reactive non-reactive non-reactive non-reactive 2.0 1.23 Patient’s Value 1.0 1.2 HBSAG ANTI HBS ANTI HBC IGM HBEAG ANTI HBE ANTI HAV IGM • Kidney Function test (8/16/10) Female Normal Values 63 Patient’s Value 62-102 umol/L 547 186 145 9-72 u/L 32-92 mmol/L mmol/L Creatinine ALAT (SGPT) Alkaline Phospatase Sodium Potassium 3.8 14.5 1.13 0.18 0.Eosinophils 04 • Prothrombin Test (8/17/10) 14.010 Clear 6.02 1.0 10 MIU/ML 1.002 0.15 0.2 1.02 0.02 96.90 • Urinalysis (8/16/10) Color Light yellow Transparency Reaction pH SPGR 1.0 Microscopic Findings Cells Pus cells 0-1/HPF .

RBC 0-1/HPF Squamous RARE Amorphous urates Amorphous P04 Bacteria RARE RARE MUCUS THREADS: Yeasts Chemical test Albumin (-) Sugar (-) • 8/19/10 Source of Specimen – Vaginal Discharge Gram (+) cocci occurring singly and in pairs – few Gram (-) bacilli few Leukocytes – rare No intra/extracellular gram (-) diplococcic seen .

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