V.

PHYSICAL ASSESSMENT

A. INTEGUMENTARY SYSTEM

Skin is brown in complexion, moist, warm to touch and sites exposed to

the sun are slightly darker, with wrinkled face, loose skin, skin turgor is less than
3 sec, T=36.8°C per axilla, scattered acrochordons (skin tags) noted, with birth
marks extending from L side of anterior and posterior chest extending to the L
upper extremity, lentigines noted on both L & R upper extremities, dry & scaly
skin in both lower extremities; Hair is grey with white streaks, appropriately
distributed according to gender and age, no infestations noted, with unshaved
facial hair; Nails are dirty and untrimmed, very pale nail beds, capillary refill of
less than 3 seconds, no clubbing noted.

B. NEUROLOGIC / EENT

Conscious and oriented to time, person and place; Head is normocephalic

, neck is in midline; Eyes are symmetric, pale conjunctiva, brown iris, PERRLA,
constrict from 3mm to 4mm, gray-white arcus senilis noted around cornea,
eyebrows move symmetrically as expression changes; Ears are symmetric,
cerumen noted on both ears, can hear moderate tone voice at a distance of 1
foot, no lesions noted; Nose is at midline, no discharges noted, intact nasal
septum, with NGT to gravity drain inserted at R nares draining to approximately
10cc of yellowish secretions; lips are dry, teeth have dental carries, missing lower
R & L 1st and 2nd molars; CN1 intact, able to smell alcohol; CN2 intact as
manifested by ability to recognize faces of folks; CN 3, 4 & 6 PERRLA and able
to follow ocular movements; CN5 can differentiate sharp and blunt points of the
pencil and ballpen; CN7 intact, able to raise eye brows, close eyes and puff
cheeks, and also display appropriate facial expression; CN8 can hear moderate
tone voice at a distance of 1 foot; CN9 can slightly move tongue from side to
side; CN10 able to swallow saliva; CN11 intact, able to move head from side to
side with little difficulty; CN12 able to protrude tongue in midline and move it up
and down; C6, 7 & 8 Unable to fully close L hand when asked to do so.

C. RESPIRATORY SYSTEM

Nose is at midline, patent nares, with NGT to gravity drain on R nares

draining to yellowish secretions approximately 10cc in amount; thorax is
symmetrical and elliptical, symmetric upon chest expansion, resonant upon
percussion, crackles heard over L lung, breathing pattern: deep inhalation and
shallow expiration; RR= 27 breaths/min.
 D. CARDIOVASCULAR/CIRCULATORY SYSTEM:

L & R temporal pulse 90 bpm, L carotid 90 bpm, PMI between 2 nd and 3rd
intercostal space 87 bpm; BP=110/60 mmHg; with IVF of PNSS x KVO as main
line in L cephalic vein, BT 20 gtts/min via piggyback; with CVP line attached to R
subclavian vein with PNSS at KVO, CVP=5cm H 2O; pale conjunctiva, pale nail
beds, capillary refill of more than 3 seconds.

E. GASTROINTESTINAL & HEPATOBILIARY

Lips are dry, R and L 2nd and 3rd molars are no longer present, tongue pink
and moist, pink and hydrated gums, tonsils at grade +2, pink oral mucosa, gag reflex
elicited, able to swallow saliva, abdominal girth of 30 inches, protuberant, inverted
umbilicus, foods PO, able to expel flatus, dullness on liver, tympanic over umbilical
region upon percussion, defecated to semi-solid yellowish discharges on diaper in
moderate amount on shift.

F. GENITO-URINARY SYSTEM

With Foley catheter inserted already for 1 day draining approximately 250
mL of yellowish colored urine to urobag during shift

G. REPRODUCTIVE
Circumcised, no tenderness and lesions noted on breast.

H. ENDOCRINE

On NPO, increased thirst; HGT = 192 mg/dL.

I. MUSCULOSKELETAL
Upper and lower extremities strength rated at 2/5 ROM with gravity
eliminated, poor muscle strength.

J. LYMPHATIC SYSTEM
Palpable axillary lymph nodes; tonsils at grade +2.

K. HEMATOPOEITIC
No blood transfusion reaction; Hematology result: 9/18/07 Hgb=85g/L,
RBC Volume Fraction=0.26L/L, RBC number concentration= 3.47x10 12 /L,
Leukocyte number concentration=7.9x10 9/L, Neutrophil number fraction=0.86,
Lymphocyte No. Fraction=0.11, Eosinophils No. Fraction=0.03.