Professional Documents
Culture Documents
Documentation
Documentation
Documentation
For
Patient X
Donnabell L. Dayuday
A. Demographic Data
Name: Cassey Nicole Libron
Age: 19 years old
Gender: Male
Address: Talay, Dumaguete City
Date of Birth: October 17, 2000
Place of Birth: Bonawon Siaton, Negros Oriental
Nationality: Filipino
Marital Status: Single
Educational Level: College (Ongoing)
Occupation: Student
Usual Source of Income: None
Informant: Patient
B. Physical Examination
a) General Survey
1. Appearance
The patient appears to be the same as his reported age. His sexual
development is appropriate. He is alert & oriented with no signs of acute
distress and facial features are symmetrical.
2. Body structure/ mobility
Weight and and height are within the normal range. His body parts are equal
bilaterally. He stands erect, sits comfortably, gait is coordinated, and his walk
is smooth and well balanced with full mobility of joints.
3. Behavior
The patient maintains eye contact with appropriate expressions, comfortable
and cooperative. His speech is clear and his clothing is appropriate to the
climate. He looks clean and fit and appears to be clean and well-groomed.
b) Skin
The patient’s skin color is even-toned, with pigmentation appropriate for his
genetic background and no obvious lesions, edema or variations in color. Skin
is smooth and dry with minimal perspiration and oiliness and is uniformly
warm. Skin lifts easily and snaps back immediately to its resting position.
c) Nails
The patient’s nail is well-rounded and convex. It is smooth with a uniform
appearance, no visible lesions, and no signs of dryness, softness, brittleness,
splitting, peeling, ridges, or pitting. Nail beds are pink and capillary refills
within 1-2 seconds after the nail bed is pressed and no tenderness noted. No
signs for clubbing, cyanosis or ingrown as well.
d) Hair
The patient’s hair is evenly distributed and color matches the patient’s racial
and genetic make-up. Hair is resilient to minimal pressure. The scalp is
smooth and inelastic with even coloration and equal distribution. No visible
lesions and tenderness noted.
e) Head
The patient’s head is upright and still, the skull is generally round with
prominences in the frontal area anteriorly and the occipital area posteriorly.
No visible lesions and tenderness.
f) Face
The contour of the patient’s face matches the color of the patient’s body with
no involuntary movements noted. A small amount of pustule is present with
no visible lesions, masses and tenderness noted. Cranial nerves intact as per
positive result in the CN VII test. The patient’s eyebrow is symmetrical in
appearance and no involuntary movement. No visible lesions and tenderness.
g) Eyes
The patient’s eyelid does not cover the pupil when the eyes are open but it
does partially cover the iris. Eyelashes are normally distributed evenly and
curved outward away from the eyes. Conjunctiva is moist and pink with no
drainage. Sclera appears to be china white. The Cornea is clear and bright
with no signs of opacity or cloudiness. Iris appears to be flat with a round
regular shape and even coloration. Pupil normally appears round, regular, and
of equal size in both eyes.
Visual Acuity Result
OD 20/20 with no mistake
OS 20/20 with 1 mistake
OU 20/20 with 1 mistake
l) Breast
The patient’s breast is even with the chest wall, and contains darkly
pigmented nipple and areola, breast skin color is uniform to the patient’s skin.
Skin is intact and smooth, no presence of nipple discharge, swelling, lesions,
scaling or cracks around nipples, dimples, or lumps. No tenderness noted around
the breast and the lymph nodes surrounding the breast and axilla.
m) Respiratory System
Breathing rate and depth is normal, rhythm is regular. Side to side
symmetric chest shape, spine is straight without lateral deviation, scapula is
symmetrical and closely attached to the thoracic wall, no bulging or active
movement of ICS during breathing. No presence of crepitus upon palpation. Faint
symmetrical vibrations is present as the patient speaks. Resonance and Dullness
is heard during percussion and bronchial, bronchovesicular and vesicular sound is
normally heard upon auscultation.
n) Cardiovascular System
Regular heart rate and rhythm, No presence of heart murmur, thrills,
varicose veins, swelling of legs. PMI is heard in the apical pulse.
o) Gastrointestinal System
Color is symmetrical as the rest of the patient’s body. No presence of
scars, bruise, venous patterns, lesions, and striae. Abdomen is soft and non-tender.
Umbilicus is midway between the xiphoid process and the symphysis pubis.
Shape is flat, no signs of inflammation, no discharge and protruding mass.
Swallowing is intact, positive bowel signs. Peristalsis is present, audible sound is
heard 18 times per minute. No rebound tenderness noted.
p) Musculoskeletal System
Muscle strength +5. Movements smooth and coordinated. Gait balanced
and fluid with conformity of phases. No muscular pain/weakness, joint swelling,
soreness, or stiffness, leg cramps, bone defects noted. Negative Romberg’s test.
Able to perform ROM in all areas in the body.