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  • Physical Assessment

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    Aziil Liiza
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    The physical examination and review of systems document summarizes the patient's condition, noting pertinent positive and negative findings. The patient appears weak and fatigued with noticeable weight loss. Skin is dry with pallor. Chest pain and hypotension were observed. Gastrointestinal issues include anorexia, nausea, and vomiting. Urinary problems involve proteinuria and oliguria. Neurological signs comprise peripheral neuropathy, muscle cramping, twitching, and weakness preventing ambulation. The patient is anemic with weight loss and decreased appetite. Psychologically, the patient is stressed and anxious due to the illness.

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    The physical examination and review of systems document summarizes the patient's condition, noting pertinent positive and negative findings. The patient appears weak and fatigued with noticeable weight loss. Skin is dry with pallor. Chest pain and hypotension were observed. Gastrointestinal issues include anorexia, nausea, and vomiting. Urinary problems involve proteinuria and oliguria. Neurological signs comprise peripheral neuropathy, muscle cramping, twitching, and weakness preventing ambulation. The patient is anemic with weight loss and decreased appetite. Psychologically, the patient is stressed and anxious due to the illness.

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    247 views2 pages

    Physical Assessment

    Uploaded by

    Aziil Liiza
    The physical examination and review of systems document summarizes the patient's condition, noting pertinent positive and negative findings. The patient appears weak and fatigued with noticeable weight loss. Skin is dry with pallor. Chest pain and hypotension were observed. Gastrointestinal issues include anorexia, nausea, and vomiting. Urinary problems involve proteinuria and oliguria. Neurological signs comprise peripheral neuropathy, muscle cramping, twitching, and weakness preventing ambulation. The patient is anemic with weight loss and decreased appetite. Psychologically, the patient is stressed and anxious due to the illness.

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    of 2

    ACTIVITY 3: PHYSICAL EXAMINATION &

    REVIEW OF SYSTEMS
     
    PHYSICAL EXAMINATION & REVIEW OF SYSTEMS 
    Read your book regarding the case and write down focused assessment on the
    organs/system affected and state all pertinent findings appropriately (+/-)

    General Survey + Consciously lying on bed which appears weak,


    fatigue
    + noticeable weight loss

    Skin + skin is dry


    + pallor
    - fair complexion

    Head, Eyes, Ears, Nose, Throat - hair is evenly distributed


    - absence of nodules
    + facial grimace
    - tenderness
    - responsive to moderate voice
    - symmetric with the nasal septum at the center
    - no lumps or swollen glands

    Neck - no lumps or swollen glands


    - coordinated, smooth movements with no
    discomfort

    Chest - tenderness
    - masses

    Respiratory - no wheezing
    - no hemoptysis

    Cardiovascular + chest pain


    + hypotensive with BP of 90/60 mm/Hg

    Gastrointestinal + anorexia
    + nausea and vomiting

    Urinary + proteinuria
    + oliguric

    Genital  - no libido
    - no masses
    - no unusual discharges on genital area
    Peripheral / Vascular  + peripheral neuropathy

    Musculoskeletal + muscle cramping


    + muscle twitching
    + weakness
    + unable to ambulate

    Neurologic  + peripheral neuropathy

    Hematologic  + anemic

    Endocrine + noticeable weight loss


    + decreased appetite
    - no thyroid enlargement

    Psychiatric + stressed due to illness


    + anxious

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