8|ograph|c Data

at|ent's In|t|a|s CA
Age 44 years old
Gender lemale
Date of b|rth AugusL 31 1967
|ace of b|rth Manlla
Current Address #469 lnL 6 Peroes 8d 96 SL L1 873
ke||g|ous Cr|entat|on 8oman CaLhollc
Nat|ona||ty llllplno
Mar|ta| Status SeparaLed
Ch|ef Comp|a|nt Severe uC8
Adm|tt|ng D|agnos|s neumoLhorax Seceondary Lo CA 18
hys|c|an ur Cruz
8ed Number 349

Nurs|ng n|story

AS1 nLAL1n nIS1Ck
Ch||dhood |||ness
1he paLlenL clalms LhaL she had only experlence mlld lllnesses such as fever cough and colds
8aLher Lhan LhaL she denled any ma[or dlseases durlng her chlldhood years Wala naman akong
naranasang maLlndlng saklL noong baLa pa ako" as verballzed by Lhe paLlenL

Accordlng Lo Lhe paLlenL's charL she had or currenLly poslLlve wlLh Lhe followlng dlseases such
as measles 18 uM u1l and lL was sald LhaL she ls a heavy smoker

Immun|zat|ons
1he paLlenL ls unaware and does noL anymore recall her lmmunlzaLlons

A||erg|es
Accordlng Lo paLlenL's charL she nelLher has drug allergles nor food allergles

Acc|dents
1he paLlenL clalms LhaL she dld noL experlence any accldenLs way back before or even
recreanLly Sa awa naman ng ulyos hlndl ako nakaranas ng accldenLe sa buong buhay ko" as verballzed
by Lhe paLlenL

nosp|ta||zat|ons
1he paLlenL sald LhaL Plndl pa naman ako nahosplLal daLl ngayon pa lang unang beses nagulaL
nga ako aL blglang nangyarl sa akln lLo"

Med|cat|ons used or current|y taken


Iore|gn 1rave|
1he paLlenL clalmed LhaL she hasn'L Lravel ln forelgn counLrles She also sald LhaL she wenL Lo
Manlla when she was 12 Lo look for a [ob Slnce Lhen she wasn'L able Lo LeyLe


nIS1Ck CI kLSLN1 ILLNLSS
1he paLlenL was rushed lnLo Lhe hosplLal because of severe dlfflculLy of breaLhlng and cough
whlch already lasLed for days upon Lhe dlagnosls regardlng her condlLlon she was advlsed Lo
undergo LhoracosLomy because of pneumoLhorax She was also dlagnosed of havlng 18

IAMIL nIS1Ck
Accordlng Lo Lhe paLlenL's charL Lhere ls a heredlLary dlsease LhaL runs ln Lhelr famlly such as
ulabeLes MellLus And slnce 18 and pneumonla ls hlghly communlcable Lhere ls a hlgh posslblllLy LhaL
her famlly members also have Lhls condlLlon


lv AC1lvl1lLS Cl uAlL? LlvlnC
8efore nosp|ta||zat|on

Dur|ng nosp|ta||zat|on

Interpretat|on and Ana|ys|s

NU1kI1ICN
aLlenL eaLs her meals 3 Llmes a
day and lL ls compose of red
meaL flsh and vegeLables
SomeLlmes she also eaLs frulLs

LaL once a day and mosL of Lhe
Llme she eaLs blsculLs
l 1here are blg dlfferences ln her
nuLrlLlon before and durlng
hosplLallzaLlon

A paLlenLs who are hosplLallzed
may have an lnadequaLe dleLary
lnLake because of Lhe lllness or
dlsorder LhaL necesslLaLed Lhe
hosplLal sLay or because Lhe
hosplLal's food ls unfamlllar or
unappeallng

(8toooet ooJ 5oJJbotts
MeJlcol
5otqlcol Notsloq 11
tb
eJltloo
volome 1 poqe 8J)
L||m|nat|on
usual urlnaLlon was 6 Llmes a
day and once a day sLool
urlne 4 Llmes a day
SLool once every 2 days
l 1he cllenL has dlmlnlshed urlne
ouLpuL durlng Lhe
hosplLallzaLlon

A decrease ellmlnaLlon ls due Lo
decrease food lnLake 1he
average dally urlne ouLpuL for
adulL ls 1200 Lo 1300 ml urlnary
frequency ls voldlng aL frequenL
lnLervals LhaL ls more Lhan 4 Lo
6 Llmes per day An lncreased
lnLake of fluld causes some
lncrease ln Lhe frequency of
voldlng 1he normal color ls
sLraw amber and LransparenL
1he odor should be falnL
aromaLlc

(looJomeotols of Notsloq by
kozlet tbs 8
tb
Jltloo volome
2 pp 1288129J)


Lxerc|se
1he paLlenL usually walks aL
mornlng for abouL 20 mlnuLes
She consldered walklng as a
form of exerclse Powever she
menLloned LhaL Lhls ls noL
conslsLenL She also does her
rouLlnes llke cooklng and oLher
household chores MosL of her
free Llme ls used ln waLchlng 1v
MosL of Lhe Llme she ls [usL
seaLed or lled all day long ln bed
SomeLlmes she ls chaLLlng wlLh
her daughLer and room maLes ln
Lhe hosplLal
l before he exerclse ofLen buL
when she was hosplLallzed she
doesn'L exerclse

A arLlclpaLlng ln regular
exerclse can prevenL dlseases
such as obeslLy dlabeLes and
hyperLenslon lndlvlduals who
have lnacLlve llfesLyles or who
are faced wlLh lnacLlvlLy are rlsk
for many problems LhaL affecLs
ma[or body sysLems

(looJomeotols of Notsloq by
kozlet tbs 8
tb
Jltloo volome
2 pp 1117 124J)


S|eep and kest
1he paLlenL usually sleeps aL 1
am and wakes up aL 6 am 1he
paLlenL usually sleeps
unlnLerrupLedly wlLhln 3 hours
per day She also sald LhaL she
Lakes naps around 1 or 2 pm ln
Lhe afLernoon
1he paLlenL sleeps aL around 8
pm and wakes up aL 6 am
Powever lL ls always lnLerrupLed
whenever she feels Lhe urge Lo
urlnaLe and when she ls glven
her medlcaLlons She also Lakes
naps whenever she wanLed slnce
she ls ln Lhe hosplLal
l 1he paLlenL has dlmlnlshed
quallLy of sleep

A MosL healLhy adulLs need 7 Lo
9 hours of sleep a nlghL
Powever Lhere are lndlvldual
varlaLlons as some adulLs may be
able Lo funcLlon well wlLh 6
hours of sleep and oLhers may
need 10 hours of sleep Lo
funcLlon opLlmally

(looJomeotols of Notsloq by
kozlet tbs 8
tb
Jltloo volome
2 p 1669)

nyg|ene
1he paLlenL Lakes a baLh aL leasL
once a day She also brushes her
LeeLh Lwlce a day 1he paLlenL
has denLal carrles and she losL
mosL of her LeeLh
1he paLlenL was noL able Lo Lake
a baLh slnce Lhe day of her
admlsslon She only changes her
cloLhes Also she cannoL brush
her LeeLh because she Lends Lo
lle on Lhe bed mosL of Lhe Llme
l 1he paLlenL cannoL malnLaln
her hyglenlc pracLlces

A Pyglene ls Lhe selfcare by
whlch people aLLend Lo such
funcLlons as baLhlng LolleLlng
general body hyglene and
groomlng Pyglene ls a hlghly
personal maLLer deLermlned by
lndlvldual values and pracLlces lL
lnvolves care of Lhe skln halr
nalls LeeLh oral and nasal
cavlLles eyes ears and perlneal
genlLal areas

(looJomeotols of Notsloq by
kozlet tbs 8
tb
Jltloo volome
2 pp 1117 124J)

Sexua| Act|v|ty
SlnCL 1PL CLlLn1 lS SLA8A1Lu SPL nC LCnCL8 LnCACL ln1C SLxuAL AC1lvl1?

*5ome doto ore hypothetico/ becouse we were not ob/e to hove on interview with the c/ient due to
sofety protoco/s*

Fhys|co| Assessment
Areo o| Assessment Normo| ||nd|ngs Actuo| ||nd|ngs
Evo|uot|on
8ody bu||d, he|ght,
we|ght
Froport|onote, vor|es w|th
|||esty|e
enccmcrph
WI: ncI Icken
Ncrmc|
Fosture ond go|t,
stond|ng s|tt|ng
wo|k|ng
ke|oxed, erect posture;
coord|noted movement
Fe|cxec, bent posture
DevicIicn
frcm
ncrmc|
Overo|| hyg|ene ond
groom|ng
C|eon, neot bnt|dy |ook|ng
DevicIicn
frcm
ncrmc|
8ody ond breoth
odor
No body odor or m|nor
body odor re|ot|ve to
work or exerc|se; no
breoth odor
Hos notob|e body odor
ond breoth odor
DevicIicn
frcm
ncrmc|
$|gns o| d|stress |n
posture ond |oc|o|
express|on
No d|stress noted Nc ci:Ire:: ncIec
Ncrmc|
Obv|ous s|gns o|
heo|th ond |||ness
Heo|thy oppeoronce
Sign: cf i||ne:: i:
uncppcrenI
Ncrmc|
Att|tude
Cooperot|ve, ob|e to
|o||ow |nstruct|ons
CccpercIive, cL|e Ic
fc||cw in:IrucIicn:
Ncrmc|
A||ectJmood Appropr|ote to s|tuot|on /pprcpricIe Ic :iIucIicn
Ncrmc|
Quont|ty ond quo||ty
o| speech
bnderstondob|e,
moderote poce; c|eor
tone ond |n||ect|on;
exh|b|ts thought
ossoc|ot|on
Uncer:IcnccL|e, fc:I
pcce: c|ecr Icne cnc
inf|ecIicn: exhiLiI:
IhcughI c::ccicIicn
Ncrmc|
ke|evonce ond
orgon|zot|on o|
thoughts
Log|co| sequence;
mokes sense, hos sense
o| reo||ty
Lcgicc| :euence:
mcke: :en:e, hc: :en:e
cf rec|iIy
Ncrmc|
Areo to be Assessed Normo| ||nd|ngs

INIEGbMENIAkY





$k|n
Co|or vor|es |rom
||ght to deep brown
Genero||y un||orm
|n co|or
No edemo
Mo|sture |n sk|n
|o|ds ond the ox|||oe
Genero||y un||orm
|n temperoture ond w|th|n
normo| ronge
$pr|ngs bock to
prev|ous stote when
p|nched

ccrk Lrcwn in
cc|cr
d|sco|orot|on o|
r|ght |oot [po|e wh|te}
presence o|
edemo on honds ond
||ngers ond on r|ght |oot.
Fresence o|
crocks ond |es|ons on
r|ght |oot


Ncrmc|
DevicIicn
frcm
ncrmc|
DevicIicn
frcm
ncrmc|
DevicIicn
frcm
ncrmc|
No||s
Convex curvoture,
10 degree ong|e;
smooth texture;
h|gh|y voscu|or, p|nk |n
||ght-sk|nned, brown |n
dork-sk|nned c||ents;
|ntoct ep|derm|s;
or|g|no| co|or returns
genero||y |ess thon 4 sec.
$hort ond c|eon

n/c
po|e wh|te |n co|or

inIccI epicermi:
n/c
|ong ond
untr|mmed



DevicIicn
frcm
ncrmc|
Ncrmc|

DevicIicn
frcm
ncrmc|
HEAD

$ku||
kounded
[normocepho||c ond
symmetr|c w|th |ronto|,
occ|p|to| ond por|eto|
prom|nence}; smooth
Fcuncec
{ncrmccephc|ic)




Ncrmc|
sku|| contour;
Absence o|
nodu|es ond mosses

n/c
$co|p
L|ghter thon |oc|o| sk|n,
mo|st, no scor;
No |es|ons ond
tenderness upon
po|pot|on
LighIer Ihcn fccic|
:kin, nc :ccr
n/c

Ncrmc|
Ho|r
Even|y d|str|buted;
th|ck; s||ky ond
res|||ent;
no |n|ect|on or
|n|estot|on
ven|y ci:IriLuIec
Ihick
n/c
Ncrmc|
Ncrmc|
Foce
$ymmetr|c |oc|o|
|eotures
$ymmetr|c |oc|o|
movements
SymmeIric fccic|
fecIure:
n/c
Ncrmc|
EYE$
No |es|ons ond
|n||ommot|ons
Nc |e:icn: cnc
inf|cmmcIicn:
Ncrmc|
Eyebrows
Ho|r even|y d|str|buted;
sk|n |ntoct
$ymmetr|co||y o||gned;
equo| movement
cir even|y
ci:IriLuIec
SymmeIricc||y
c|ignec:
n/c

Ncrmc|
Ncrmc|
Eye|oshes
Equo||y d|str|buted;
Cur|ed s||ght|y outword
uc||y ci:IriLuIec
n/c
Ncrmc|
Eye||ds
$k|n |ntoct; no
d|schorge, no
d|sco|orot|on
L|ds c|ose
symmetr|co||y
Approx. 15 - 20
|nvo|untory b||nks per
m|nute; b||otero| b||nk|ng;
hen ||ds ore open, no
v|s|b|e sc|ero obove
corneos, ond upper ond
|ower border o| corneo
ore s||ght|y covered
nc ci:chcrge, nc
ci:cc|crcIicn

Lic: c|c:e
:ymmeIricc||y

Li|cIerc| L|inking:

n/c

Ncrmc|


Ncrmc|

Ncrmc|
Conjuct|vo:
8u|bor Conjuct|vo

Fo|pebro| Conjuct|vo
Ironsporent; cop|||or|es
somet|mes ev|dent
$h|ny, smooth, ond
p|nk or red
n/c

n/c

$c|ero sc|ero oppeors wh|te :c|erc cppecr: whiIe
Ncrmc|
Corneo
Ironsporent, sh|ny ond
smooth
C||ent b||nks when the
%rcn:pcrenI, :hiny
cnc :mccIh
n/c
Ncrmc|
corneo |s touched
Ir|s
Froport|ono| to the s|ze
o| the eye, w|th
tronsporent onter|or
chomber
!rcpcrIicnc| Ic Ihe
:ize cf Ihe eye
Ncrmc|
Fup||s
8|ock; equo| |n s|ze;
normo||y 3-7 |nches |n
d|ometer; round, smooth
border, |r|s ||ot ond round
|cck: euc| in :ize:
rcunc

Ncrmc|
'|suo| ocu|ty
Ab|e to reod newspr|nt
14 |nches owoy
20J20 v|s|on on
$ne||en-type chort
unob|e to reod
newspr|nt 14 |nches
owoy
n/c

DevicIicn
frcm
ncrmc|
Fup||s reoct|on ond
Accommodot|on
Fup||s constr|ct when
|ook|ng ot neor object;
pup||s d||ote when |ook|ng
ot |or objects;
Fup||s converge when
neor object |s moved
towords nose
!upi|: ccn:IricI when
|ccking cI necr cLjecI:
pupi|: ci|cIe when
|ccking cI fcr cLjecI::
!upi|: ccnverge
when necr cLjecI i:
mcvec Icwcrc: nc:e
Ncrmc|


Ncrmc|
Locr|mo| g|ond,
|ocr|mo| soc ond
noso|ocr|mo| g|ond
No edemo, no
tenderness or teor|ng
noted
n/c

Extroocu|or musc|es
8oth eyes
coord|noted, move |n
un|son, w|th poro||e|
o||gnment
cIh eye:
cccrcincIec, mcve in
uni:cn, wiIh pcrc||e|
c|ignmenI
Ncrmc|
'|suo| ||e|ds
hen |ook|ng stro|ght
oheod, the c||ent con see
objects |n per|phery
n/c

EAk$
Aur|c|es
Co|or some os |oc|o|
sk|n; symmetr|co|;
A||gned w|th outer
contus o| eye, obout 10
degrees |rom vert|co|;
Mob||e, ||rm ond not
tender; p|nno reco||s o|ter
|t |s |o|ded
Cc|cr :cme c: fccic|
:kin: :ymmeIricc|:
/|ignec wiIh cuIer
ccnIu: cf eye, cLcuI 10
cegree: frcm verIicc|:
n/c

Ncrmc|

Ncrmc|


Externo| Eor Cono|
D|sto| th|rd conto|ns
ho|r |o|||c|es ond g|onds,
dry cerumen, groy|sh-ton
co|or, or st|cky, wet
cerumen on vor|ous
shodes o| brown
n/c

Heor|ng ocu|ty
Normo| vo|ce tones
oud|b|e;
Ab|e to heor t|ck|ng |n
Ncrmc| vcice Icne:
cuciL|e
n/c

Ncrmc|
both eors when
per|orm|ng the wotch
th|ck test
$ound |s heord |n both
eors or |s |oco||zed ot the
center o| the heod
[eber Negot|ve} when
per|orm|ng the tun|ng |ork
test
AC heor|ng |s greoter
thon 8C heor|ng [pos|t|ve
r|nne}


n/c


n/c
NO$E
Externo|
Interno|
$|nuses
$ymmetr|c ond
stro|ght; No d|schorge or
||or|ng; bn||orm co|or
Not tender; no |es|on
A|r moves |ree|y os the
c||ent breothes through
the snores
Mucoso p|nk; C|eor
wotery d|schorge; no
|es|ons; noso| septum |s
|ntoct ond |n m|d||ne
Mox|||ory ond |ronto|
s|nuses ore not tender
SymmeIric cnc
:IrcighI: Nc ci:chcrge cr
f|cring: Unifcrm cc|cr
nc |e:icn
n/c
n/c
n/c


Ncrmc|


Ncrmc|


MObIH
L|ps
Outer ||ps: bn||orm p|nk
co|or; so|t, mo|st, smooth
texture; symmetry o|
contour; ob|||ty to purse
||ps
Inner ||ps: bn||orm p|nk
co|or
uIer |ip:: Unifcrm
po|e |n co|or, dry,
:ymmeIry cf ccnIcur:
cLi|iIy Ic pur:e |ip:
nner |ip:: Unifcrm
po|e |n co|or

DevicIicn
frcm
ncrmc|
Ncrmc|
8ucco| mucoso
mo|st, smooth, so|t,
g||sten|ng, ond e|ost|c
texture
mci:I
Ncrmc|
Ieeth
32 odu|t teeth; smooth,
wh|te, sh|ny tooth enome|

Ye||ow|sh
Incomp|ete
decoyed


DevicIicn
frcm
ncrmc|

gums
p|nk gums; mo|st ond
||rm texture to gums; no
retroct|on o| gums
dork p|nk gums:
mci:I
DevicIicn
frcm
ncrmc|


Iongue or ||oor o| the
mouth
centro| pos|t|on; p|nk
co|or; mo|st; s||ght|y
cenIrc| pc:iIicn:
pink cc|cr: mci:I: :|ighI|y


rough; th|n wh|t|sh
coot|ng; smooth |otero|
morg|ns; no |es|ons; ro|sed
pop|||oe
moves |ree|y; no
tenderness
smooth tongue bose
w|th prom|nent ve|ns
smooth w|th no
po|pob|e nodu|es
so||vory duct
open|ngs hove some
co|or o| bucco| mucoso
ond ||oor o| the mouth
rcugh: Ihin whiIi:h
cccIing: nc |e:icn::


mcve: free|y
n/c
n/c

Ncrmc|




Ncrmc|
Fo|otes
bvu|o
||ght p|nk, smooth so|t
po|ote; ||ghter p|nk hord
po|ote w|th |rregu|or
texture
uvu|o |s pos|t|oned |n
the m|d||ne o| so|t po|ote
n/c
n/c

Orophorynx
Ions||s
orophorynx: p|nk ond
smooth poster|or wo||
tons||: p|nk ond
smooth; no d|schorge; o|
normo| s|ze or not v|s|b|e
presence o| gog re||ex
n/c

n/c

n/c

Neck
musc|es equo| |n s|ze;
heod centered
coord|noted smooth
movements w|th no
d|scom|ort
mu:c|e: euc| in :ize:
hecc cenIerec
cccrcincIec :mccIh
mcvemenI: wiIh nc
ci:ccmfcrI
Ncrmc|

Ncrmc|
Lymph nodes
non po|pob|e ond no
tenderness noted
pc|pcL|e |ymph
ncce: cn Ihere i:
Iencerne:: upcn
pc|pcIicn
DevicIicn
frcm
ncrmc|
Irocheo
centro| p|ocement |n
m|d||ne o| neck; spoces
ore equo| |n both s|des
n/c

Ihyro|d g|ond
not v|s|b|e |on
|nspect|on
g|ond oscends dur|ng
swo||ow but |s not v|s|b|e
|obes moy not be
po|poted; || po|poted,
|obes ore smo||, smooth,
centro||y |ocoted, po|n|ess
ond r|se |ree|y w|th
n/c

n/c

n/c

swo||ow|ng
IHOkAX





Foster|or Ihorox

Anteroposter|or to
tronsverse d|ometer |n
rot|o o| 1:2
Chest symmetr|c
$p|ne vert|co||y
o||gned
bn||orm
temperoture, sk|n |ntoct;
no tenderness, no mosses
Fu|| ond symmetr|c
chest expons|on; thumbs
normo||y seporote 3-5
cm.
8||otero| symmetry
o| voco| |rem|tus
Frem|tus |s heord
most c|eor|y ot the opex
o| the |ungs
Low- p|tched
vo|ces o| mo|es ore more
reod||y po|poted thon
h|gher p|tched vo|ce o|
|emo|e
Fercuss|on notes
resonote, except over
scopu|o
Lowest po|nt o|
resononce |s o ot the
d|ophrogm
'es|cu|or ond
bronchoves|cu|or breoth
sounds

Ihe chest |s
osymmetr|co|

Fresence o|
mosses, po|n upon
po|pot|on.
eok chest
expons|on
bpon
ouscu|tot|on, ro|es |s
heord.












DevicIicn
frcm
ncrmc|




Anter|or Ihorox
Qu|et, rhythm|c ond
e||ort|ess resp|rot|ons
bn||orm temperoture,
sk|n |ntoct; no tenderness,
no mosses
Fu|| ond symmetr|c
chest expons|on; thumbs
normo||y seporote 3-5 cm
$ome os poster|or
voco| |rem|tus; normo||y
decreosed over heort ond

Lobored
resp|rot|on ond use o|
occessory musc|es.






DevicIicn
frcm
Ncrmc|
breost t|ssue
Fercuss|on notes
resonote down to the s|xth
r|b ot the |eve| o| the
d|ophrogm but ore ||ot
over oreos o| heovy
musc|e ond bone, du|| on
oreos over the heort ond
the ||ver, ond tympon|c
over the under|y|ng
stomoch
8ronch|o| ond tubu|or
breoth sounds
8ronchoves|cu|or ond
ves|cu|or breoth sounds

CAkDIO'A$CbLAk

Aorf|c ond pu|mon|c
oreos
No pu|sot|ons n/c

%r|cusp|d oreos
No pu|sot|ons
No |||t or heove

n/c
n/c

Auscu|fofe oorf|c,
pu|mon|c, fr|cusp|d
ond op|co| vo|ves
$1: bsuo||y heord ot
o|| s|tes
bsuo||y |ouder ot
op|co| oreo
$2: bsuo||y heord ot
o|| s|tes
bsuo||y |ouder ot the
bose o| the heort
$ysto|e: s||ent |ntervo|;
s||ght|y shorter durot|on
thon d|osto|e ot normo|
heort rote [0-0 bpm}
D|osto|e: s||ent
|ntervo|; s||ght|y |onger
durot|on thon systo|e ot
normo| heort rotes
$3: |n ch||dren ond
young odu|ts
$4: |n mony o|der
odu|ts
n/c

n/c

n/c

n/c

n/c

n/c

n/c

n/c

Corot|d Arter|es

!o|pofe corof|d orfery
w|fh exfreme couf|on
$ymmetr|c pu|se
vo|umes
Fu|| pu|sot|ons,

n/c
n/c

thrust|ng quo||ty
Quo||ty remo|ns the
some when c||ent
breothes, turns heod ond
chonges |rom s|tt|ng to
sup|ne pos|t|on
E|ost|c orter|o| wo||

n/c

n/c

Auscu|fofe corof|d
orfer|es
No sound heord on
ouscu|tot|on
n/c

ugu|or 'e|ns

nspecf jugu|or ve|ns 'e|ns not v|s|b|e n/c

8kEA$I AND AXILLAE

$|ze, symmefry,
confour or shope
wh||e fhe c||enf |s |n
fhe s|ff|ng pos|f|on
Mo|es: 8reosts even
w|th the chest wo||; ||
obese, moy be s|m||or |n
shope to |emo|e breost
n/c


$|n of fhe breosf for
|oco||zed
d|sco|orof|ons ond
hyper p|gmenfof|ons,
refrocf|on, d|mp||ng,
|oco||zed
hypervoscu|or oreos,
swe|||ng or edemo
$k|n un||orm |n co|or
$k|n smooth ond
|ntoct
$tr|oe, mo|es or nev|
n/c
n/c
n/c

nspecf oreo|o for
s|ze, shope,
symmefry, co|or,
surfoce chorocfer|sf|cs
ond ony moss or
|es|ons
kound or ovo| ond
b||otero||y the some
Co|or vor|es w|de|y
|rom ||ght p|nk to dork
brown
Irregu|or p|ocement
o| seboceous g|onds on
the sur|oce o| oreo|o
n/c

n/c

n/c


nspecf for n|pp|e
s|ze, shope, pos|f|on,
co|or, d|schorge ond
|es|ons
kound, everted ond
equo| |n s|ze; s|m||or |n
co|or; so|t ond smooth;
both n|pp|es po|nt |n the
some d|rect|on
n/c


!o|pofe for breosf
mosses, fenderness
No tenderness,
mosses, nodu|es or
d|schorges
n/c

!o|pofe n|pp|es for
fenderness ond
d|schorges
No tenderness,
mosses, nodu|es or
d|schorges
n/c

nspecf oreo|o for
s|ze, shope,
Mo|es: 8reosts even
w|th the chest wo||; ||
n/c

symmefry, co|or,
surfoce chorocfer|sf|cs
ond ony moss or
|es|ons
obese, moy be s|m||or |n
shope to |emo|e breost
A8DOMEN

nspecf fhe obdomen
for s|n |nfegr|fy
bnb|em|shed sk|n
bn||orm co|or
n/c
n/c

nspecf fhe obdomen
for confour ond
symmefry
F|ot, rounded
[convex}, or scopho|d
[concove}
No ev|dence o|
en|orgement o| ||ver or
sp|een
$ymmetr|c contour
n/c
n/c

n/c

bserve obdom|no|
movemenfs
ossoc|ofed w|fh
resp|rof|on, per|sfo|s|s,
or oorf|c pu|sof|ons
$ymmetr|c
movements coused by
resp|rot|on
'|s|b|e per|sto|s|s |n
very |eon peop|e
Aort|c pu|sot|ons |n
th|n persons ot ep|gostr|c
oreo
SymmeIric
mcvemenI: ccu:ec Ly
re:pircIicn
n/c
n/c

Ncrmc|
bserve fhe voscu|or
poffern
No v|s|b|e voscu|or
pottern
n/c

Auscu|fofe fhe
obdomen for bowe|
sounds, voscu|or
sounds, ond
per|foneo| fr|cf|on rubs
Aud|b|e bowe| sounds
Absence o| orter|o|
bru|ts
Absence o| |r|ct|on
rub
n/c
n/c
n/c

!ercuss severo| oreos
|n eoch four quodronfs
fodeferm|ne presence
of fympony ond
du||ness
Iympony over the
stomoch ond gos-||||ed
bowe|s; du||ness,
espec|o||y over the ||ver
ond sp|een, or o |u||
b|odder
n/c

!ercuss fhe ||ver fo
deferm|ne |fs s|ze
to 12 cm |n the
m|dc|ov|cu|or ||ne; 4 to 8
cm ot the m|dsterno| ||ne
n/c

!erform ||ghf
po|pof|on f|rsf fo
defecf oreos of
fenderness
No tenderness;
re|oxed obdomen w|th
smooth, cons|stent tens|on
n/c

!erform deep
po|pof|on over o|| four
quodronfs
Ienderness moy be
present neor x|pho|d
process, over cecum, ond
over s|gmo|d co|on
n/c

!o|pofe fhe ||ver fo
defecf en|orgemenf
Moy not be po|pob|e n/c

!o|pofe for fhe
b|odder on fhe oreo
obove fhe pub|c
symphys|s.
Not po|pob|e n/c

Mb$CbLO$ELEIAL
$Y$IEM


Musc|es

nspecf musc|es for
s|ze. Compore fhe
musc|es on one s|de
of fhe body fo fhe
some musc|e on fhe
ofher s|de.
Equo| s|ze on both
s|des o| the body
uc| :ize cn LcIh
:ice: cf Ihe Lccy

Ncrmc|
nspecf fhe musc|es
ond fendons for
confrocfures
No controctures n/c

nspecf fhe musc|es
for fremors
No tremors n/c

!o|pofe musc|es of
resf fo deferm|ne
musc|e fon|c|fy
Normo||y ||rm n/c

!o|pofe fhe musc|es
wh||e fhe c||enf |s
ocf|ve ond poss|ve for
f|occ|d|fy, sposf|c|fy,
ond smoofhness of
movemenf
$mooth coord|noted
movements
n/c

nJo - not per|ormed, not opp||cob|e
*5ome doto ore hypothetico/ becouse we were not ob/e to hove on interview with the c/ient due to
sofety protoco/s*