PHYSICAL ASSESSMENT Date assessed: July 30, 2012 Diagnosis: Gastroesophageal reflux disease related to systemic lupus erythematous

Initial vital signs: Temp: 36.8 degrees C Pulse: 77 bpm RR: 20 cpm BP: 120/80 mmHg Area Assessed GENERAL: Body build, height and weight Posture and gait Inspection Proportionate varies with lifestyle Clean, neat Normal build for woman with proportionate parts Standing shows no abnormal deviation on the spinal prominence Absence of odor in axillae but slight halitosis noted. Normal Technique Normal Findings Actual Findings Evaluation

Inspection

Normal

Body and breath odor

Inspection

No body or but breath odor

Signs of distress

Inspection

No distress noted

Signs of health or illness Attitude Affect / mood

Inspection

Healthy appearance Cooperative Appropriate to situation

Inspection Inspection

Activities of daily living was seen properly done Ambulatory Normal and can do self-care Positive Normal Mood depress Normal due to hospitalization.

Due to decrease immune system the patient was in constant face masked thereby neglecting her oral care and erosion of dental enamel associated to GERD. Normal

Quantity, quality Inspection and organization of speech

Understandable, moderate pace, exhibits thought association

Relevance and organization of thoughts SKIN: Color

Inspection

Logical sequence, makes sense, has sense of reality

Moderate pace Normal in talking and shows appropriate answer to simple questions Able to identify Normal herself, time, place, and such.

Inspection

Soles and palms Inspection

Moisture

Inspection/ Palpation

Temperature

Palpation

Texture

Palpation

Turgor

Palpation

Light brown, Tanned skin tanned skin (vary with dark according to race) brown parts especially in the armpits Lighter colored Bruising was palms, soles found in the arms. Extending from the palms to the brachial artery part. Skin normally dry Dry skin in the exposing part but some moisture on the skin folds like axillae. Normally warm 36.8 degrees Celsius and warm upon palpation Smooth and soft Skin was soft and no swelling was noted Skin snaps back Skin returns immediately after a quick pinch. No edema was also noted

Normal

Due to inappropriate IV medication introduction leading to the scarring of the veins. Normal

Normal

Normal

Normal

NAILS: a. Nails Inspection Transparent, smooth and convex Pinkish Small, round nail in convex shape Slightly pale Normal

Nail beds

Inspection

Nail base

Inspection

Firm

Capillary refill

Inspection/ Palpation

Firm with160 degrees nail base. White color of nail Capillary refill bed under in 3-4 seconds pressure should after pressure return to pink within 2-3 seconds Evenly distributed The scalp was white with hair covering the entire scalp. Hair was thick and shiny Free form masses, lumps, nits, dandruff and lesion. With no area of tenderness upon palpation.

Due to decreased blood flow Normal

Due to slightly decrease blood flow in the peripheral area.

b. Hair Distribution

Inspection

Normal

Color Texture

Inspection Inspection/ Palpation

Black Smooth

Normal Normal

EYES: Eyes Inspection Parallel to each other Parallel, symmetrical and not protruding and clear in inspection Pupil is same shape as the round size of the iris and Normal

Visual Acuity

Inspection (penlight)

PERRLA- Pupils equally round react to light and accommodation

Normal

Eyebrows

Inspection

Eyelashes

Inspection

Eyelids

Inspection

Conjunctiva

Inspection

both of them constrict with light at the same time. Symmetrical in Black in color size, extension, and hair texture and symmetrical movement and can able to raise both in the same time. Distributed evenly Small in and curved amount but is outward distributed evenly and curved outward. Same color as Same color as the skin the exposing skin areas. Blinks involuntarily and Fixed and bilaterally up to involuntary 20 times per blinked and is minute irritated to foreign objects. Do not cover the pupil and the The upper sclera, lids eyelids cover a normally close small portion symmetrically of the sclera but patients said it was inborn. Transparent with Slightly pink in light pink color outer area with bland part of yellowish area.

Normal

Normal

Normal

Normal

Normal

Sclera

Inspection

Color is white

Cornea

Inspection

Transparent, shiny

White, clear and moist-like in inspection. Transparent and shiny.

Due to callous like thickening of the conjunctiva making it more prone to irritations. Normal

Normal

Pupils

Inspection

Black, constrict briskly

Iris

Inspection

Clearly visible

Black and rounded with the normal ability to constrict to light. Transparent, Proportionate in the size of the eyes and moist

Normal

Normal

EARS: Ear canal opening Inspection Free of lesions, discharge of inflammation Bean like helix in shaped no discharge and parallel to one another. No inflammation and canal wall are slightly tanned pink. 3 out of 3 whispers were heard by the client in the shoulder distance. Normal

Inspection

Canal walls pink

Normal

Hearing Acuity

Inspection

Client normally hears words when whispered

Normal

NOSE: Shape, size and skin color Inspection Smooth, symmetric with same color as the face Symmetric and Normal straight with no obvious enlargement.

Nares

Inspection

Oval, symmetric and without discharge

Nasal septum in midline with discharge and lesion was seen.

Normal

MOUTH AND PHARYNX: Lips Buccal mucosa

Inspection

Pink, moist symmetric Glistening pink soft moist

Inspection

Pale in color and slightly dry. Pale in color.

Lack of fluid intake

Gums

Inspection

Slightly pink color, moist and tightly fit against each tooth

Tongue

Inspection

Moist, slightly rough on dorsal surface medium or dull red

Teeth

Inspection

Firmly set, shiny

Due to decrease blood supply in buccal area associated to SLE. Slightly dark in Due to acid color same as reflux faltering the color of her from GERD. lips but in a more bland type. Tooth is Somehow loosed in some areas. Noticeable Due to prolong fissures and masked dryness. wearing because of decrease immune system thereby neglecting her oral care. Pale yellowish, Due to noticeable irreversible loss decrease in of tooth size but no structure due to dental carries chemical noted. dissolution by acids

NECK: Symmetry of neck muscles, alignment of trachea Inspection Neck is slightly hyper extended, without masses or asymmetry Symmetrical with head at the center and no masses were observed in the trachea part. Was able to move in 4 directions Normal

Neck ROM

Inspection

Neck moves freely, without discomfort

Normal

Thyroid gland

Palpation

Rises freely with swallowing and free of masses

upon instruction. No mass, Normal nodules, lesion were noted upon palpation.

ABDOMEN: Skin Color Inspection Skin same color with the rest of the body Normal

Contour and symmetry

Inspection

4 quadrants

Auscultation

Audible bowel sounds

Concave and rises due to breathing with same color as the other part of skin. Audible bowel sounds

Normal

Normal

Percussion

Tympany over the Tympany over stomach; dullness the stomach; over the liver dullness over the liver

Normal

EXTREMITIES: Symmetry Inspection Symmetrical No positional deviation was seen and are symmetrical Same color as the exposing skin area Warm in the trunk part of the extremities with slight decrease in temp on the finger parts No masses, Normal

Skin color

Inspection

Same with the color of other parts of the body Warm to touch

Normal

Skin Temperature

Palpation

Normal

Presence of

Inspection /

No lesions

Normal

lesion ROM

Palpation Inspection Moves freely without discomfort

lesion, rashes, etc. was noted The patient shows full ROM of every extremity of her body with ease and no pain.

Normal