Physical Exam

Physical Examination Date: July 17, 2009 Time: 12:45pm Description: Received pt lying on bed, conscious and coherent, with ongoing IVF of D5LR at 550 cc level in 40 gtts/min regulation intact and infusing well on the left arm. PARAMETERS Hair Scalp Skull Face Eyebrows Eyelids Sclera Conjunctiva Pupil Visual Field Extraoccular movement Ears Nose Mouth Gingival area Tongue Neck and Lymp nodes Chest Abdomen

METHOD USED Inspection Inspection Inspection Inspection Inspection Palpation Inspection Palpation Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Palpation Inspection Auscultation Inspection Palpation Percussion Auscultation

Upper Extremities

Lower Extremities

FINDINGS Well distributed Oily and sticky (-) dandruffs (-) tenderness and swelling Normocephalic (-) nodules Flashy face Warm to touch Evenly distributed (-) lesions Symmetrical bilaterally blinking Redness in color (+) lacrimation PERRLA 3mm Reactive Follows finger’s direction (+) cerumen (-) discharge (-) epistaxis (+) sore throat (+) partial bleeding (+) swelling and redness (+) swelling (+) palpable lymp nodes (-) tenderness and swellings (-) adventitious sounds (+) bruises No palpable masses Tympanic

Inspection Palpation Palpation Palpation

Audible sound on the epigastric region, (+) regurgitation (+) bruises on both extremities Clean and well trim nails Warm to touch CR: 4 sec Slow venous filling

Inspection Inspection

(+) bruises (left proximal) Long and dirty toenails

Inspection

INTERPRETATIONS Normal d/t poor hygiene Normal Normal Normal Normal d/t fever d/t fever Normal Normal Normal d/t fever d/t fever Normal Normal Normal d/t poor hygiene Normal Normal d/t infection d/t low platelet count d/t infection d/t infection d/t infection Normal Normal d/t low platelet cound Normal d/t airfilled stomach and eagerly eat foods d/t gastric inflammation and sensitivity 2 to bleeding tendencies d/t low platelet count Normal d/f fever d/t low platelet count d/t low platelet count associated with plasma leakage and low hemoglobin d/t low platelet count d/t poor hygiene