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A.

Introduction
Patient: Date and Time of Admission: C/C: V/S: T PR RR Initial Diagnosis: History of Present Illness:

BP

Demographic Profile Date & time of assessment: Date & time of admission Name of patient: Husband: Hospital: Room & bed #: Sex: Attending physician: Civil status: Nationality: Religion: Age: Birth date: Birth place: Address: Educational attainment: Occupation: Chief Complaints: General Impression: notes upon receive on patient Diagnosis: B. Diagnostic Procedures and Evaluation LAB EXAMS AND CORRELATION Laboratory exams CBC Hct Hgb WBC Differential count: BUN Eosinophil Monocyte Basophil Platelet Urinalysis Color Transparency Specific gravity Glucose Protein pH Microscopic exam Pus cells RBC Epith cells Blood type ABO type RH type Results Normal values 37-44% - females 12-14gm% -females 4.5-11T/cumm 0-10% 1-4% 1-8% 0-5% 0-5% 150-400T/cumm Straw to dark yellow 1.005-1.035 Negative Negative 4.5-8 2-4/hpf 0-2/hpf Correlation

B.2 PATHOPHYSIOLOGY Etiology

Signs and Symptoms

Risk factors Pre-disposing factors Precipitating factors


B.3 TREATMENT MODALITIES TREATMENT RATIONALE

B.4 Family history with genogram B.5 PHYSICAL ASSESSMENT FINDINGS CLIENT: DATE AND TIME: EXAMINER: AGE: SEX: PHYSICAL ASSESSMENT first notes: STATE AND AWARENESS / LEVEL OF CONCIOUSNESS: GENERAL SURVEY: A. PHYSICAL APPEARANCE: B. BODY STRUCTURE: C. VITAL SIGNS: 1. Circulatory System INSPECTION Intercostals space ( 1 cs )

Normal findings * Small apical impulse ( 2.5 cm ) or medial to left midclavicular line at forth or fifth 1 cs. May not be visible in client w/ large chest.

Findings

PALPATION Mitral Area ( DMI ) * DMI is felt as a pulsation and is approximately the size of a nickel. May not palpate in large chest.

PERCUSSION Perscussion may be done to define Define cardiac borders by indentifying Areas of dullness, But it is generally unreliable. Size of heart Can be more accurately determined by chest X ray AUSCUCTATION Auscuctate to indentify the first heart sound ( 5 ), or lub and the Second heart sound ( S2), or dubb. Auscultate for the rate and rhythm. * S1 follows the long diastolic pouse and preceds the short systolic pause and corresponds to each carotid pulsation. S2 follows the short systolic phase and preceds the long diastole phase. * Rate: 60 100 bmp Rhythm: regular

Reproductive Discharges Inspect mons pubis Normal findings Clear, milky, serosanguineous, with menstrual cycle. Pubic hair is distributed in an inverted triangular pattern. They are no signs of infestation. The labia majora are equal in size and free of lesions, swelling and excoriations. The surface of the cervix is normally smooth, pink, and even. Findings

Inspect the labia minora and perineum Inspect the cervix

LMP: M Sexually active: Has regular monthly period. Urinary Normal findings Inspect for color, odor, consistency and frequency Head to toe Physical assessment Inspection Skin: Color: Moisture: Texture:. Lesions: Nails: Color: Thickness: Shape: Angle: Head: Face Contour: Symmetry: Involuntary movements: Edema: Eyebrow: Quantity: Eyes: Conjunctiva and Sclera: Cornea and Lens: Pupils: Extraocular Movement: Eyelids: Nose: Mouth and Pharynx: Lips: Gums or Buccal Mucosa Tongue: Trachea, Thyroid, Trachea: and lymph node Neck Anterior and Anterior Posterior Chest: Posterior Breast: Breast: Color: Dimpling or Retractions: Nipples:. Rashes or Lesions: Abdomen Scars: Striae: Contour: Symmetry: Peristalsis Cardiovascular Inspect pulsations System Urine color is amber yellow, scanty odor Findings

Palpation Mobility: Temperature:

Percussion

Auscultation

Capillary Refill: .