Professional Documents
Culture Documents
any known disease or illness. The patient has also 7 children, 6 are male and 1 is female who are
all disease free also.
VI. Personal and Social History
The patient is a Pedicab driver, he financially supports his family through driving a Pedicab. The
client doesnt smoke but occasionally drinks alcohol with his friends.
VII. Review of Systems
The clients health in general is currently not in good condition. He was chronically ill for a long
time and now he is experiencing epigastric pain. The client has rashes, dryness and color changes
in skin and nails. The client is also currently experiencing headache and dizziness. The client
also has vision problem but is not wearing any glasses. the client has also difficulty in hearing.
The client is also experiencing frequent colds. He has no any problem in throat. The client also
experiences prolonged cough. The client doesnt have any known Cardiovascular problem. The
client is currently experiencing vomiting and blood in stools. The client has also no genitourinary
or genial problems. The client has also no problem in peripheral, musculoskeletal and psychiatric
problem. He also doesnt have Neurologic, hematologic, endocrine and immunologic problems.
B. PHYSICAL EXAMINATION
I. Physical Presence
The clients chronological age is congruent with the apparent age which is 47 years old. The
patient exhibits body symmetry, no obvious deformity, and but doesnt have a well appearance
due to his chronic illness which is Psoriasis. Client doesnt have a humpbacked appearance with
unsteady and slowed movement that might be due to her the pain he is currently having. There
has a relevant body due to his current condition which signifies that he doesnt have a good
hygienic ritual.
The client has symmetrical and in line with each other eyebrows. It is black in color and is
evenly distributed. Eyes are evenly placed and in line with each other, non-protruding, and has
equal palpebral fissure. Eyelashes are black in color and is evenly distributed and turned
outward.
IX. Ears
The earlobes are bean shaped, parallel, and symmetrical. The upper connection of the earlobe is
parallel with the outer canthus of the eye. Skin is same in color as in complexion. No lesions
noted upon observation. The auricles appear firm. No discharge and lesions noted.
X. Nose and Paranasal Sinuses
Nose is at the midline. No discharges. No nasal flaring. Both nares are patent except that there is
a nasogastric tube attached on right nares. No bone and cartilage deviation noted. Nasal septum
is in the midline and is not perforated.
XI. Mouth and Oropharynx
Lips has visible margin, symmetrical in appearance, pinkish in color, and has no edema visible.
Gums has no bleeding and is pinkish in color. The patient has no teeth, and no any abnormal
breath odor. Tongue is pinkish in color with white taste buds on the surface. No lesions noted.
Able to move tongue freely.
XII. Neck
The neck is straight and has no visible mass or lumps. Symmetrical and has no jugular venous
distension. Trachea is also at the midline.
XIII. Thorax and Lungs
The shape of the thorax is elliptical. The client doesnt use accessory muscles upon breathing and
has a normal respiratory rate for up to 20 breaths per minute. The client has also cough and
crackles might be heard upon auscultation due to phlegm.
XIV. Heart
The clients heart rate is 80 which is normal. The client doesnt have any chest pain or
palpitations. The clients blood pressure is 120/70 mmHg.
XV. Breast
Breast has no any visible lumps, depression, or lesions visible. It is also equal in shape and
size.
XVI. Abdomen
The clients abdomen is round in shape with erythematous skin. It is also painful due to his
current condition which is UGIB.
XVII. Extremities
extremities are equal in size. Have same contour with prominences of joints. No involuntary
movements. No edema. Color is even. temperature is warm and even.
XVIII. Genitourinary System
The client has no problem in Genitourinary system.