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Physical Assessment

The physical examination and review of systems document summarizes the patient's condition, noting pertinent positive and negative findings. The patient appears weak and fatigued with noticeable weight loss. Skin is dry with pallor. Chest pain and hypotension were observed. Gastrointestinal issues include anorexia, nausea, and vomiting. Urinary problems involve proteinuria and oliguria. Neurological signs comprise peripheral neuropathy, muscle cramping, twitching, and weakness preventing ambulation. The patient is anemic with weight loss and decreased appetite. Psychologically, the patient is stressed and anxious due to the illness.

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Aziil Liiza
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911 views2 pages

Physical Assessment

The physical examination and review of systems document summarizes the patient's condition, noting pertinent positive and negative findings. The patient appears weak and fatigued with noticeable weight loss. Skin is dry with pallor. Chest pain and hypotension were observed. Gastrointestinal issues include anorexia, nausea, and vomiting. Urinary problems involve proteinuria and oliguria. Neurological signs comprise peripheral neuropathy, muscle cramping, twitching, and weakness preventing ambulation. The patient is anemic with weight loss and decreased appetite. Psychologically, the patient is stressed and anxious due to the illness.

Uploaded by

Aziil Liiza
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
  • Activity 3: Physical Examination & Review of Systems

ACTIVITY 3: PHYSICAL EXAMINATION &

REVIEW OF SYSTEMS
 
PHYSICAL EXAMINATION & REVIEW OF SYSTEMS 
Read your book regarding the case and write down focused assessment on the
organs/system affected and state all pertinent findings appropriately (+/-)

General Survey + Consciously lying on bed which appears weak,


fatigue
+ noticeable weight loss

Skin + skin is dry


+ pallor
- fair complexion

Head, Eyes, Ears, Nose, Throat - hair is evenly distributed


- absence of nodules
+ facial grimace
- tenderness
- responsive to moderate voice
- symmetric with the nasal septum at the center
- no lumps or swollen glands

Neck - no lumps or swollen glands


- coordinated, smooth movements with no
discomfort

Chest - tenderness
- masses

Respiratory - no wheezing
- no hemoptysis

Cardiovascular + chest pain


+ hypotensive with BP of 90/60 mm/Hg

Gastrointestinal + anorexia
+ nausea and vomiting

Urinary + proteinuria
+ oliguric

Genital  - no libido
- no masses
- no unusual discharges on genital area
Peripheral / Vascular  + peripheral neuropathy

Musculoskeletal + muscle cramping


+ muscle twitching
+ weakness
+ unable to ambulate

Neurologic  + peripheral neuropathy

Hematologic  + anemic

Endocrine + noticeable weight loss


+ decreased appetite
- no thyroid enlargement

Psychiatric + stressed due to illness


+ anxious

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