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Lyceum of the Philippines University
College of Nursing
Name M.M Age 69 - year-old Diagnosis Upper GI Bleeding Secondary To Bleeding Peptic Ulcer Disease Hospital No. Ward/RM GERIATRIC WARDQ PHYSICAL ASSESSMENT General Appearance Patient looks pale and weak but he is calm and cooperative. Vital Signs T: 36. RR: 20 CR: 120 BP: 110/ Body Parts Methods Findings Analysis Skin Head & Neck Conjunctiva Sclera Mouth Thyroid Lymph node Breast Breast & Nipples Inspection Inspection Inspection Palpation Inspection & Palpation
- (+) pallor
- Pale
- White and no sign of jaundice
- Lips is dry and pale
- Not enlarged
- Not palpable
- Symmetrical
- No fungal infection beneath
- Pallor indicates that there is a loss or decrease of blood flow to the skin.
- Not normal. Pale appearance of conjunctiva and lips ‘indicates anemia
- It shows that there is no abnormal lymph node enlargement in the neck
- This indicates that there are no abnormalities noted on the breast. No
Cardiovascular System Chest Heart Respiratory System Chest Lungs Lungs Inspection Auscultation Inspection Palpation Percussion
- Symmetrical, with no scar, no precordial bulging, no visible apex beat, no prominent dilated veins
- First and second heart sounds are normal with no murmurs
- Moved symmetrically with respiration and no deformity seen. No sign of respiratory distress. No scars, prominent dilated
- Chest expansion and vocal fremitus are equal anteriorly and posteriorly at all three zones of the lung
- Lung was resonant bilaterally, anteriorly, signs of breast cancer is noted
- This indicates absence of any congenital chest wall deformities or medical conditions such as pneumothorax
- No murmurs generally indicates normal blood flow through the heart valves.
- No sign of chest wall deformities and no sign of COPD
- Both sides take off at the same time and to the same extent
- Areas of lung are devoid of air
Central Nervous System Inspection Mental status : He was alert, conscious, oriented to time, place, and person. His memory function was intact. He was not in a state of confusion. inhibits friction to the joint.
- Patient has no sign for any neuropsychiatric abnormalities
Lyceum of the Philippines University
College of Nursing
Name: M.M Age: 69 Gender:M Civil Status:M Address:Calamba, Laguna Education: High School Graduate Information Source: Patient Goal of Interaction:
