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    3ros & Pe

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    Mel Izhra N. Margate
    The patient presented with periorbital swelling, blurry vision, and skin lesions. On physical exam, the patient had pale lips and gums, swollen eye lids, and tenderness in the abdomen. Laboratory results showed normal vital signs. During admission, the skin lesions and eye swelling persisted on follow up exam.

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    3ros & Pe

    Uploaded by

    Mel Izhra N. Margate
    16 views4 pages
    The patient presented with periorbital swelling, blurry vision, and skin lesions. On physical exam, the patient had pale lips and gums, swollen eye lids, and tenderness in the abdomen. Laboratory results showed normal vital signs. During admission, the skin lesions and eye swelling persisted on follow up exam.

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    The patient presented with periorbital swelling, blurry vision, and skin lesions. On physical exam, the patient had pale lips and gums, swollen eye lids, and tenderness in the abdomen. Laboratory results showed normal vital signs. During admission, the skin lesions and eye swelling persisted on follow up exam.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    16 views4 pages

    3ros & Pe

    Uploaded by

    Mel Izhra N. Margate
    The patient presented with periorbital swelling, blurry vision, and skin lesions. On physical exam, the patient had pale lips and gums, swollen eye lids, and tenderness in the abdomen. Laboratory results showed normal vital signs. During admission, the skin lesions and eye swelling persisted on follow up exam.

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    REVIEW OF SYSTEMS

    GENERAL SURVEY Patient was awake with no changes in level of


    consciousness, oriented to time, place, and to
    people around her. Speech is not slurred. She
    is fairly groomed with no evidence of weight
    loss has body weakness noted, no loss of
    appetite. Has edema on the periorbital area.

    SKIN Skin has no jaundice with good skin turgor.


    With lesions on the left leg and orbital area
    noted.

    HEAD Head is proportional and symmetrically


    round, hard, smooth, and in midline to the
    client’s body without lesions or bumps. No
    tenderness upon palpation

    EYES Patient experienced blurring of vision Sclera


    are unicteric. She experienced periorbital
    swelling, tenderness, and purulent drainage.

    EARS No tenderness, and no abnormal discharges


    noted.

    CARDIOVASCULAR Patient has normal pulse rate (100 bpm). No


    palpitations, and no heart murmurs heard
    upon auscultation.

    NOSE AND SINUSES No discharge, no tenderness, and no lesions


    noted

    MOUTH AND THROAT Lips are pale and dry without lesions and
    swelling. Buccal mucosa is pale in color.
    Uvula is at the midline, and tonsils are not
    inflamed. Tongue has a lesion and whitish
    pigments on the side.

    MUSCULOSKELETAL No muscle and joint pain noted

    RESPIRATORY Patient has normal Respiratory rate (20cpm)


    with symmetric chest expansion. No
    adventitious sounds heard upon auscultation.

    GASTROINTESTINAL There is tenderness noted upon palpation. No


    masses and lesions noted.

    GENITOURINARY Lochia Serosa reported and voids about 3-5


    times a day; but no pain, no polyuria, and no
    oliguria noted.

    HEMATOLOGY No bruises and no bleeding tendencies.


    NERVOUS There is no decreased level of consciousness.
    No numbness, no headache, and no tremors
    noted.
    PHYSICAL EXAMINATION

    UPON ADMISSION DURING DUTY


    (FEB. 11, 2018) (FEB. 19, 2018)

    Blood pressure: 130/80 mmHg Blood pressure: 120/60 mmHg

    HR: 100 bpm HR: 98 bpm

    RR: 20 cpm RR: 20 cpm

    Temperature: 36.6 ° C Temperature: 37.4 ° C

    SKIN Skin has no jaundice, warm and dry to touch


    with good skin turgor. Hair is evenly
    distributed and capillary refill is immediate
    (<3 sec.). With lesions on the left leg and
    orbital area noted.

    HEAD Head is proportional and symmetrically


    round, hard, smooth, and in midline to the
    client’s body without lesions or bumps. No
    tenderness upon palpation.

    EYES Eyeballs are symmetrically aligned in sockets


    without protruding or sinking. Bulbar
    conjunctiva is clear and moist; and palpebral
    conjunctiva is pinkish and swollen noted.
    Sclera is anicteric without increased
    vascularity or lesions noted. Pupils equally
    round and reactive to light and
    accommodation. Eyebrows are symmetrical,
    fine and black in color. Eyelashes are also
    fine, black in color and is oriented outwards.
    EARS Ears are equal in size bilaterally. Bilateral
    auricles, tragus, mastoid processes are non-
    tender. No abnormal discharges noted. Only
    small amount of odorless cerumen observed.

    NOSE Nose is patent and uniform in color without


    deformity. Nasal septum is at the midline
    without bleeding and deviation. No discharge,
    tenderness, and lesions noted.
    MOUTH AND THROAT Lips are pale and dry without lesions and
    swelling. Buccal mucosa is moist and pale in
    color. Uvula is at the midline, and tonsils are
    not inflamed.

    NECK Neck is supple. Trachea is at the midline, and


    no cervical lymphadenopathy and masses
    noted.

    CHEST AND LUNGS Patient has normal Respiratory rate (20cpm)


    with symmetric chest expansion. No
    adventitious sounds heard upon auscultation.

    CARDIOVASCULAR Heart has a normal rate (98 bpm) and has


    regular rhythm. No murmuring heart sounds
    and thrills auscultated.

    BREAST Breast is symmetric and no abnormal


    discharges noted

    ABDOMEN There is tenderness upon palpation. No


    masses and lesions noted. No diarrhea and
    constipation noted.

    EXTREMITIES All extremities have no edema. No active


    lesions noted.

    NEUROLOGIC There is no decreased level of consciousness,


    no numbness, no tremors and no tingling
    sensation noted.

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