V Date : July 26, 2010

V Time: 5:00 pm
V patient was lying on bed, conscious, coherent, and
responsive to stimuli
V with an IVF of D5NSS 1 liter @ 140 cc/hr infusing well
@ left metacarpal vein @ 1000cc level
V wearing hospital gown
V height: 5ǯ3dz
V weight: 48 kg
 esult Normal Values

Temperature 38.9hC (febrile) 36.5hC -37.5hC

Pulse ate 95bpm 60bpm-100bpm

Cardiac ate 97bpm 60bpm-100bpm

espiratory ate 30cpm 16cpm-20cpm

Blood Pressure 100/70mmHg 90/60-

130/90mmHg
O



V fair complexion, smooth, warm to touch and has good

turgor
V was febrile with a temperature of 38.9°C
V no presence of lesions, edema and abrasions noted
V her nails were well trimmed, pinkish and have convex
curvature
O 
O   

V black curly hair

V evenly distributed and has an equal length
V normocephalic
V no lice, dandruff, lesions and tenderness noted
V no edema and masses observed on her face
V face was oval and has symmetrical facial movements
ÿ 
V eyebrows were thick and evenly distributed
V no presence of scars and lesions noted
V eyelids were clear with no discharges noted.
V the lacrimal duct openings were evident at the nasal
side of the upper and lower lids
V her eyelashes were equally distributed having an
outward curvature
V her irises were dark brown and her pupils were both
round and reactive to light accommodation with pupil
size of 2mm..
V near sighted and uses corrective eyeglasses.
ÿ

V both ears were symmetrical

V pinna has the same color with her skin
V no lesions, masses, tenderness and discharges noted
V external canals were clear with minimal cerumen
V no impacted cerumen and inflammation noted
V normal sense of hearing, she can hear spoken words
and responds accordingly.


V symmetrical
V nasal septum was in midline and intact
V able to breathe freely through the nares as inspected
V mucosa was pinkish with no discharges, lesions and
swelling noted
-outh, Throat and Lips

V lips were dry and pale with no lesions noted

V teeth were yellowish, she has 4 missing teeth -- 2
upper and lower molars
V no dentures as verbalized
V her tongue and uvula was in midline.
V tonsils and palates were not inflamed.
V she was able to masticate and swallow. There was no
hoarseness of voice noted.


V no swelling and masses noted

V lymph nodes were not palpable and thyroid was not
enlarged
V can move her neck without any discomfort
V range of motion was normal which includes right and
left lateral, flexion, extension and hyperextension.
Ä 

V thorax was symmetrical with no deformities noted

V has an equal chest expansion with clear breath sounds
V respiratory rate and rhythm was regular
V there were no adventitious sounds such as crackles and
wheezing noted upon auscultation
V
V cardiac rate and rhythm was regular
V there were no abnormal beats, pulsations, and
murmurs noted

(

V patient refused to assess her breast but she verbalized
that there were no tenderness, lesions and masses
V axillary nodes were not palpable.
V her axilla has uneven color compared to the other part
of her skin
V rashes and signs of infection were not noted


V abdomen was soft, symmetrical and not distended

V no foul odor, discharges and inflammation noted in
the umbilical area
V surgical site on the right lower quadrant was properly
dressed
V dressing was intact and not soaked
V able to fart and defecate which shows that she has
good bowel movement
r



V patient refused to be assessed but she verbalized that

her vulva has no lesions, inflammation, and foul
smelling discharges. Her pubic hair was evenly
distributed
V has no difficulty in micturating.
‰pper limb

V shoulders and arms were symmetrical with no

deformities noted
V elbows, forearms, hands and wrist has normal range of
motion, which includes flexion and extension
Lower Limb and Back

V legs and knees were symmetrical and have normal

range of motion
V peripheral pulses were symmetrical
V spine is in the midline
V gait was well coordinated
 [ctual Score Total
eactive Level Scale 1=[lert 1

Glasgow Coma Scale

Eye opening 4=Spontaneou 15

s
Verbal response 5=Oriented

-otor esponse 6=Obeying

LS/GCS 1/15
-
V

V first part of the digestive tract. It is adapted

V to receive food by ingestion, break it into small
particles by mastication, and mix it with saliva.
V contains the teeth and tongue and receives the
secretions from the salivary glands.
OÄVÿÿ
O

Î help hold food in the mouth and keep it in place for

chewing
Î used in the formation of words for speech
Î contain numerous sensory receptors that are useful for
judging the temperature and texture of foods
ÿ

V the roof of the oral cavity

V separates the oral cavity from the nasal cavity
V the anterior portion, the hard palate, is supported by
bone
V the posterior portion, the soft palate, is skeletal muscle
and connective tissue
V posteriorly, the soft palate ends in a projection called
the uvula. During swallowing, the soft palate and uvula
move upward to direct food away from the nasal cavity
and into the oropharynx.
 r
ÿ

 manipulates food in the mouth

 used in speech
 the surface is covered with papillae that provide
friction and contain the taste buds

ÿÿV

V Primary teeth contains 20 teeth

V Secondary teeth contains 32 permanent set
V the shape of each tooth type corresponds to the way it
handles food
V

V passageway that connects the nasal and oral cavities to

the larynx and esophagus
V serves both the respiratory and digestive systems as a
channel for air and food
V nasopharynx contains the pharyngeal tonsils, or
adenoids, functions as a passageway for air, and has no
function in the digestive system.
V oropharynx is the first region food enters when it is
swallowed. The opening from the oral cavity into the
oropharynx is called the fauces
V laryngopharynx, or hypopharynx. The laryngopharynx
opens into both the esophagus and the larynx.
ÿO Vr
O

V gullet is a collapsible muscular tube

V serves as a passageway between the pharynx and
stomach.
V it passes through an opening in the diaphragm, called
the esophageal hiatus, and then empties into the
stomach
V the mucosa has glands that secrete mucus to keep the
lining moist and well lubricated to ease the passage of
food
V upper and lower esophageal sphincters control the
movement of food into and out of the esophagus
O -ÄV

V C-shaped found on the left side of the abdominal

cavity, nearly hidden by the liver and diaphragm
V receives food from the esophagus
V divided into the fundic, cardiac, body, and pyloric
regions
O-ÿOÿO

V the bodyǯs major digestive organ, which extends from

the pyloric sphincter to the ileocecal valve, where it
empties into the large intestine
V finishes the process of digestion, absorbs the
nutrients, and passes the residue on to the large
intestine
V the absorptive surface area of the small intestine is
increased by plicae circulares, villi, and microvilli
V the most important factor for regulating secretions in
the small intestine is the presence of chyme
rÿÿOÿO

V is much larger in diameter than the small intestine but

shorter in length. [bout 1.5 m (5 feet) long
V it extends from the ileocecal valve to the anus
V Its function is to dry out the indigestible food residue
by absorbing water and to eliminate these residues
from the body as feces.
ÿ

V contains the lymphatic tissue that is part of the

immune system for making antibodies
V contains a layer of muscle, but the muscle is poorly
developed
V a potential trouble spot. Since it is usually twisted, it is
an ideal location for bacteria to accumulate and
multiply.
ÿÄ
O
O

V is the final straight portion of the large intestine

V anus is the external opening of the rectum
V the primary function of the anus is to expel feces from
the body
V Generic Name: [cetaminophen
V Brand Names: Paracetamol, [ldep, [lvedon,
[minofebrin, Baropurine, Biogesic
V Classification: [nalgesics, -uscle elaxants.
‰ricosurics
V Indication: elief of mild-to-moderate pain; treatment
of fever.
V [ction: Decreases fever by inhibiting the effects of
pyrogens on the hypothalamic heat regulating centers
and by a hypothalamic action leading to sweating and
vasodilation. elieves pain by inhibiting prostaglandin
synthesis at the CNS but does not have anti-
inflammatory action because of its minimal effect on
peripheral prostaglandin synthesis.
V Generic Name: -efenamic [cid
V Brand Names: [cidan, [nalcid, [prostal, Biogenerics
-efenamic [cid, Calibral, DLI -efenamic [vid,
Dolfenal
V Classification: [nalgesics, -uscle
V Indication: elief of pain including muscular,
rheumatic, traumatic, dental, post-operative and
postpartum pain, headache, migraine, fever and
dysmenorrhea, pain from rheumatoid arthritis ([)
including Stillǯs disease, soft tissue injuries. Therapy
should not exceed 7 days.
V [ction: [spirin-like drug that has analgesic,
antipyretic and anti-inflammatory activities. These
activities appear to be due to its ability to inhibit
cyclooxygenase and also antagonize certain effects of
prostaglandins. -efenamic acid displays central and
peripheral activities.
V Generic Name: Co-[moxicillin ([moxicillin,
Clavulanic [cid)
V Brand Name: [moclav, [ugmentin, [ugmex,
Bactoclav, Bioclavid, Clavace, Drugmakerǯs Biotech
[moxicillin + Clavulanic [cid, Enhamox, Exten,
Natravox
V Classification: [nti-infectives
V [ction: Prevents bacterial cell wall synthesis during
replication. Bactericidal
V Indication: Treatment of infections of respiratory
tract, skin and skin structures, genitourinary tract,
otitis media, meningitis, septicemia, sinusitis,
bacterial endocarditic prophylaxis.
V Generic Name: -etronidazole
V Brand Names: [bott -etronidazole (premixed), [--
Europharma -etronidazole, [nerobia, B. Braun
-etronidazole
V Classification: [nti-infectives
V [ction: Direct-acting amebicide/trichomonacide. It
binds to bacterial and protozoal DN[ to cause loss of
helical structure, strand breakage, inhibition of
nucleic acid synthesis and cell death.
V Indication: Infections in the intra-abdominal, skin and
skin structure, bone and joint, gynaecologic, bacterial
septicemia, CNS, lower respiratory system, and
endocarditic. Treatment of susceptible protozoal
infections and in the treatment and prophylaxis of
anaerobic bacterial infections. [naerobic infections,
trichomoniasis, amoebas, giardiasis. [ctive ulcerative
gingivitis. Pre- and post-operative prophylaxis in
gynaecological and GI surgery.
V Generic Name: Nalbuphine
V Brandnames: Nubain, Nalbuphine Hcl
V Classification: [nalgesics, -uscle elaxants and
‰ricorurics
V [ction: Binds with opiate receptors in the CNS;
ascending pain pathways in limbic system, thalamus,
midbrain, hypothalamus, altering perception of and
emotional response to pain. elieves pain.
V Indication: elief of moderate to severe pain; for pre-
operatively analgesia, supplement to balanced
anesthesia, surgical anesthesia, obstetrical analgesia.
V Generic Name: Omeprazole
V Brand Names: [cifre, Gastriloc, Lopep, Losec,
-epracid, Omenole, Omeprone, O- 20, Opehex,
isek, Wilom, Prisolec
V Classification: Gastrointestinal/Hepatobiliary drugs
V [ction: Suppresses gastric secretion by inhibiting
hydrogen/potassium [TPase enzyme system in the
gastric parietal cell: characterized as a gastric acid
pump inhibitor, since it blocks the final step of acid
production
V Indication: Short term treatment of active duodenal
ulcer, gastroesophageal reflux disease (GED),
including erosive esophagitis and symptomatic GED;
long term treatment of pathologic hypersecretory
conditions; to maintain healing of erosive esophagitis;
in combination with clarithromycin to eradicate H.
pylori, use clarithromycin and amoxicillin in
combination with omeprazole in patients with a 1-year
history of duodenal ulcer or active duodenal ulcers to
eradicate H. pyrlori; short-term treatment of active
benign gastric ulcer.
V Generic Name: Ketorolac
V Brand Names: Kortezor, [cular, Toradol
V Classification: [nalgesics, -uscle elaxants,
‰ricosurics
V [ction: [nalgesic, anti-inflammatory and antipyretic.
Inhibits prostaglandin synthesis by inhibition of cyclo-
oxygenase enzyme. It also inhibits leukotriene
synthesis, help stabilize lysosomal membranes and
exert anti-bradykinin activity.
V Indication: Opthalmic: Treatment of allergic
conjunctivitis, and for prophylaxis and reduction of
inflammation and associated symptoms following
ocular surgery. Solution for injection: Short term
V Generic Name: potassium chloride
V Brand Name: Kalium Durule
V Classification: Electrolytes and replacement solutions
V Indications: To prevent hypokalemia. Prophylaxis
during treatment w/ diuretics.
V [ction: eplaces potassium and maintains potassium
level.
V Brand Name: Kalimate
V Classification: Electrolytes and replacement solutions
V Indication: Prevention & treatment of hyperkalemia
resulting from acute or chronic renal failure
V Generic Name: -idazolam Hydrochloride
V Brand name: -idazolam
V Classification: Benzodiazepine
V [ction: -ay potentiate the effects of G[B[, depress
the CNS, and supress the spread the seizure activity
V Indication: Pre-operative sedation (to induce
sleepiness or drowsiness and relieve apprehension.
Conscious sedation before short diagnostic or
endoscopic procedures. To enduce sleepiness and
amnesia and to relieve apprehension before anesthesia
or before and during procedures. To enduce general
anesthesia. [s continuous infusion to sedate intubated
patients in critical care unit.
V Generic Name: anitidine hydrochloride
V Brand Name: ‰lcin
V Classification: [ntacids, [ntireflux [gents & [ntiulcerants
V Indication: Treatment of duodenal ulcer, benign gastric
ulcer, post-op ulcer, reflux esophagitis, ollinger-Ellison
syndrome & the following conditions where reduction of
gastric secretion & acid output is desirable: Prophylaxis of
GI hemorrhage from stress ulceration in seriously ill
patients, prophylaxis of recurrent hemorrhage in patients
w/ bleeding peptic ulcer & before general anesth in
patients at risk of acid aspiration, esp obstetric patients
during labor (-endelson's syndrome).