Integumentary System Lab Report

The general assessment findings regarding the patient ranked the general assessment as very poor regarding clothing, hygiene, nutrition and/or dehydration, and poor findings regarding skin integrity. The general assessment showed that the patients clothing were not clean; saturated with urine and food stains. In regards to nutrition this ranked very poor as well, considering the patient has lost 10 pounds since her last hospitalization only two weeks ago. This weight loss also could be because of dehydration or nutritional imbalance; further labs will need to be completed to decide if weight loss was regarding nutrition, dehydration or both. Albumin levels will be assessed for nutritional status (Bharadwaj, 2016). Skin integrity ranked a poor on the scale. The diffused red abrasions noted in sacral area could be a stage 1 ulcer. (Advanced Tissue, April 2014). Being unkempt, soiled and dirty is large warning sign of neglect especially for elderly patients (HelpingGuide.org, 2017).

M. H. states that she is generally in good overall health. No cardiac, respiratory, endocrine, vascular, musculoskeletal, urinary, hematologic, neurologic, genitourinary, or gastrointestinal problems.

1. The clear, keratinized portion of a fingernail is known as the nail _PLATE_. It has a root, body, and free edge.

Breasts: no masses, no nipple retraction, no discharge. Heart: S1 and S2, no gallops, rubs, or murmurs appreciated. Abdomen is scaphoid, soft and non-tender with positive bubble sounds. Pelvic/ Rectal: deferred as patient has recently visited her GYN for a routine Pap smear. Neurologic exam reveals normal motor strength in all muscle

11. The fact that a patient has experienced recent weight loss, fatigue, and loss of appetite would be included in which part of the review of systems (ROS)?

No scalp lesions. Dry eyes with conjunctival injection. Mild exophthalmos. Dry nasal mucosa. Marked cracking and bleeding of her lips with erosions of the mucosa. She has a large ulceration of the mucosa at the bite margin on the left. She has some scattered ulcerations on her hard and soft palette. She has difficulty opening her mouth because of pain. Tonsils not enlarged. No visible exudate. SKIN: She has some mild ecchymosis on her skin and some erythema, she has some patches but no obvious skin breakdown. She had some fissuring in the buttocks crease. PULMONARY: Clear to precussion and auscultation, bilaterally. CARDIOVASCULAR: No murmurs or gallops noted. ABDOMEN: Soft, non-tender, protuberant, no organomegaly, and positive bowel sounds. NORALOGIC EXAME: Cranial nerves ii – xii are grossly intact, diffuse hyporeflexia. MUSCULAR SKELETAL: Erosive destructive changes in elbows, wrist, and hands consistent with rheumatoid arthritis. Has had bilateral total knee replacements with stovepipe legs and perimalledal pitting edema 1+. I feel no pulse distally in either leg. PHYCIATRIC: Patient is a little anxious about these new symptoms and there significance. We discussed her situation and I offered her psychiatric services, she refused for now.

An abnormal heartbeat can be an indicator for other issues, such as a damaged heart valve. The next step is checking percussion, this portion of the examination the provider will tap on the patient's chest and abdomen. The provider is looking and listening for a specific sound under normal conditions. If there is a change in fluids or air there will be a different sound. The last portion of the physical examination is palpation. The provider will apply pressure using his fingers feeling along the body regions and organs. Palpation provides information about the size of an organ and changes in its consistency, shape, and tenderness, and can help determine the presence of a foreign mass. Based on the results of Mr. Smith's physical examination the provider determined that additional labs would need to be drawn. The provider ordered a complete blood count, which includes: a platelet, red blood cell, and white blood cell count, as well as a blood potassium check. Mr. Smith's labs were not within the normal limits, so the provider admitted him into the hospital. Hospital staff treated his deficiencies and sent him

They also did not have any idea about her preventative steps if she had taken any which made the situation even more demanding for the doctors to conduct all possible tests to diagnose her condition as accurately as possible. Let us look at the ideal CDVC in parallel to the care delivery which Mrs. Lushko received at Johnson Medical center.

Client reported no known allergies to food or drugs. Client reported that she has 8 years daughter. Client indicated her physical health "average". Client reported that she does not have a current primary care physician at the time of assessment. Client reported that she is not currently pregnant and does not taking medication for medical purpose. Client denied any issues in this dimension. Indicated no current condition or medications that would interfere with treatment. Client exhibited adequate ability to tolerate and cope with physical discomfort. No immediate biomedical services are needed at the time of assessment.

I would perform a peripheral vascular assessment on both upper and lower extremities. First, I would inspect and palpate her face and both her arms for color and consistent warmth. Then, I would do skin turgor and assess for capillary refill time bilaterally. Since patient also has vitamin deficiencies, I would at that point inspect her nails. I would move on to palpate her radial pulse bilaterally. Then, I would move to her lower extremities and inspect and palpate for color and consistent warmth. I would then palpate for pretibial edema and pedal pulses bilaterally. After that, I would assess for capillary refill time bilaterally. If there were abnormalities, then I would do a more comprehensive cardiovascular assessment. Patient also has Spina Bifida. I would inspect her back, then have her bend to palpate her spinal curvature. Patient is deaf on her right ear, so I would start out by inspecting and palpating both her ears. I would then do a focus neurological assessment for her ears. I would test for cranial nerve 8, which is acoustic. Since patient has hearing loss on her right ear, I would then perform a whisper test. I would also do a screening of patient’s heart and lung. I would start out by inspecting patient’s anterior chest and cardiac landmark for pulsation. Then palpate and auscultate the patient’s cardiac landmark. If there are no abnormalities I would move on to the lungs. I would note the

Diagnostic tests that Sherry may order are blood tests such as a CBC to help the

The patient was engaging, open about her recovery, and remained alert. There was no evidence of

The Y-shaped incision is performed from the shoulders joining over the sternum and continuous cut through umbilical region down to the pubic bone. He examines the oral cavity, and the air tube from back of the nose pharynx that connects to the voice box larynx; all of these are normal. However, the inflammation of esophagus is found right behind the upper esophageal sphincter. He predicted the victim used to suffer postprandial burning chest pain. Chyme is found in the duodenum part of the small intestine. The pathologist can take them to the laboratory for further examination. He also isolates the pancreas which is connected to the duodenum to examine any pancreatic diseases. The result is the victim had type 2 diabetes; it means the pancreas is unable to produce insulin to control the blood sugar level. In victim’s urinary system, he dissects the kidney and found she had pyelitis which is the inflammation of renal pelvic region of the kidney. The victim may experience the unconscious urination such as micturition syncope as well. About the reproductive system, the victim had no

The following procedures were performed on this visit and/or recommended: manipulation; physical performance test; and