INTRODUCTION: Pneumonia is an inflammatory condition of the lungaffecting primarily the microscopic air sacs known as alveoli.

It is usually caused by infection with viruses or bacteria and less commonly other microorganisms, certain drugs and other conditions such as autoimmune diseases. Typical symptoms include a cough, chest pain, fever, and difficulty breathing. Diagnostic tools include x-rays and culture of the sputum. Vaccines to prevent certain types of pneumonia are available. Treatment depends on the underlying cause. Pneumonia presumed to be bacterial is treated with antibiotics. If the pneumonia is severe, the affected person is, in general, admitted to hospital. People with infectious pneumonia often have a productive cough, fever accompanied by shaking chills, shortness of breath, sharp or stabbing chest pain during deep breaths, and an increased respiratory rate. In the elderly, confusion may be the most prominent sign. The typical signs and symptoms in children under five are fever, cough, and fast or difficult breathing.[10] Fever is not very specific, as it occurs in many other common illnesses, and may be absent in those with severe disease or malnutrition. In addition, a cough is frequently absent in children less than 2 months old. More severe signs and symptoms may include: blue-tinged skin, decreased thirst, convulsions, persistent vomiting, extremes of temperature, or a decreased level of consciousness. Bacterial and viral cases of pneumonia usually present with similar symptoms. Some causes are associated with classic, but non-specific, clinical characteristics. Pneumonia caused by Legion Ella may occur with abdominal pain, diarrhea, or confusion, while pneumonia caused by Streptococcus pneumoniae is associated with rusty colored sputum,and pneumonia caused by Klebsiella may have bloody sputum often described as "currant jelly. Bloody sputum (known as hemoptysis) may also occur with tuberculosis, Gram-negative pneumonia, and lung abscesses as well as more commonly with acute bronchitis. Mycoplasma pneumonia may occur in association with swelling of the lymph nodes in the neck, joint pain, or a middle ear infection. Viral pneumonia presents more commonly with wheezing than does bacterial pneumonia. Septic shock is a serious condition that occurs when an overwhelming infection leads to life-threatening low blood pressure. Septic shock

occurs most often in the very old and the very young. It also occurs in people who have other illnesses. Any type of bacteria can cause septic shock. Fungi and (rarely) viruses may also cause the condition. Toxins released by the bacteria or fungi may cause tissue damage, and may lead to low blood pressure and poor organ function. Some researchers think that blood clots in small arteries cause the lack of blood flow and poor organ function. The body also produces a strong inflammatory response to the toxins. This inflammation may contribute to organ damage.

Demographic Data

Name: Patient R.H.P Age: 41 years of age Sex: Female Civil Status: Single Address: Mangyan, Sibonga, Cebu Religion: Roman Catholic Nationality: Filipino Birthdate: November 11, 1971 Admitting Diagnosis: Septic Shock secondary to PTB with pneumonia, severe anemia of chronic disease t/c lymphatic obstruction left leg

X-RAY REPORT Procedure: Leg ( left) APL Findings: The bones are normal in density, texture and modeling. There is no evidence of fracture, bone erosion, no bone destruction. Impression: Normal bones of the left leg Procedure: Chest Pa Findings: There are in homogenous and nodular densities on both lungs. There is a homogenous density at the left paracardiac area. There is a haziness in the right lung. Heart is normal in size and shape. The thoracic aorta is tortous. The trachea is at the midline. Both hemidiaphragms are sharp and distinct. The osseous tjoracic cage showed no significant bony abnormality Impression: Pneumonia, both lungs, suggest after 10-14 days for comparative study Artherosclerosis of the thoracic aorta.

SPUTUM MICROSCOPY RESULTS

Visal Appearance Reading Lab Diagnosis: POSITIVE

1 Mucoid 0

2 Mucoid +1

- Specimen 2 & 3= not applicable if sputum follow-up - Muco- purulent, blood stained, saliva, etc.

HEMATOLOGY Result Reticulocyte Count 99 Unit 10^3/L Reference 5-20

Peripheral Smear

Smears show a slightly hypochromic normocytic erythrocytes. Leukocytes are increased in number, demonstrating Neutrophilia. No immature or blast cells are seen. Platelets are adequate in quantity with normal morphology.

CLINICAL MICROSCOPY URINALYSIS Color Transparancy Specific Gravity pH Glucose Protein RBC WBC Cast Hyaline Cast Fine Granular Cast RESULT Yellow Cloudy 1.030 6.0 neg (-) +1 0-2 3-5 2-4 1-3 UNIT

/hpf /hpf /lpf /lpf

MISCELLANEOUS STRUCTURES Squamous E. Cells Bacteria Mucus Threads Few Mod Few

DRUG STUDY Generic Name: Brand Name: Classification: Mechanism of Action: Contraindication: Piperacillin Sodium and Tazobactam Sodium Zosyn Antibiotic Inhibits cell-wall synthesis during bacterial multiplication Contraindicated in patients hypersensitive to drug or other penicillins. Use cautiously in patients with bleeding tendencies, uremia, hypokalemia, and allergies to other drugs, especially cephalosporins, because of possible crosssensitivity. Drug: Hormonal Contraceptives: may decrease contraceptive effectiveness. Advise use of another fform of contraception during therapy. Oral Anticoagulants: May prolong effectiveness. Monitor PT and INR closely. Vecuronium: May prolong neuromuscular blockade. Monitor patient closely. CNS: headache, insomnia, fever, seizures, agitation, anxiety, dizziness, pain EENT: rhinitis GI: diarrhea, constipation, nausea, pseudomembranous, abdominal pain, dyspepsia, stool changes, vomiting GU: candidiasis, interstitial nephritis HEMA: leukopenia, neutropenia, thrombocytopenia, anemia, eosinophilia

Interaction:

Adverse and Side effects:

SKIN: pruritis, rash OTHERS: anaphylaxis, hypersensitivity reactions, phlebitis at I.V site Drug may alter normal colon flora. Monitor patient for diarrhea and initiate therapeutic measures as needed. Drug may need to be stopped. Because peritoneal dialysis removes 6% of the piperacillin dose and 21% of the tazobactam dose, and hemodialysis removes 30% to 40% of a dose in 4 hours, additional doses may be needed after each dialysis period. If large doses are given or if therapy is prolonged, bacterial or fungal superinfection may occur, especially in elderly, debilitated, or immunesuppressed patients. Monitor hematologic and coagulation parameters Drug contains 2.35 mEq sodium/ g of piperacillin. Monitor patients sodium intake and electrolyte levels. Tell patient to report any adverse reaction Tell patient to alert w health care professionals about discomfort at the I.V site

Nursing Intervention (minimum of 5)

Patient Teaching

Generic Name: Brand Name: Classification: Mechanism of Action:

Acetylcysteine Acetadote Mucolytic Reduce the viscosity of pulmonary secretions by splitting disulfide linkages between mucoprotein molecular complexes. Also, restores liver stores of glutathione to treat acetaminophen toxicity. Contraindicated in patients hypersensitive to drug. Use cautiously in elderly or debilitated patients with severe respiratory insufficiency. Use I.V form cautiously in patients with asthma or a history of bronchospasm.

Contraindication:

Interaction:

Drug: Activated charcoal: May limit acetylcysteines effectiveness. Avoid using activated charcoal before or with acetylcysteine.

Adverse and Side effects:

Activity: CNS: abnormal thinking, fever, drowsinees, gait disturbance

EENT: rhinorrhea, ear pain eye pain, pharyngitis, throat tightness

GI: nausea, stomatitis, vomiting

SKIN: clamminess, diaphoresis, pruritis, rash, urticaria

OTHERS: anaphylactoid reaction, angioedema, chills Monitor cough type and frequency If you suspect acetaminophen overdose, obtain baseline, AST, ALT, bilirubin, PT, BUN, creatinine, glucose, and electrolyte levels Facial erythema may occur within 30 to 60 minutes of start of I.V infusion and usually revolves without stopping infusion When acetaminophen level is below toxic level according to nomogram, stop therapy The vial stopper doesnt contain natural rubber latex, dry natural rubber, or blends of natural rubber

Nursing Intervention (minimum of 5)

Patient Teaching

Warn patient that drug may have a foul taste or smell that may be distressing For maximum effect, instruct patient to cough to clear his airway before aerosol administration

Generic Name: Brand Name: Classification: Mechanism of Action:

Acetaminophen Acephen Analgesic Thought to produce analgesia by inhibiting prostaglandin and other substances that sensitize pain receptors. Drug may relieve fever through central action in the hypothalamic heatregulating center Contraindicated in patients hypersensitive to drug Use cautiously in patients with any type of liver disease and in patients with long-term alcohol use because therapeutic doses cause hepatoxicity in these patients. Chronic alcoholics shouldnt take more than 2g of acetaminophen every 24 hours

Contraindication:

Interaction:

Drug: Amphetamines, anticholinergics, mecamylamine, procainamide, quinidine: May decrease renal clearance of these drugs, increasing toxicity. Monitor patient for toxicity Cyclosporine: May increase cyclosporine level, causing nephrotoxicity and neurotoxicity. Monitor patient for toxicity Diflunisal: May increase acetazolamide adverse effects; may significantly decrease IOP. Use together cautiously Lithium: May increase lithium excretion, decreasing its effect. Monitor lithium level Methenamine: May reduce methenamine effect. Avoid using together Primidone: May decrease serum and urine primidone levels. Monitor patient closely

Adverse and Side effects:

Activity: CNS: seizures, drowsiness, paresthesia, confusion, depression, weakness, ataxia EENT: transient myopia, hearing dysfunction, tinnitus GI: nausea, vomiting, anorexia, metallic taste, diarrhea, black tarry stools, constipation

GU: polyuria, hematuria, crystalluria, glycosuria, phosphaturia, renal calculus HEMA: aplastic anemia, leukopenia, thrombocytopenia, hemolytic anemia

SKIN: pain at injection site, stevensjohnson syndrome, rash, urticaria

OTHERS: sterile abscesses

Nursing Intervention

Cross-sensitivity between bacterial sulfonamides and sulfonamide- derivative diuretics such as acetazolamide has been reported

(minimum of 5)

Patient Teaching

Monitor fluid intake and output, glucose, and electrolytes, especially potassium, bicarbonate, and chloride. Monitor elderly patients closely because they are especially susceptible to excessive diuresis Weigh patient daily. Rapid or excessive fluid loss may cause weight loss and hypotension Monitor patient for signs of hemolytic anemia Tell patient to take oral form with food to minimize GI upset Tell patient not to crush, chew, or open capsules Caution patient no to perform hazardous activities if adverse CNS reaction occur Instruct patient to avoid prolonged exposure to sunlight because drug may cause phototoxicity Instruct patient to notify prescriber of any unusual bleeding, bruising, tingling, or tremors

Generic Name: Brand Name: Classification: Mechanism of Action: Contraindication:

Ketorolac tromethamine Toradol NSAID May inhibit prostaglandin synthesis, to produce anti-inflammatory, analgesic, and antipyretic effects Contraindicated in patients hypersensitive to drug and in those with active peptic ulcer disease, recent GI bleeding or perforation, advanced renal impairment, cerebrovascular bleeding, hemorrhagic diathesis, or incomplete hemostasis

Interaction:

Drug: ACE inhibitor, angiotensin II receptor antagonists: May cause renal impairment, particularly in volume-depleted patients. Avoid using together in volume-depleted patients Anticoagulants: may increase anticoagulant levels in the blood. Use together with extreme caution and monitor patient closely Anticonvulsants: may increase seizure activity. Use together cautiously Antihypertensives, diuretics: may decrease effectiveness. Monitor patient closely Lithium: may increase lithium level. Monitor patient closely Methotrexate: may decrease methotrexate clearance and increased toxicity. Avoid using together Pentoxifylline: may increase risk of bleeding

Adverse and Side effects:

CNS: headache, dizziness, drowsiness, sedation

EENT: inomfort, rhinalgia, rhinitis, throat irritationcreased lacrimation(nasal spray only), nasal disc

GI: dyspepsia, GI pain, nausea, constipation, diarrhea, flatulence, peptic ulceration, stomatitis, vomiting

GU: renal failure

HEMA: decreased platelet adhesion, prolonged bleeding time, purpura

SKIN: diaphoresis, pruritus, rash

OTHERS: pain at injection site

Nursing Intervention (minimum of 5)

Correct hypovolemia before giving Dont give drug epidurally or intrathecally because of alcohol content Carefully observe patients with coagulopathies and those taking anticoagulants Dont give drug concomitantly with other

forms of ketorolac or other NSAIDs NSAIDs may mask signs and symptoms of infection because of their antipyretic and anti-inflammatory actions

Generic Name: Brand Name: Classification: Mechanism of Action:

Salbutamol + Ipratropium DuoNeb Bronchodilator Is used to treat severe breathing trouble caused by ongoing lung diseases (chronic obstructive pulmonary disease-COPD, which include chronic bronchitis and emphysema). It helps to relax the muscles around your airways so that they open up to make breathing easier. It helps to reduce shortness of breath, wheezing, and coughing. This medication is a combination of 2 drugs, ipratropium and albuterol. Albuterol is also called salbutamol in some countries. Ipratropium is an anticholinergic bronchodilator and albuterol (salbutamol) is a betaagonist bronchodilator. Contraindicatedwithhypersensitivityto atropine or itsderivatives. Drug: Your healthcare professionals (e.g., doctor or pharmacist) may already be aware of any possible drug interactions and may be monitoring you for it. Do not start, stop or change the dosage of any medicine before checking with them first.Avoid taking MAO inhibitors (e.g., furazolidone, isocarboxazid, linezolid, moclobemide, phenelzine, procarbazine, rasagiline, selegiline, tranylcypromine) within 2 weeks before, during, and after treatment with this medication. In some cases a serious, possibly fatal drug interaction may occur.Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of: anticholinergic drugs (e.g., atropine,scopolamine), certain antihistamines (e.g., diphenhydramine, meclizine), antispasmodic

Contraindicatio n: Interaction:

drugs (e.g., dicyclomine, hyoscyamine), certain anti-Parkinson's drugs (e.g., benztropine, trihexyphenidyl), some beta-blockers (such as propranolol), bladder control drugs (e.g., oxybutynin, tolterodine),pramlintide, stimulant-like drugs (e.g., ephedrine, epinephrine), tricyclicantidepressants (e.g., amitriptyline, nortript yline), certain "water pills" (diuretics that cause potassium loss from the body such as furosemide,hydrochlorothiazide).Check the labels on all your medicines (e.g., cough-and-cold products, diet aids) because they may contain ingredients that could increase your heart rate or blood pressure. Ask your pharmacist about the safe use of those products.

Adverse and Side effects:

CNS: headache, dizziness, blurred vision GI: nausea, diarrhea, constipation, dry mouth CV: palpitations, chest pain SKIN: rash

Nursing Intervention

Monitor the patients vital signs, noting hypotension and an irregular or abnormal pulse .Maintain a quiet, comfortable environment to minimize anxiety and perhaps decrease palpitations. Teach the patient pursed-lip breathing, diaphragmatic breathing, and chest splinting.

Patient Teaching

Never take more than the prescribed dose. If you suspect that you have taken, or someone else has taken, an overdose of this medicine, go to the accident and emergency department of your local hospital at once. Take the container with you, even if it is empty. If you are having an operation or dental treatment tell the person carrying out the treatment which medicines you are taking. This medicine is for you. Never give it to other people even if their condition appears to be the same as yours. Never keep out-of-date or unwanted medicines. Take them to your local pharmacy which will dispose of them for you.

Generic Name: Brand Name: Classification: Mechanism of Action:

erythromycin E-Mycin MACROLIDE ANTIBIOTIC More active against gram-positive organisms than against gram-negative organisms due to its superior penetration into gram-positive organisms Erythromycin is contraindicated in patients with known hypersensitivity to this antibiotic. Erythromycin is contraindicated in patients taking terfenadine, astemizole,cisapride, pimozide, ergotamine, or dihydroergotamine Drug:

Contraindication:

Interaction:

Activity: Adverse and Side effects: GI: Nausea, vomiting, abdominal cramping, diarrhea, heartburn, anorexia SKIN: (topical use) Erythema, desquamation, burning, tenderness, dryness or oiliness, pruritus

Nursing Intervention (minimum of 5)

Report onset of GI symptoms after PO administration to physician. These are doserelated; if symptoms persist after dosage reduction, physician may prescribe drug to begiven with meals in spite of impaired absorption. Observe for S&S of superinfection by overgrowth of nonsusceptible bacteria or fungi.Emergence of resistant staphylococcal strains is highly predictable during prolongedtherapy. Monitor for S&S of hepatotoxicity. Premonitory S&S include: Abdominal pain, nausea,vomiting, fever, leukocytosis, and eosinophilia; jaundice may or may not be present.Symptoms may appear a few days after initiation of drug but usually occur after 12 wk of continuous therapy. Symptoms are reversible with prompt discontinuation of erythromycin. Monitor for ototoxicity that appears to develop most frequently in patients receiving 4 g/dor more, older adults, female patients, and patients with kidney or liver dysfunction. It is reversible with prompt discontinuation of drug. Report any ototoxic effects including dizziness, vertigo, nausea, tinnitus, roaring noises, hearing impairment Advise patient to report any adverse effect

Patient Teaching

ANATOMY AND PHYSIOLOGY

The respiratory system

The respiratory system is composed of various structures and organs that ensure that the body is able to maintain its internal environment through the exchange of air between the lungs and the atmosphere. In order to survive the body needs a constant supply of oxygen, which it obtains from the air. The body also needs to dispose of carbon dioxide, made as a waste product from the process of cell metabolism. The ingestion of oxygen and the discarding of carbon dioxide, occurs through the process of respiration or breathing.

Structure The respiratory system is comprised of the:

nose nasopharynx mouth sinuses larynx trachea bronchi lungs alveoli

The respiratory system contains the upper and the lower respiratory tracts. The upper respiratory tract contains the respiratory organs located outside the chest cavity: the nose and the nasal cavities, pharynx, larynx and upper trachea. The lower respiratory tract consists of organs located in the chest cavity: the lower trachea, bronchi, bronchioles, alveoli and the lungs. The lower parts of the bronchi, the bronchioles and alveoli, are all located in the lungs. The alveoli are the point at which gas exchange takes place. The pleura are a membrane that covers the lungs. The muscles that form the chest cavity are also part of the lower respiratory tract. The respiratory centre in the brain, which is located in the medulla oblongata, regulates breathing. (Herlihy et al. 2000). Function The function of the respiratory system is to supply oxygen and to remove carbon dioxide from cells. Oxygen is needed by cells to produce heat and energy. In using oxygen, the cells produce carbon dioxide as waste. Inhaled air is moistened and warmed as it passes through the upper respiratory tract - the nose, the pharynx and the larynx. The clean air passes on through the lower respiratory tract - the trachea and lungs where the exchange of gases takes place (Sorrentino, 1997). Respiration Respiration involves the passage of air in and out of the lungs. Air passes from nose to the pharynx to the larynx to the trachea to the left and right bronchus to the bronchioles to the alveoli (where a gas

exchange takes place and oxygen and carbon dioxide are exchanged in the pulmonary capillaries) (Herlihy et al. 2000). Air enters the body via the nasal passages, where it is warmed, moistened and filtered. Air then passes down through the pharynx and into the larynx and trachea. The air continues into the right and left bronchi and then into the lungs. In the lungs the bronchi then branch into smaller bronchioles, that each have air sacs called alveoli, attached to them. The exchange of oxygen and carbon dioxide takes place at this level, between the alveoli and the blood capillaries. Through this process oxygen enters the bloodstream and can be transported around the body. The circulatory system is an organ system that permits blood and lymph circulation to transport nutrients (such as amino acids and electrolytes), oxygen, carbon dioxide, hormones, blood cells, etc. to and from cells in the body to nourish it and help to fight diseases, stabilize body temperature and pH, and to maintain homeostasis. This system may be seen strictly as a blood distribution network, but some consider the circulatory system as composed of the cardiovascular system, which distributes blood, and the lymphatic system,which returns excess filtered blood plasmafrom the interstitial fluid (between cells) as lymph. While humans, as well as other vertebrates, have a closed cardiovascular system (meaning that the blood never leaves the network of arteries, veins and capillaries), some invertebrate groups have an open cardiovascular system. The more primitive, diploblastic animal phyla lack circulatory systems. The lymphatic system, on the other hand, is an open system providing an accessory route for excess interstitial fluid to get returned to the blood. Two types of fluids move through the circulatory system: blood and lymph. Lymph is essentially recycled blood plasma after it has been filtered from the blood cells and returned to the lymphatic system. The blood, heart, and blood vessels form the cardiovascular (from Latin words meaning 'heart'-'vessel') system. The lymph, lymph nodes, and lymph vessels form thelymphatic system. The cardiovascular system and the lymphatic system collectively make up the circulatory system.

Systemic circulation Systemic circulation supplies nourishment to all of the tissue located throughout your body, with the exception of the heart and lungs because they have their own systems. Systemic circulation is a major part of the overall circulatory system. The blood vessels (arteries, veins, and capillaries) are responsible for the delivery of oxygen and nutrients to the tissue. Oxygen-rich blood enters the blood vessels through the heart's main artery called the aorta. The forceful contraction of the heart's left ventricle forces the blood into the aorta which then branches into many smaller arteries which run throughout the body. The inside layer of an artery is very smooth, allowing the blood to flow quickly. The outside layer of an artery is very strong, allowing the blood to flow forcefully. The oxygenrich blood enters the capillaries where the oxygen and nutrients are released. The waste products are collected and the waste-rich blood flows into the veins in order to circulate back to the heart where pulmonary circulation will allow the exchange of gases in the lungs. During systemic circulation, blood passes through the kidneys. This phase of systemic circulation is known as renal circulation. During this phase, the kidneys filter much of the waste from the blood. Blood also passes through the small intestine during systemic circulation. This phase is known as portal circulation. During this phase, the blood from the small intestine collects in the portal vein which passes through the liver. The liver filters sugars from the blood, storing them for later.

History of Present Illness A case of patient RHP 41 years old, female, single, from Mangyan Sibonga, Cebu. One year prior to admission, she has positive symptoms of on and off cough with yellowish phlegm. Knowing that these signs and symptoms were just of forms of little discomforts, so she self medicated herself with Tuseran and never seek medical advice. Two months prior to admission patient RHP observed that her left leg is getting bigger and swelling and she has difficulty in moving her left leg. She went to hospital XX to seek medical treatment about her condition and the patients admitting diagnosis was Septic Shock secondary to PTB with Pneumonia, Severe Anemia to consider Lymphatic Obstruction left leg.

Gordons Functional Health Pattern A. Health Perception and health management pattern. Patient states that having a stable life health condition would make life easy especially when you have work to do. Patient is well aware and informed to his present condition. B. Nutritional and Metabolic Pattern Patient has normal diet as tolerated, patients eats meals on time and has biscuit for snacks, patient drinks water every after snacks and major meals, and in time when she is feels thirsty. The total amount of fluid take orally is 600-800 daily per afternoon shift. C. Elimination Pattern Patient urinates with more than the minimum around per hour. Client urinates 2-4 times per shift. Patients total outcome in urination limits from 400-600 ml per afternoon shift. D. Activity/ Exercise Pattern Patient was observed to have minimal activity to compensate for her weakness. Patient well rested on bed. E. Cognitive and Perceptual Pattern

Patient was able to answer most of the questions thrown to her and was responding well of her knowledge gained in her experiences. Patient educational attainment was until 4 th year highschool. F. Sleep and rest Pattern She had difficulty in sleeping during the first day of admission because she is experiencing difficulty in breathing. Patient also verbalized that the environment is not soothing for her sleeping pattern because of its hot and noisy environment.

G. Self-Perception and Self Concept Pattern Patient loves to have conversation and states that she finds it hard to do her daily activities or work when she feels bad. Patient states that having a good health make you do anything with ease. H. Role & Relationship Pattern Patient is living with her family and is satisfied with the relationship of her parents and siblings, Patient is working with minimal wage to help finance the family. I. Sexuality and Reproductive Pattern Patient is a lesbian and have never been experience sex with her partner. J. Coping Stress Pattern To cope up with external and internal stressors. Patient will have her rest until she will feel energized to face the real world. Patient also drink alcoholic beverages like tanduay together with her friend. Patient will also watch television or play hand games to divert her attention from stressors. K. Value Belie Pattern

Patient values oneself, being good to other and having positive attitude towards life. Patient values her religion as she prays to be spiritually free from diseases.

Physical Assessment General Survey Appearance: Clean Grooming: well-groomed, dressed properly Temperature: 37.0 Weight: Pulse Rate: 90 Respiratory Rate: 28 Blood Pressure: 80/60 Skin: Hair

fair complexion smooth dry skin returns after 2 seconds upon pinch no lesions noted

Black evenly distributed thin and straight in texture no lesions noted

Nails pinkish white curve in shape no tenderness noted Eyes symmetrical PEERLA pupils constrict when looking at the near object and dilate when looking at the far object pupils have direct and consensual reaction to light Eyelashes hair is evenly distributed Blink reflex is present Able to see

Nose Symmetrical Able to smell No tenderness noted Ears Consistent with facial skin color Able to hear Symmetrical No tenderness noted No lesion noted

Mouth & Oropharynx Lips Pallor No lesions Gums Pinkish No lesions Tongue Symmetrical Moves freely Pinkish Respiratory

Symmetrical No thoracic tenderness noted Crackles/ wheezing during expiration

Chest Symmetrical Same as the body Abdomen Same as with the body Flat No murmur Genitourinary tract Able to urinate No lesions noted Extremities Left dorsalis pedis ( not palpable with edema of left lower extremity)