Question

Ht 4'11", Wt 100 Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU: SKIN: Breath sounds clear and diminished in bases, short of breath. Tachycardia, regular rhythm, no edema Muscle tone generally weak Mucous membranes pale, tongue smooth/shiny, abdomen soft, non-tender, spleen palpable. Patient has not voided yet Pale, intact w/o erythema or ecchymosis RELEVANT Assessment Data: Clinical Significance:

Answer 1

Parameter	Assessment finding	Significance
General appearance	Ht 4’11”, wt 100	Weight is within normal range for height (91.6 – 123.3 lb) BMI of patient is 20.2 and is in normal range.
Respiration	Breath sounds clear, diminished in base, short of breath	Normal lung sounds occur in all parts of the chest area, including above the collarbones and at the bottom of the rib cage. Decreased sounds at the base of lung can mean: Presence of air or fluid in or around the lungs (like in conditions such as pneumonia, pleural effusion, pneumothorax, pulmonary oedema, heart failure), increased thickness of the chest wall, over-inflation of a part of lung (may happen due to emphysema), reduced airflow to part of the lungs. It needs further evaluation.
Cardiac	Tachycardia, regular rhythm, no oedema	Tachycardia is a heart rhythm disorder, usually caused by a glitch in the flow of electrical signals flow along a pathway from the heart’s upper chambers/ atria to its lower chambers/ ventricles. A short-circuit anywhere along this path affect rhythm of the heart. Tachycardia occurs when an abnormality in the heart produces rapid electrical signals that quicken the heart rate, which is normally about 60 to 100 beats a minute at rest. Tachycardia may occur in a number of conditions including heart-related conditions such as poor blood supply to the heart muscle due to coronary artery diseases, high blood pressure (hypertension), heart failure, or infections, valvular disease, , cardiomyopathy. Other disorders such as certain lung diseases thyroid disease, electrolyte imbalance, and alcohol or drug abuse can also lead to tachycardia. It demands further investigation.
Neuro	Muscle tone generally weak	Poor muscle tone may happen due to variety of neurological conditions, electrolyte imbalances
GI	Mucous membrane pale, tongue smooth/ shiny, abdomen soft, non-tender, spleen palpable	Glossitis (swelling of the tongue)may cause the tongue to appear smooth. It is common in people with dentures. Normally spleen is not palpable. A palpable spleen may occur in a variety of infections, anaemia, blood cancer ,liver cirrhosis, metabolic disorders
GU	Patient has not voided yet	It can be caused by variety of conditions that affect the kidneys, bladder or prostate gland (in men) and urethra. It is a medical emergency and require immediate medical attention
Skin	Pale, w/o erythema and ecchymosis	Paleness of the skin refers to an abnormal lightening of the skin or mucous membranes. It indicates poor oxygenation of tissue and may happen in variety of conditions like shock, anaemia, heart disease, heart disease, drug abuse