The client LACA, who is male, 18 years old and currently residing in 2657 B. Villanueva St. Pasay City, is the primary client in this assessment. His birthday is Aug 12 1987 and born at San Antonio Quezon Province.
The ethnic background is primarily Filipino with Tagalog as the primary language spoken. The patient LACA is single, current educational Attainment is second Year College, studying at Fatima University with Nursing course, and Roman Catholic as his religious orientation. The Usual source of Medical Care is the family.
According to the present health concern, the patient’s primary concern is the severe presence of acne particularly on his facial area since he was 4th year high school.
According to past health assessment, the client, Mr. Laca, had mumps twice, which primarily occurred when he was 9 years old (1999) and 15 years old (2002), and each lasted for a week.
According to the client, his immunization was only DPT, and was acquired when he was Grade 5 (11 years Old) only because of their school vaccination program at Pury San Antonio Quezon Province public school. In terms of references, there have been no medical records supporting claims of vaccinations such as baby book, medical documents, etc.
There has been no presence of any type of allergies in drugs, foods or other reasons according to the client. There have been no records of accidents and injuries. The client is not using any prescribed medications. The client also has not had any foreign travels.
In terms of the past health illness of Mr. LACA, the client’s family had history of hypertension brought by the father, and diabetes brought by the mother from the paternal ancestry according to the Genogram.
The hypertension was passed from the grandparents of Mr. Laca to his uncle, JA (50 yrs old), two aunts namely CA (48 years old) and NA (46 years old), and the client’s father, Brigidio (44 years old) who was deceased by the said condition.
From the maternal side, no presence of hereditary diseases was detected. The siblings of Mr. Brigido and Mrs. Violeta, which are brothers of Mr. Laca including him, also failed to inherit any of the hereditary diseases (see Genogram in appendix).
Other than the chief complaint of Mr. LACA, everything else felt by him is stated normal and appropriate according to his perception. The client Mr. Laca has a height of 151cm and a weight of 52 Kg. Moreover, his current BMI is 22.8 indicating a normal state.
Deviations that have been seen in the client are presence of acne as the primary lesions and facial cars as the secondary lesions. In assessing the skin integrity, Mr. LACA has been found having insect bites particularly in lower extremities. In addition, scars from wounds have been observed in both Mr. LACA’s proximal upper extremities as well as the lower extremities. However, fresh wounds, abscesses and other skin infections are not found in these areas.
The client’s posture and gait is relaxed with erect posture. Motor movements, such as sitting, standing and walking are coordinated. There are no body odors or minor any body odors relative to work or exercise. Communication and level of speech are organized, comprehensible and well understood.
Starting out with the patient’s integument, the patient’s skin is deep brown with presence of eythematous and pruritic lesions particularly in the lower and upper extremities with more severe manifestations on the lower extremities. There is no noted jaundice, edema, pallor or cyanosis in any parts of the patient’s integument. In terms of skin moisture, the skin folds and the axillae are moist without evidence of bad odor.
Through palpation, it has been noted that the patient possesses uniform and within normal range skin temperature with no manifesting hyperthermia or hypothermia. Skin turgor is good as manifested by springing back to previous state right after pinching.
In terms of hair assessment, the patient has been found to possess evenly distributed hair in the scalp, thick hair, no reflection or infestation noted and variable body hair. There is no observed alopecia or patches of hair loss, as well as sores, flaking and nits.
Upon inspection of the fingernails, the findings in the patient are convex curvature with angle of nail plate about 160 degrees and smooth in texture. The toenail’s bed color is highly vascular and pink to brown color; since, the Mr. LACA possesses darker skin color.
The tissues surrounding the nails are intact without manifesting parenchyma or hangnails. During the performance of blanch test of capillary refill, prompt return of nail bed usual color has been observed.
In the assessment of the head, it has been noted that the skull size is rounded, normocephalic, symmetrical, with frontal, parietal, and occipital prominences. In addition, the skull possesses smooth contours and with no manifesting alterations in other bony sections or prominence of the skull.
By means of palpations, the skull has been noted uniform in consistency and absent in any nodules or masses. The facial features are symmetric with palpebral fissures equal in size and symmetric nasolabial folds. There has been no noted edema; however, Mr. LACA has been noted of having sunken eyeball with darkening at the lower portion of the eye. The facial movements are noted symmetrical with no signs of any alterations.
In the assessment of external eye structures, the eyebrows are evenly distributed, the skin is intact and symmetrically aligned with equal movements.
The eyelids have been noted to produce discharge and with manifesting red discoloration in the left eye of the patient. The blinking count is 36 blinks per minute with bilateral and involuntary in nature. Sclera appears reddish particularly in the left eye; however, the palpebral conjuctiva is shiny, smooth and pinkish.
The pupil constricts as a direct response when illuminated and constricts again as consensual response when the pupil is non-illuminated. The pupils constrict when looking at near objects, and dilate when looking at far objects. In addition, the pupil converge when near object is moved toward the nose. Mr. LACA possesses 20/ 180 vision, both eyes coordinated, move in unison and with parallel alignment.
In terms of hearing, Mr. LACA is able to hear normal voice tone, ticking sounds heard in both ear, and Air conduction is greater than bone-conduction hearing. In terms of physical characteristics, the auricle is aligned in the outer canthus of the eyes, about 10 degrees from vertical.
In terms of nasal assessment, the physical features are symmetric and straight, uniform in color, with presence of primary and secondary lesions accompanied with pain and tenderness due to severe acne. Internal assessment reveals pink mucosa, clear and water discharge, intact nasal septum located in the midline and not tenderness observed in the sinuses.
There are palpable nodules in the neck area of the patient, lymph nodes on postauricular and supraclavicular are evidently manifesting accompanied by tenderness.
The oral mucosa possesses ulcerations, 31 teeth present (other one is molar and removed due to tooth decay. Presence of brown and black stains at the front teeth and some parts is observed. Foul odor is also emitted and tooth decay in present in the canine and left molar regions of the client.
In the palpation of the chest and thorax, Mr. LACA possesses anteroposterior to transverse diameter in ratio of 1:2, symmetric chest, vertically aligned spine, right and left shoulders and hips are at same height and chest wall intact with no tenderness and masses.
Full and symmetric expansion is noted when the client takes a deep breath as manifested by the thumb separation of 4 cm. Vocal fremitus possesses bilateral symmetry and clearly heard at the apex of the lungs. Vesicular and bronchovesicular breath sounds are also heard. Respirations are also noted to be quiet, rhythmic and effortless, and full symmetric excursion noted.
Temperature, pulsations, respiration and blood pressure are noted, and the data are 38.2 degree Celsius, 66 beats/ min., 18 breaths/ min. and 110/ 80. In the assessment of the abdomen, flat, symmetric contoured and no evidence of enlargement of liver or spleen is noted.
There are symmetric movements caused by respiration, visible peristalsis, no visible vascular pattern, audible bowel sounds, absence of arterial bruit and absence of friction rub. In the musculoskeletal, the client has no contractures, smooth coordinated movements, equal strength on each body side, no deformities, no tenderness or swelling in bony prominences and joints move smoothly.