PHYSICAL EXAMINATION
 INTRODUCTION
My patient name is KhemanKurbhkar, who is 36 yrs old and admitted to GMS ward on 30/01/11,
with the complain ofpain in the right side of the abdomen, constipation, loss of appetite, nausea
since 1 month .
 BIODATA :
Name– KhemanKurbhkar
Age / Sex-male/36 yrs
Date of admission – 30/01/11
Registration No - 664386
Ward –GMS ward
Bed no – 1
Diagnosis – Stomach Cancer
 CHIEF COMPLAINT:
My patient complains of pain in the right side of the abdomen, constipation, loss of appetite, nausea
since 1 month.
 PHYSICAL EXAMINATION ( FOLLOW NANCY BOOK)
 General appearance: Conscious
 Expression: normal
 Mental status: Irritable, oriented to time and place
 Height: 164cm
 Weight: 72kg
 Vital signs Temperature: 101.2degree Fahrenheit
 Pulse: 92/minute
 Respiration: 24/minute
 BP: 140/90 mm of Hg
 Head and neck Hair (area of scalp covered) -shaved
 Texture of scalp hair- normal
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 Edema/ puffiness- present
 Size- symmetry
 Neck vein- not prominent
 Neck movement- stiff
 Lymph node- not palpable
Eyes Eye hygiene- clean
 Eye brows- symmetrical
 Eye lashes- equally distributed
 Eye lids- swelling
 Pupillary reflex- equal reaction to light.
 Conjunctiva- normal
Nose Nasal pathway- patent
 Septum-normal
 Rhinorrhoea- absent
 Polyp- absent
Mouth & pharynx
 Breath odor- foul smelling
 Lips color- pale
 Dental hygiene- poor
 Tongue- pink
 Position-central
 Tonsil- normal
 Pharynx- normal
Ear  Position- normally placed
 Hygiene – maintained
 Discharge- no discharge
 Hearing- normal
Neck  Neck vein- not prominent
 Neck movement- stiffness
 Lymph node- not palpable
Cardio-respiratory Chest- symmetrical
 Heart sounds- on auscultation heard
 Heart rate- 92/mt
 Rhythm- regular
 Volume- adequate
 Palpitation- not observed
 Murmur- not heard
 S1&S2 audible
 Breath sound-normal
 Respiratory rate- 24/mt
 Rhythm- regular
 Cyanosis- not observed
 Cough- absent
 Flaring of nostrils- nor observed
 Presence of wheezing/stridors- not observed
 Axillary nodes- not palpable
 Abdomen On inspection Abdomen- distended
 Ascitis-absent
 Palpable mass- observed
 Abdominal reflex- contraction of abdominal muscles observed
 Bowel sound- Not present
 Liver- not palpable
 Spleen- palpable, normal
 Appetite-anorexia
 Umbilicus-clean, no discharge
 Upper& lower extremities Postural curve- normal
 Muscle tone- normal
 Symmetry- both hands and legs symmetrical
 Range of motion- normal
 Deformity- absent
 Reflexes- normal
 Dependency level-partial dependent
Bowel & urinary pattern Voiding- regular and normal
 Color of urine- normal
 Bowel elimination pattern- abnormal
 Genitalia: No abnormalitie, No hemorrhoids
 Reflexes- On examination reflex is normal
 Biceps- On examination biceps reflex is normal
 Triceps- On examination triceps reflex is normal
 Patellae- On examination patellae is normal
 Planter reflex- Extension is present on examination
 FINAL DIAGNOSIS - Stomach cancer
 DEFINITION- Stomach cancer, which is also called gastric cancer, is a growth of
cells that starts in the stomach.
 NURSING DIAGNOSIS
 Acute pain related to the growth of cancer cells
 Anxiety related to plan surgery
 Imbalanced Nutrition Less Than Body Requirements related to nausea, vomiting and
no appetite.
 Activity intolerance related to physical weakness.
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