Buerger’s Disease

Thromboangitiis ObliteransTAO

21st century Opportunities

Challenges

providing high-quality, evidence-based care in traditional as well as new innovative and

customized health care settings.

NURSING PROCESS Assessment to the patient

Nursing diagnosisPlanning

Interventions Outcome evaluation

A rare chronic disorderaffects young or middle-aged male cigarette smokers

40-45 years of age recent years, more affected women have been reported in the medical literature and yet increasing.

Narrowing or blockage (occlusion) of the veins and arteries of the extremities, resulting in reduced blood flow to these areas (peripheral vascular disease). A

chronic disease characterized by segmental inflammation and thrombosis of the small and medium

size arteries and veins of both the peripheral upper and lower limbs. The legs are affected more often than

the arms.

Extreme pain of the lower arms and legs while at rest

Cramping in the legs when they walk that, in rare cases, may cause limping (claudication)

Sores (ulcers) on the extremities, numbness and tingling and a lack of normal blood flow to the

fingers and/or toes when exposed to cold temperatures (Raynaud's phenomenon),

and/or inflammation and clotting of certain veins (thrombophlebitis)

Severe Cases

Exhibit tissue death (gangrene) of affected limbs.

Exact cause is UNKNOWN

Most affected individuals are linked to be

Heavy tobacco users

GLOBALLYWorld Health Organization

February 2010

6,000 children less than 18 years of age 2,000 will become regular smokers 440,000 Americans die each year

364,000 Britons are admitted to hospitals each year 7000 a week / 1000 a day

60 million people worldwide died5 million die prematurely each year as a result of

buerger’sSeen more in people over the age of 50.

Von Winiwarter (Germany,1879)

“A strange form of endarteritis and endophlebitis with gangrene of the feet”

1 9 0 8 Leo Buerger

“presenile spontaneous gangrene”

Highest Natives of India, Korea, Japan, Israeli Jews of

Ashkenazi descent & South Asians

PHILIPPINES

17. 3 MILLION are Smokers

200 BILLION

January 2008

Vascular System diseases ranked Number 2

closely related to ranked Number 1Heart disease

Peripheral Artery Disease

All types of Aneurysms and Dissections

Atherosclerosis

Buerger’s Disease

Raynauld’s Phenomenon

Arterial embolism

Thrombosis

88 Years old

Female

Amputated

Buerger’s Disease

“AGUA”

BACKGROUND OF THE STUDYBACKGROUND OF THE STUDY

Thromboangiitis ObliteransThromboangiitis Obliterans also known as also known as Buerger’s DiseaseBuerger’s Disease is marked by segmental is marked by segmental thrombosing, acute, and chronic inflammation of thrombosing, acute, and chronic inflammation of intermediate and small arteries and veins in the intermediate and small arteries and veins in the extremities.extremities.

The cause isThe cause is unknownunknown. It mostly affects men but . It mostly affects men but women, who used to represent about women, who used to represent about 5%5% of cases. of cases.

Most patients with Buerger’s are Most patients with Buerger’s are heavy smokersheavy smokers, , but some cases occur in patients who smoke but some cases occur in patients who smoke ““moderatelymoderately” (averagely 1 pack a day); others ” (averagely 1 pack a day); others have been reported in users of smokeless have been reported in users of smokeless tobacco. tobacco.

There is There is No treatmentNo treatment known to be effective known to be effective

Our patient is an eighty-eight (88) year old woman Our patient is an eighty-eight (88) year old woman chronic smoker chronic smoker

19961996 - initially diagnosed with Buerger’s Disease - initially diagnosed with Buerger’s Disease underwent Below the Knee Amputation of the Right underwent Below the Knee Amputation of the Right

leg in the said yearleg in the said year

then advised to discontinue smoking but had difficulty then advised to discontinue smoking but had difficulty complying.complying.

19991999 – diagnosed with hypertension for 11 years, – diagnosed with hypertension for 11 years,takes Beta-Blockers as her maintenance drug takes Beta-Blockers as her maintenance drug

(metoprolol)(metoprolol)

Davao Medical CenterDavao Medical Center (now SPMC) (now SPMC)gangrenous on 3rd, 4th and 5th digits of the left foot. gangrenous on 3rd, 4th and 5th digits of the left foot.

treated surgically on her second amputation procedure, treated surgically on her second amputation procedure, (BKA of the left leg).(BKA of the left leg).

OBJECTIVESOBJECTIVES

General Objective General Objective

After a week of involvement with our After a week of involvement with our subject, the group aims to assess andsubject, the group aims to assess and

gather pertinent data about the gather pertinent data about the patient’s condition subjectively andpatient’s condition subjectively and

objectively. Furthermore, the group objectively. Furthermore, the group intends to develop an in depth intends to develop an in depth

understanding on the disease process understanding on the disease process of Thromboangiitis obliterans of Thromboangiitis obliterans

(Buerger's disease) and share this(Buerger's disease) and share this knowledge to the readers.knowledge to the readers.

Specific ObjectivesSpecific Objectives

** To formulate SMART objectives, general and To formulate SMART objectives, general and specific; which will serve as a guide in the specific; which will serve as a guide in the making of the manuscript; making of the manuscript;

** To find a specific patient for the case-study;To find a specific patient for the case-study;

** Establish rapport with the client;Establish rapport with the client;

** Formulate an introduction relevant to the case;Formulate an introduction relevant to the case;

** To know the patient’s profile and background of To know the patient’s profile and background of the case;the case;

** Obtain client’s health history including both past Obtain client’s health history including both past and present health histories as well as the and present health histories as well as the sociocultural background of the family;sociocultural background of the family;

* * To present other significant information of the To present other significant information of the patient; Obtain background facts from the patient; Obtain background facts from the client that are needed to present a genogram;client that are needed to present a genogram;

** Trace the pathophysiology of the disease from Trace the pathophysiology of the disease from the etiologic factors to actual and potential the etiologic factors to actual and potential complications;complications;

** Perform a thorough comprehensive physical Perform a thorough comprehensive physical assessment of the patient giving emphasis on assessment of the patient giving emphasis on abnormal findings; abnormal findings;

** Determine different laboratory and diagnostic Determine different laboratory and diagnostic exams taken for the client in relation to the exams taken for the client in relation to the case with interpretations, significance and case with interpretations, significance and nursing responsibilities;nursing responsibilities;

** Identify nursing theories applicable to the study Identify nursing theories applicable to the study with related nursing diagnosis;with related nursing diagnosis;

** Enumerate the different drugs administered and Enumerate the different drugs administered and taken by the client with respective actions, taken by the client with respective actions, indications, side and adverse effects, complications indications, side and adverse effects, complications and nursing responsibilities;and nursing responsibilities;

** Formulate four (4) prioritized nursing care plans for Formulate four (4) prioritized nursing care plans for problems identified; problems identified;

** Calculate the possible prognosis of the clientCalculate the possible prognosis of the client

** Enumerate attainable health teachings for the Enumerate attainable health teachings for the discharge plan through the “METHODS” process; discharge plan through the “METHODS” process; andand

** Gain insights and recommendations from the whole Gain insights and recommendations from the whole experience.experience.

NURSING HISTORYNURSING HISTORYDemographic DataDemographic Data NameName : : “Agua”“Agua” AgeAge : : 88 years old88 years old SexSex : : FemaleFemale Civil StatusCivil Status : : WidowWidow AddressAddress :: Crystal Meadows Subdivision, Crystal Meadows Subdivision,

Sasa, Davao CitySasa, Davao City ReligionReligion :: Roman CatholicRoman Catholic BirthplaceBirthplace :: Zamboanga Del NorteZamboanga Del Norte Birth dateBirth date :: October 20 1922October 20 1922 Name of FatherName of Father :: Geronimo (Deceased)Geronimo (Deceased) Name of MotherName of Mother :: Anunciacon (Deceased)Anunciacon (Deceased) SpouseSpouse :: Felipe (Deceased)Felipe (Deceased) EducationEducation :: Elementary LevelElementary Level OccupationOccupation :: Fruit and Vegetable VendorFruit and Vegetable Vendor

Clinical DataClinical Data

Chief ComplaintChief Complaint : : Gangrenous 3rd, Gangrenous 3rd, 4th and 5th 4th and 5th digit of the digit of the Left footLeft foot

Time of AdmissionTime of Admission :: 1: 29 pm1: 29 pm Type of AdmissionType of Admission :: January 27, 2010January 27, 2010 Admitting DoctorAdmitting Doctor :: Ryan L. LonzagaRyan L. Lonzaga Admitting DiagnosisAdmitting Diagnosis :: Buerger’s Disease/ TAOBuerger’s Disease/ TAO Final DiagnosisFinal Diagnosis :: Buerger’s Disease/ TAOBuerger’s Disease/ TAO

Initial AssessmentInitial Assessment Mental StatusMental Status : : Oriented & Lethargic; Oriented & Lethargic;

Glascow Coma Glascow Coma Scale of 15Scale of 15

Vital signs ofVital signs of : : Temperature 37.1; Temperature 37.1; Heart Rate 76; RR24; Heart Rate 76; RR24; BP170/90 mmHgBP170/90 mmHg

History of Past IllnessHistory of Past Illness

A typical elementary student, A typical elementary student,

Started smoking at the age of sixteen (16). Started smoking at the age of sixteen (16).

Claimed to smoke “moderately” Claimed to smoke “moderately”

Tried the smokeless tobacco, Tried the smokeless tobacco, Tres BTres B, which she could easily buy at the , which she could easily buy at the ““palengkepalengke” and started chewing it every so often. ” and started chewing it every so often.

Stated to being an occasional drinker of alcoholic beverages. Stated to being an occasional drinker of alcoholic beverages. Was not fully immunized, could only recall two doses of vaccines and Was not fully immunized, could only recall two doses of vaccines and seems to be unsure what she actually received during school years. seems to be unsure what she actually received during school years.

1996, brought to Davao Medical Center (DMC) because of gangrenous 1996, brought to Davao Medical Center (DMC) because of gangrenous and painful right ankle and big toe. and painful right ankle and big toe. Six Months before the admission, family thought that her big toe at the Six Months before the admission, family thought that her big toe at the right foot only had an “right foot only had an “ingrowningrown” (paronychia) and they thought that it ” (paronychia) and they thought that it might just go away. might just go away.

Few weeks later, condition of the right foot worsens and they decided Few weeks later, condition of the right foot worsens and they decided to seek medical help. to seek medical help.

Patient Agua was surgically treated, below the knee Patient Agua was surgically treated, below the knee amputation (BKA) was performed on her right leg, amputation (BKA) was performed on her right leg, after having seen and examined by doctors that she after having seen and examined by doctors that she had Buerger’s disease.had Buerger’s disease.

She was advised to discontinue smoking and do physical She was advised to discontinue smoking and do physical exercises. exercises.

She claimed to have stopped but her eldest daughter She claimed to have stopped but her eldest daughter admitted that she did for a few weeks but had admitted that she did for a few weeks but had resumed smoking afterwards.resumed smoking afterwards.

1999 Patient Agua had a cerebrovascular accident (CVA) 1999 Patient Agua had a cerebrovascular accident (CVA) but with no residual weakness. While admitted in but with no residual weakness. While admitted in Davao Medical Center (DMC), she was diagnosed to Davao Medical Center (DMC), she was diagnosed to have myocarditis as well as hypertension but was have myocarditis as well as hypertension but was discharged thereafter with maintenance drugs such as discharged thereafter with maintenance drugs such as beta-blockers.beta-blockers.

History of Present IllnessHistory of Present Illness

Patient AguaPatient Agua with limited mobilitywith limited mobility

stayed at home most of the time. stayed at home most of the time. her grandchildren sometimes would carry her and her grandchildren sometimes would carry her and bring her to the owned vegetable and fruit stall, bring her to the owned vegetable and fruit stall, now managed by her youngest daughternow managed by her youngest daughter

Six (6) months prior to admission, Six (6) months prior to admission, noticed intermittent tingling on her left foot which noticed intermittent tingling on her left foot which caused mild discomfort. caused mild discomfort. Recognized that maybe it is due aging and had a Recognized that maybe it is due aging and had a ““HilotHilot” worked on it which provided relief. ” worked on it which provided relief.

Months later,Months later, the arch of the foot became numb and her family the arch of the foot became numb and her family could see skin changes like blanching and cyanosis could see skin changes like blanching and cyanosis especially during cold nights. especially during cold nights.

Weeks prior to admission,Weeks prior to admission,noted small open sores at the 3rd and 4th digits of noted small open sores at the 3rd and 4th digits of her left foot that caused a lot of pain. Suspected her left foot that caused a lot of pain. Suspected and some had known that her condition was and some had known that her condition was likened to what she experienced when she was likened to what she experienced when she was initially amputated.initially amputated.

Patient Agua bore the pain before getting medical Patient Agua bore the pain before getting medical help because of financial restraints. help because of financial restraints.

By the time they finally decided to have a By the time they finally decided to have a consultation, recently, patient already had consultation, recently, patient already had gangrenous 3rd, 4th and 5th digits of the left foot, gangrenous 3rd, 4th and 5th digits of the left foot, edematous and cold to touch thus prompting edematous and cold to touch thus prompting clearance and treatment by below the knee clearance and treatment by below the knee amputation (BKA) of the left leg.amputation (BKA) of the left leg.

Family BackgroundFamily Background

Patient Agua Patient Agua

Born in Zamboanga del Norte Born in Zamboanga del Norte

Conventional family of Six. Conventional family of Six.

Mother: AnunciaconMother: Anunciacon

Father: GeronimoFather: Geronimo

moved to Davao City at the late 1920’s moved to Davao City at the late 1920’s (unrecalled)(unrecalled)

when her mother was pregnant with their when her mother was pregnant with their youngest sister.youngest sister.

raising them grounded to God as a Roman Catholic, raising them grounded to God as a Roman Catholic,

both of parents, died of old age. both of parents, died of old age.

* (Genogram)* (Genogram)

Patient Agua has five (5) siblings and she is the fifth Patient Agua has five (5) siblings and she is the fifth child.child.

Her mother suffered a miscarriage with her initial Her mother suffered a miscarriage with her initial pregnancy and after a year, her older brother, Jose, pregnancy and after a year, her older brother, Jose,

was born.was born.

By age of twenty six (26), Jose was injured in a By age of twenty six (26), Jose was injured in a motor accident and consequently died. motor accident and consequently died.

Her older sister, Adelina, who was the third child Her older sister, Adelina, who was the third child passed away four years ago due to natural cause passed away four years ago due to natural cause

or old age.or old age.

Eugenio, being the fourth child, died of a liver Eugenio, being the fourth child, died of a liver disease owing to years of heavy drinking. disease owing to years of heavy drinking.

Her youngest sister, Perla, is alive and well. She is Her youngest sister, Perla, is alive and well. She is currently living in Iloilo city with a family of her currently living in Iloilo city with a family of her

own.own.

NURSING ASSESSMENTNURSING ASSESSMENT

PHYSICAL ASSESSMENTPHYSICAL ASSESSMENT

A physical assessment was performed last January A physical assessment was performed last January 29, 2010 between 1-3 pm29, 2010 between 1-3 pm

WeightWeight :: 55 kgs55 kgsHeight Height :: 137.16 cm137.16 cm

TemperatureTemperature :: 37.537.5PulsePulse :: 60bpm60bpmRespirationRespiration :: 24cpm24cpmBlood PressureBlood Pressure :: 130/90 mmHg 130/90 mmHg

(right arm)(right arm)120/80 mmHg (left 120/80 mmHg (left

arm)arm)

GENERAL SURVEYGENERAL SURVEY Appearance and Mental Status Appearance and Mental Status

- The patient appeared to be thin and weighed - The patient appeared to be thin and weighed approximately 55 kilograms. She stands 137.16 approximately 55 kilograms. She stands 137.16 centimetres. appeared relaxed, in good centimetres. appeared relaxed, in good disposition and cooperative upon assessment. disposition and cooperative upon assessment. Coherent and oriented to time, place and person, Coherent and oriented to time, place and person, but were observed to have episodes of confusion. but were observed to have episodes of confusion. Appeared to be clean and tidy. No unpleasant Appeared to be clean and tidy. No unpleasant odour noted. Speaks clearly and in audible tone. odour noted. Speaks clearly and in audible tone. Complained of pain on her stump with a pain Complained of pain on her stump with a pain scale of 7 out of 10 that signifies moderate pain. scale of 7 out of 10 that signifies moderate pain. Guarding behaviours over the post-operative site Guarding behaviours over the post-operative site where observed. Pallor was noted upon where observed. Pallor was noted upon assessment. Worked as fruit and vegetable assessment. Worked as fruit and vegetable vendor before. had her youngest daughter as a vendor before. had her youngest daughter as a helper in her own little store. Known to be helper in her own little store. Known to be moderate smoker where she can consume an moderate smoker where she can consume an average of 1 pack per day. She was also known average of 1 pack per day. She was also known for drinking occasionally not to the point of for drinking occasionally not to the point of intoxication.intoxication.

SKIN & HAIRSKIN & HAIR

- Pallor skin noted. Erythema at left residual - Pallor skin noted. Erythema at left residual lower limb noted. Some parts of the body lower limb noted. Some parts of the body noted areas of hypigmentation due to aging. noted areas of hypigmentation due to aging. With various interruptions in skin integrity, With various interruptions in skin integrity, dryness noted, generally uniform skin color dryness noted, generally uniform skin color except in areas exposed to sunlight, skin except in areas exposed to sunlight, skin warm to touch. When pinched skin springs warm to touch. When pinched skin springs back to previous state. With evenly back to previous state. With evenly distributed hair with some loss at the scalp, distributed hair with some loss at the scalp, dry hair, some flaking noted, hair in the face, dry hair, some flaking noted, hair in the face, eyebrows, ears, and nostrils were coarse and eyebrows, ears, and nostrils were coarse and bristle-like. Fine white/ grey hair noted in bristle-like. Fine white/ grey hair noted in variable. No known allergies reported.variable. No known allergies reported.

NAILSNAILS -Positive mild late clubbing noted (greater than -Positive mild late clubbing noted (greater than 180 degrees angle). Fingernails appeared to be 180 degrees angle). Fingernails appeared to be thick with presence of grooves, beau’s line not thick with presence of grooves, beau’s line not noted. Bluish or purplish tint in color and pallor noted. Bluish or purplish tint in color and pallor noted. Some longitudinal bands developed that noted. Some longitudinal bands developed that may indicate some protein deficiency.may indicate some protein deficiency.

SKULL & FACESKULL & FACE-Normocephalic and symmetrical; no local -Normocephalic and symmetrical; no local deformities or depressions from any trauma deformities or depressions from any trauma noted, no nodules, masses and sebaceous cysts. noted, no nodules, masses and sebaceous cysts. Eyelids are in normal position and intact, dry skin Eyelids are in normal position and intact, dry skin and coarse features noted. With symmetrical and coarse features noted. With symmetrical nasolabial folds, no periorbital edema noted, with nasolabial folds, no periorbital edema noted, with symmetrical facial movements, slight tremors symmetrical facial movements, slight tremors noted and tensing of facial muscles.noted and tensing of facial muscles.

EYES & VISIONEYES & VISION- Visual acuity decreased, previously worn - Visual acuity decreased, previously worn eyeglasses for reading, reported to be presbyopic eyeglasses for reading, reported to be presbyopic (loss of ability to see close objects). No signs of (loss of ability to see close objects). No signs of cataracts, conjunctivitis and any inflammation in cataracts, conjunctivitis and any inflammation in the eyes as well as symptoms of glaucoma. Pupils the eyes as well as symptoms of glaucoma. Pupils black in color, with 2-3mm pupil sizes and both black in color, with 2-3mm pupil sizes and both eyes react relatively. Noted with equal alignment eyes react relatively. Noted with equal alignment and movement of eyebrows. Scaling and flaking of and movement of eyebrows. Scaling and flaking of skin noted, eyelids are intact no discoloration and skin noted, eyelids are intact no discoloration and discharges. Eyes appeared to be dry. Bilateral discharges. Eyes appeared to be dry. Bilateral blinking noted and lids closed symmetrically, no blinking noted and lids closed symmetrically, no ptosis noted. Conjunctivas are shiny and pink, ptosis noted. Conjunctivas are shiny and pink, sclera are non-icteric, appeared to be slightly sclera are non-icteric, appeared to be slightly pale. Cornea appeared to be transparent, shiny pale. Cornea appeared to be transparent, shiny and smooth; details of the iris are also visible. and smooth; details of the iris are also visible. Arcus senilis (thin-grayish white ring around the Arcus senilis (thin-grayish white ring around the margin of cornea is also evident. Both eyes are margin of cornea is also evident. Both eyes are coordinated; move in unison, with parallel coordinated; move in unison, with parallel alignment. No nystagmus noted. With skin folds at alignment. No nystagmus noted. With skin folds at the upper lids noted and lower lids slightly sag. the upper lids noted and lower lids slightly sag.

EARS & HEARINGEARS & HEARING - Color same as facial skin, symmetrical in size, - Color same as facial skin, symmetrical in size, auricle aligned with outer canthus of the eye. auricle aligned with outer canthus of the eye. Auricles are mobile, firm, and not tender, pinna Auricles are mobile, firm, and not tender, pinna recoils after it is folded, linear wrinkling over the recoils after it is folded, linear wrinkling over the pinna was noted with fine hairs present in the canal pinna was noted with fine hairs present in the canal opening. Ears are equal in size bilaterally, with no opening. Ears are equal in size bilaterally, with no swelling or thickening. With dry cerumen, grayish-swelling or thickening. With dry cerumen, grayish-tan color. Normal voice tones audible. Able to hear tan color. Normal voice tones audible. Able to hear ticking of a watch 2-3cm in both ears. Able to hear ticking of a watch 2-3cm in both ears. Able to hear whispered sounds. Able to hear uttered words 1-2 ft. whispered sounds. Able to hear uttered words 1-2 ft. away. The earlobes are elongated. away. The earlobes are elongated.

NOSE & SINUSESNOSE & SINUSES- Nose is in midline and proportion to other facial - Nose is in midline and proportion to other facial features. Uniform in color. No discharges noted and features. Uniform in color. No discharges noted and slight nasal flaring noted. No deformity, signs of slight nasal flaring noted. No deformity, signs of inflammation and trauma noted. Mucosa appeared to inflammation and trauma noted. Mucosa appeared to be pink. Nasal septum intact and in midline. Facial be pink. Nasal septum intact and in midline. Facial sinuses are not tender.sinuses are not tender.

MOUTH & OROPHARYNXMOUTH & OROPHARYNX- Outer lips are slightly pale, symmetric in contour, - Outer lips are slightly pale, symmetric in contour, smooth, and soft in texture. Uniform in color. Able to smooth, and soft in texture. Uniform in color. Able to purse lips. Slight crusts (cheilosis) noted in the lips and purse lips. Slight crusts (cheilosis) noted in the lips and fissures at the side. Inner lips are in pink color. Irritations fissures at the side. Inner lips are in pink color. Irritations from dentures noted. Some plaques and tartar are visible from dentures noted. Some plaques and tartar are visible in both upper and lower teeth. Buccal mucosa and the in both upper and lower teeth. Buccal mucosa and the gums slightly pale. No lesions or lumps were noted. gums slightly pale. No lesions or lumps were noted. Patient had 5/32 teeth still with 2 upper molars and 2 Patient had 5/32 teeth still with 2 upper molars and 2 lower molars and one canine. No lesions or lumps noted. lower molars and one canine. No lesions or lumps noted. Tongue is pale pink dry-furry with roughened papillae, Tongue is pale pink dry-furry with roughened papillae, moves freely; no tenderness noted. Veins were visible moves freely; no tenderness noted. Veins were visible under the tongue. Intact gag reflex. under the tongue. Intact gag reflex.

NECK & THROATNECK & THROAT- Neck muscles are equal in size, symmetric and slight - Neck muscles are equal in size, symmetric and slight rigidity noted. Neck positioned at the midline and head is rigidity noted. Neck positioned at the midline and head is centered. Able to perform range of motion when asked to centered. Able to perform range of motion when asked to flex neck side by side, laterally, chin to chest and rotation. flex neck side by side, laterally, chin to chest and rotation. With equal strength noted. Nodes were movable, With equal strength noted. Nodes were movable, discretely soft and non-tender. Tonsils were visible and discretely soft and non-tender. Tonsils were visible and pale due to tobacco use with whitish debris but no pale due to tobacco use with whitish debris but no exudates were noted. Absence of bruit at thyroid gland.exudates were noted. Absence of bruit at thyroid gland.

THORAX AND LUNGSTHORAX AND LUNGS- Anteroposterior to transverse diameter of - Anteroposterior to transverse diameter of thorax in ratio of 1:1 (barrel chest). Chest is thorax in ratio of 1:1 (barrel chest). Chest is symmetric. Slight spinal curvature alignment. symmetric. Slight spinal curvature alignment. Skin is intact and with uniform temperature. Skin is intact and with uniform temperature. Skin lesions noted. Chest wall intact, no Skin lesions noted. Chest wall intact, no tenderness and no masses noted. Full and tenderness and no masses noted. Full and symmetric chest expansion noted when the symmetric chest expansion noted when the client inhales and exhales. Ribs were more client inhales and exhales. Ribs were more marked due to thinner subcutaneous fats. marked due to thinner subcutaneous fats. Scapulae were very prominent and were placed Scapulae were very prominent and were placed symmetrically. Some muscles were atrophied symmetrically. Some muscles were atrophied due to aging. Slight kyphosis noted. Fremitus is due to aging. Slight kyphosis noted. Fremitus is heard most clearly at the apex of the lungs. heard most clearly at the apex of the lungs. Fine crackles heard at the lower lung lobes. Fine crackles heard at the lower lung lobes.

CARDIOVASCULAR &CARDIOVASCULAR &

PERIPHERAL VASCULAR PERIPHERAL VASCULAR SYSTEMSYSTEM

- Apical pulse suggests episodes of - Apical pulse suggests episodes of bradycardia with values ranging from 40 to 50 bradycardia with values ranging from 40 to 50 bpm, strong and bounding. No murmurs heard bpm, strong and bounding. No murmurs heard upon auscultation, with diagnosis of 2nd AV upon auscultation, with diagnosis of 2nd AV Block Mobitz type II in electrocardiogram Block Mobitz type II in electrocardiogram reading. No lift or heave noted. Peripheral reading. No lift or heave noted. Peripheral pulses are weak, noted on radial and ulnar pulses are weak, noted on radial and ulnar pulses with values ranging from 60-80 bpm. pulses with values ranging from 60-80 bpm. Capillary refill test is 2-3 seconds. Buerger’s Capillary refill test is 2-3 seconds. Buerger’s test: Upper extremities noted delayed color test: Upper extremities noted delayed color return, marked redness of the arms, veins return, marked redness of the arms, veins filled in more than 15 seconds.filled in more than 15 seconds.

BREASTS, AXILLAE AND ABDOMENBREASTS, AXILLAE AND ABDOMEN- Breasts are generally symmetrical. No - Breasts are generally symmetrical. No lumps and abnormal skin changes noted. lumps and abnormal skin changes noted. Nipples were flat and brown, not inverted. Nipples were flat and brown, not inverted. No discharges from nipples noted. No discharges from nipples noted. Subcutaneous tissues at the triceps area Subcutaneous tissues at the triceps area are sagging, wrinkled skin and even-are sagging, wrinkled skin and even-colored. Nodes under armpits are firm colored. Nodes under armpits are firm and non-tender. Abdomen is flat and non-and non-tender. Abdomen is flat and non-distended, bilaterally symmetrical with distended, bilaterally symmetrical with presence of rash or other lesions. Aortic presence of rash or other lesions. Aortic pulsation in epigastric area noted. pulsation in epigastric area noted. Hypoactive bowel sounds noted, slight Hypoactive bowel sounds noted, slight enlargement of the liver noted upon enlargement of the liver noted upon palpation. Obvious muscle wasting noted.palpation. Obvious muscle wasting noted.

MUSCULOSKELETAL SYSTEMMUSCULOSKELETAL SYSTEM- Skin is cool to touch. Biceps and triceps - Skin is cool to touch. Biceps and triceps are more marked and less toned (muscle are more marked and less toned (muscle atrophy). Senile skin noted. With active-atrophy). Senile skin noted. With active-assistive motor function of the upper assistive motor function of the upper extremities. With upper extremities grading extremities. With upper extremities grading muscle strength of 3/5. With residual limbs muscle strength of 3/5. With residual limbs of lower extremities: left stump wrapped in of lower extremities: left stump wrapped in elastic bandage in figure of eight, secured elastic bandage in figure of eight, secured and elevated with pillow, brownish to dark and elevated with pillow, brownish to dark brown skin color with less hair distribution brown skin color with less hair distribution and shiny in appearance, edema noted at and shiny in appearance, edema noted at grade 3+ with deep pitting indentation; grade 3+ with deep pitting indentation; right limb (BKA, 1996) with contractures right limb (BKA, 1996) with contractures and surgical scars noted, skin intact. and surgical scars noted, skin intact.

Genito-UrinaryGenito-Urinary

- Thin-graying pubic hair was apparent. - Thin-graying pubic hair was apparent. Labia are atrophied. Skin at vulva is Labia are atrophied. Skin at vulva is slightly darker from the rest of the body. slightly darker from the rest of the body. Urethral orifice appears as a small slit, Urethral orifice appears as a small slit, with the same color of the skin noted, no with the same color of the skin noted, no swelling noted. With Foley catheter swelling noted. With Foley catheter attached to urobag draining yellow-attached to urobag draining yellow-colored urine.colored urine.

Cranial Nerve AssessmentCranial Nerve Assessment

I I HyposmiaHyposmia (marked) bilaterally (marked) bilaterallyII II Unable to see close objectsUnable to see close objectsIII, IV ,VI III, IV ,VI Pupils equally round and reactive to light Pupils equally round and reactive to light

accommodation, with pupil sizes of 2-3mm with brisk accommodation, with pupil sizes of 2-3mm with brisk reaction. Eyes can follow movements of examiner reaction. Eyes can follow movements of examiner finger without moving the head from side to side and finger without moving the head from side to side and up and down.up and down.

V V Blink reflex intact upon lateral sclera stimulation, able Blink reflex intact upon lateral sclera stimulation, able to sense a wisp of cotton over the forehead and to sense a wisp of cotton over the forehead and paranasal sinuses, able to distinguish cold from hot, paranasal sinuses, able to distinguish cold from hot, able to chew foods well but slowly, localize sensation able to chew foods well but slowly, localize sensation of skin on the face.of skin on the face.

VII VII Face symmetrical when requested to smile or frown, Face symmetrical when requested to smile or frown, able to close eyes, raise eyebrows, and pout out able to close eyes, raise eyebrows, and pout out cheeks, can distinguish various tastes placed on tip cheeks, can distinguish various tastes placed on tip and sides of tongue such as sugar, lemon, and bitter and sides of tongue such as sugar, lemon, and bitter taste of medications. No facial drooping noted taste of medications. No facial drooping noted

VIII VIII Able to hear whispered words and ticks of the wrist Able to hear whispered words and ticks of the wrist watchwatch

IX IX Intact swallowing ability and movement of the tongue Intact swallowing ability and movement of the tongue side by side and up and downside by side and up and down

X X Positive gag reflex per stimulation, no noticeable Positive gag reflex per stimulation, no noticeable hoarseness during speakinghoarseness during speaking

XI XI Able to shrug shoulders upon resistance, turns head Able to shrug shoulders upon resistance, turns head side to side against resistanceside to side against resistance

XII XII Can protrude tongue without tremors; move to sides Can protrude tongue without tremors; move to sides slowly.slowly.