Name: angelina orbita age: 69 years old Date of birth: April 29 1944 religion: roman catholic occupation: religious affiliation dare of admission: september 21 2013 date of interview october 9 2013

Chief complaint unconcious (ikaw ram may maisip ka mas proper?)

History of present illness on the day of admission, the patient felt a slight weakness of the body thus her decision to take a rest. 12hours pta the patient was found unconsciously lying on her bed. With the thought that the she was only resting, the patient,s sister let her rest for awhile in her room. 3 hours pta, the patient,s sister was wlarmed when the patient, still, did not wake up which prompted to seek consult and admission.

Past health history the patient was not able to have any immunizations. In 1980,the patient ws diagnosed with Papillary Cancer of the Left Lower Lobe of the Thyroig gland which resulted to the resection of the said affected lobe. She was then advised to take Lev9thyroxine 100mcg. In 1998, she was diagnosed with skin asthma. She had a fracture on her left wrist on an unrecalled date and had a surgical procedure as a therapy. Earlier this year she was d8agnosed with hypertrophy of the heart an was advised to take bisoprosol 2.5 mg. In the same year she was diagnosed to have bronchial asthma.and was given Salmeterol as her ma8ntenance drug.

Personal social. The patient is a 70 yearnold nun of the Benedictine,s Sisters located at Ulas, Davaocity. She usually grts up in the morning at 4.30 which is immedistely followd by prayers and medidation up until breakfast at 6.30am. After that, they proceed to their chores up umtil noon to have lunvh. It is then folled by a 2 hour siesta. The patient,s afternoon is spent again with prayers and meditation until dinner. The patient usually etires to bed at 8 in the evening.

The patient,s diet usually includes 2-3 cups of rice ,fish and vegetsbles per meal with snacks in between meals.

The patient had no known allergy.

Family history the patient's mother was diagnosed with rheumatoid arthritiswhile her father had a known allergy to_______.. one of her siblings wasdiagnosed with systemic lupus erythematosus. Her family had no historyof diabetes mellitus nor thyroid problems.

PE

GENERAL APPEARANCE:

70 y/o female who is awake and alert and who looks her stated age

VITALS

Temperature: 36.4° C axillary

Blood Pressure: L Arm sitting position 130/80

Cardiac rate: 68

Respiration Rate: 17

HEENT

Head: Configuration- normocephalic

Hair- normal texture

Scalp- lesions, tenderness

Eyes: Sclera- white

Conjunctiva- pink

Fundoscopy-

o Red Reflex: present

o Disc: round, sharp margins, nl color

o Vessels: nl caliber, A/V ratio ~ ½

o Background: abn pigmentation, hemorrhages or exudates

o Macula: visualized

Ears: External Ear- lesions, masses, tenderness

Auditory Canal- normal

Eardrum- TM’s gray, translucent, with nl light reflex

Nose: Color- pink discharge

Septum- midline

Inferior and Middle Turbinates – normal

Throat and

Mouth:

Teeth: Present and in good dentition

Tongue: lesions

Gums and Mucosa: swelling, bleeding, infection

Pharynx and Tonsillar Fossa: normal

Openings of Stensen's and Wharton's Ducts: identified Patient Centered Medicine 2

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NECK

Active ROM: nl flexion, extension, lateral rotation and tilting

Trachea: midline, mobile

Thyroid: non-palpable or palpable, nl size & consistency, lesions

Suprasternal Notch: pulsation

BREASTS

Inspection (Breasts and Nipples)- nl size, symmetrical--nipples symmetrical and everted

Palpation (Breasts and Nipples)- masses, nipples discharge

THORAX & BACK

Observation: symmetrical expansion with respiration

Percussion: spinal tenderness, CVA (costovertebral angle) tenderness (Comment of

findings regarding CVA tenderness under abdomen – see example *

LUNGS

Percussion and Palpation of Lung Fields- nl resonant percussion

Auscultation- clear, nl vesicular breath sounds

(An accepted abbreviation for normal lung Percussion & Auscultation is “Clear to A&P”)

HEART

Neck Veins- JVD at 45°

Carotid Arteries:

Palpation (Amplitude and Contour)- nl upstroke & amplitude bilaterally

Auscultation: bruits

Precordium:

Inspection- lifts or heaves - PMI not visible

Palpation- parasternal impulses, thrills

PMI- palpable in 5th ICS, MCL; nl size

Auscultation:

S1- heard best at apex, nl intensity

S2- heard best at base, nl splitting, A2 > P2

Extra Sounds- S3, S4

Murmurs- murmurs

ABDOMEN

Observation: scaphoid scars, striae

Auscultation: nl bowel sounds, bruits

Palpation: Superficial- tenderness, masses, guarding

Deep- tenderness, masses

Liver: Palpation- liver edge not palpable Patient Centered Medicine 2

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Percussion - Size- ~10 cm in R midclavicular line

Spleen: Palpation- non palpable

Kidneys: Left- non palpable

Right- non palpable

* CVAC

Femoral

Pulses:

Palpation- 4 / 4 bil equal

Auscultation- bruits

EXTREMITIES

Upper: Nails- cyanosis, clubbing

Palms- nl color, texture

Muscles- nl size

Joints (including ROM)

Interphalangeal- nl ROM deformities

Wrists- flexion = 90°, = extention 70°, radial deviation = 20°,

ulnar deviation = 50°

Elbows- flexion = 160°

Radial pulse- 2+, nl and symmetric

Lower: Nails- nl ( cyanosis, clubbing)

Muscles- nl size

Joints (including ROM)

Ankle- dorsiflex = 20°, plantar flexion = 40°, eversion = 20°,

inversion = 20°

Knee- flexion = 130°

Hip- flexion = 100°, internal rotation = 40°, ext rotation = 40°

Pulses:

o Posterior Tibial- 2+ bil equal

o Dorsalis Pedis- 2+ bil equal

SKIN: nl, lesions

LYMPH NODES

Neck: Submental- not palpable

Submandibular- not palpable

Anterior and Posterior Cervical- not palpable

Pre and Post Auricular- not palpable

Suboccipital- not palpable

Supraclavicular- not palpable Patient Centered Medicine 2

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Axillary: Central Axillary- not palpable

Pectoral- not palpable

Subscapular- not palpable

Lateral Axillary- not palpable

Epitrochlear: not palpable

Superficial Inguinal (horizontal and vertical): not palpable

NEUROLOGIC

Mental Status: Awake & Alert; oriented to person, place & time

Cranial

Nerves:

II: Visual Acuity- 20/20 with pocket screener, both eyes

Visual Fields- intact in all fields

II and III: Pupillary Reaction to Light- direct & consensual nl

Accommodation- nl

(Can say PERRLA, pupils, equal, round, reactive to light, and

accommodation for both)

III, IV, VI: EOM- intact

V: Light Touch Face- nl in all 3 divisions of V

VII: Wrinkle Forehead, Close Eyes, Show Teeth- nl

VIII: Hearing- nl by rough testing

X: Cough- nl

XI: Shrug Shoulders and check sternocleidomastoid muscles - nl

XII: Protrude Tongue- midline protrusion

Motor System: Normal tone

5 / 5 strength in all extremities

Sensory: Light Touch- nl

Position Sense- nl

Vibration- nl

Sharp- nl

Reflexes: Deep tendon-

o Biceps (C5-6)- 2/4

o Triceps (C6-7)- 2/4

o Brachioradialis-2/4

o Knee (L2-4)- 2/4

o Ankle (S1)- 2/4

Pathological - Plantar Reflex- none (bil down going toes)

Coordination: Gait and Balance- nl

Finger to Nose- nl

Rapid finger movements- nl

Tandem Walking- nl

Romberg- negative

kani jud ang final... sorry

GENERAL APPEARANCE:

70 y/o female who is awake and alert and who looks her stated age

VITALS

Temperature: 36.4° C axillary

Blood Pressure: L Arm sitting position 130/80

Cardiac rate: 68

Respiration Rate: 17

Wt: ?

Ht: 5 feet

BMI: ?

Skin: The patient had no rashes or lesions.

HEENT

Head:

Configuration- normocephalic

Hair- grayish, normal texture

Scalp- no lesions, tenderness

Eyes:

Sclera- anicteric

Conjunctiva- pink

Fundoscopy-

o Red-orange Reflex: present

Pupils are equal and reactive to light and accommodation. Extraocular muscles are intact. Visual fields are full by confrontation.

Ears:

External Ear- no lesions, masses, tenderness

Auditory Canal- normal

Eardrum- TM’s gray, translucent, with nl light reflex

Nose:

Color- pink with no discharge

Septum- midline

Throat and Mouth:

Teeth: incomplete with dentures

Tongue: midline with no lesions

Gums and Mucosa: pink with no swelling, bleeding, infection

Pharynx and Tonsillar Fossa: normal

NECK

Active ROM: nl flexion, extension, lateral rotation and tilting

Trachea: midline, mobile

Thyroid: well healed (longitudinal or transverse) scar post total thyroidectomy.

BREASTS

Inspection (Breasts and Nipples)- pendulous , symmetrical

Palpation (Breasts and Nipples)- no masses, nipples no discharge

LUNGS

Inspection: symmetrical expansion with respiration

Percussion and Palpation of Lung Fields-

tactile fremitus increased on Right, absent on Left lung field

Auscultation- wheezing noted on both right and left lower lung fields

HEART

Precordium:

Inspection- no lifts or heaves - PMI not visible

Palpation- no thrills

PMI- palpable in 5th ICS, MCL; nl size

Auscultation: normal S1 and S2 with no extraheart sounds and murmurs

ABDOMEN

inspection: obese with no scars, striae

Auscultation: nl bowel sounds of 9 per min

Palpation: no tenderness or masses on light and deep palpation

EXTREMITIES

Upper and lower extremities

Nails- no cyanosis, clubbing

Palms- nl color, texture

Muscles- normal size

All joints have full range of motion except for right wrist which has well healed scar for wrist surgery with bone grafting

slight edema on lower extremities

Neurologic: The patient is alert and oriented to person, place and time. Her speech is fluent. Language is intact. Both short-term and long-term memory adequate.

Cranial Nerves:

I: able to smell __________

II: Visual Fields- intact in all fields

II and III: Pupillary Reaction to Light- direct & consensual nl

Accommodation- nl

III, IV, VI: EOM- intact

V: Light Touch Face- nl in all 3 divisions of V

VII: Wrinkle Forehead, Close Eyes, Show Teeth- nl

VIII: Hearing- nl by rough testing

X: Cough- nl

XI: Shrug Shoulders and check sternocleidomastoid muscles - nl

XII: Protrude Tongue- midline protrusion

Motor System:

Normal tone

5 / 5 strength in all extremities

Sensory:

Light Touch- nl

Sharp- nl

Pathological - Plantar Reflex- none (bil down going toes)