GENERAL DATA

Source and reliability:

Reliability:

CHIEF COMPAINT:

HISTORY OF PRESENT ILLNESS

PAST HISTORY
Childhood immunization
Childhood illnesses
Adult illnesses
Medical

Obstetrics

FAMILY HISTORY
Father
Mother
Siblings
Spouse
Children
No family history of tuberculosis, diabetes mellitus, cancer, epilepsy, or mental illness.

SOCIAL HISTORY
Patient RD was born and raised in -------------. She is the ------ child among ---- siblings. She finished --------. She
was a farmer before but because of her heart condition she now stays at home and do household chores. She
doesn’t smoke nor drink any alcoholic beverages. She is not allergic to anything. There are no food restrictions.

REVIEW OF SYSTEM
GENERAL No recent weight changes.
No weakness, fatigue or fever.
INTEGUMENTARY Skin has no rashes, lumps, sores, itching, dryness, and changes of complexion.
Moles have no changes in size and color.
No changes in hair and nails.
HEENT HEAD No head injury.
No headache, dizziness or lightheadedness.
EYES No changes in vision.
Do not use glasses or contact lenses.
No pain, redness, and excessive tearing.
No double or blurred vision, spots, specks, flashing lights.
No glaucoma or cataracts.
EARS No hearing loss, tinnitus, vertigo, earaches, infection, and discharge.
NOSE No frequent colds, nasal stuffiness, discharge, itching, nosebleeds, and sinus trouble.
THROAT No conditions related to teeth and gums.
No bleeding gums, sore tongue, and dry mouth.
No frequent sore throats and hoarseness.
NECK No swollen glands, lumps, pain, or stiffness.
BREASTS No lumps, pain, or discomfort and nipple discharge.
RESPIRATORY No cough, sputum, shortness of breath (dyspnea), wheezing, pain with a deep breath
(pleuritic pain).
CARDIOVASCULAR No high blood pressure, rheumatic fever, heart murmurs, chest pain or discomfort, and
palpitations.
No need to use pillows at night to ease breathing (orthopnea).
No need to sit up at night to ease breathing (paroxysmal nocturnal dyspnea).
No swelling in the hands, ankles, or feet (edema).
GASTROINTESTINAL No trouble in swallowing, heartburn, appetite, and nausea.
No changes in bowel habits, pain with defecation, rectal bleeding or tarry stools,
hemorrhoids, constipation, and diarrhea.
No abdominal pain, food intolerance, excessive belching or passing of gas.
No jaundice, liver, or gallbladder trouble.
PERIPHERAL No intermittent leg pain with exertion (claudication), leg cramps, and varicose veins.
VASCULAR No swelling in calves, legs, or feet.
No color change in fingertips or toes during cold weather.
GENITOURINARY No frequency of urination, polyuria, nocturia, urgency, burning or pain during urination,
blood in the urine (hematuria), urinary infections, kidney or flank pain, kidney stones,
ureteral colic, suprapubic pain, and incontinence. No reduced caliber or force of the
urinary stream, hesitancy and dribbling.
MUSCULOSKELETA No muscle or joint pain, stiffness, arthritis, gout, backache.
L No neck or low back pain.
PSYCHIATRIC No nervousness, tension, mood, depression, memory change, and suicidal ideation.
NEUROLOGIC No changes in mood, attention, or speech.
No changes in orientation, memory, insight, or judgment.
No headache, dizziness, vertigo, fainting, and blackouts.
No paralysis, numbness or loss of sensation, tremors or other involuntary movements, and
seizures.
HEMATOLOGIC No anemia, easy bruising or bleeding, past transfusions, and transfusion reactions.
ENDOCRINE No heat or cold intolerance, excessive sweating, excessive thirst or hunger, and polyuria.

PHYSICAL EXAMINATION
GENERAL SURVEY Patient RD is conscious and sitting on her bed with an IV
fluid (NaCl 0.9%) inserted into her left cephalic vein.
Weight loss – from 53 to 50 kilograms was noted. Speech
is fluent and words are clear. She responds quickly to
questions.
VITAL SIGNS WEIGHT 50 kilograms
HEIGHT 5’
BODY MASS INDEX 21.5 kg/m2 (Normal)
TEMPERATURE 36.3C (Axillary)
BLOOD PRESSURE 130/90 mmHg (Sitting position, right arm)
PULSE RATE 85 beats per minute
RESPIRATORY 20 breaths per minute
RATE
O2 SATURATION 98%
INTEGUMENTARY Inspection Fair complexion.
Nails without clubbing or cyanosis.
Good capillary refill.
No rash, petechiae, or ecchymosis.
Palpation No lumps.
Good skin turgor.
Skin is warm.
HEAD Inspection Normocephalic/atraumatic.
Hair evenly distributed with average texture.
Scalp without lesion.
Symmetrical face.
Palpation No lumps.
(-) Hair fragility test.
EYES Inspection Visual acuity 25/20
Sclera white and conjunctiva is pink.
Visual fields full by confrontation.
Pupils 3mm constriction, round, regular, equally reactive to
light and accommodations.
Extraocular movements intact.
Disc margins sharp, without hemorrhage.
EARS Inspection Pinna symmetric.
No lesions, infection and skin tags.
Acuity is good to whispered voice.
Tympanic membranes with good cone of light.
NOSE Inspection Midline septum.
Nasal mucosa pink.
Palpation No sinus tenderness.
THROAT & MOUTH Inspection Oral mucosa pink.
Good dentition.
Pharynx without exudate.
Tonsils absent.
Palpation Nontender submandibular and anterior cervical lymph
nodes.
THORAX & LUNGS Inspection Breast symmetric.
Thorax with good excursion.
No nipple discharge.
Diaphragm descends 4cm bilaterally.
Palpation No tenderness.
Breast without nodules or masses.
Percussion Lungs resonant.
Auscultation Breath sounds vesicular with no added sounds.
NECK Inspection Neck supple.
Palpation Trachea midline.
Thyroid isthmus barely palpable, lobes not felt
LYMPH NODES Palpation Small (<1cm), soft, nontender, and mobile tonsillar and
posterior cervical nodes bilaterally.
 No axillary or epitrochlear nodes.
CARDIOVASCULAR Palpation th
Point of maximal impulse discrete and tapping at 5 LICS
MCL.
Auscultation No murmurs or extra sound.
ABDOMEN Inspection Flat.
Auscultation Bowel sounds active.
Percussion Tympanitic.
Palpation No direct or rebound tenderness. No palpable masses or
hepatosplenomegaly. Spleen and kidneys are not felt.
No costovertebral angle tenderness.
PERIPHERAL Palpation Extremities are warm without edema.
VASCULAR No stasis pigmentation or ulcers.
PULSES
Radial Femoral Popliteal Dorsalis pedis Posterior tibial
Right 2+ 2+ 2+ 2+ 2+
Left 2+ 2+ 2+ 2+ 2+
MUSCULOSKELETAL Inspection No deformity.
- SHOULDER Palpation No tenderness.
Range of Motion Able to:
- Flex & extend
- Abduct & adduct
- External & internal rotation
- ELBOW Inspection No deformity.
Palpation No tenderness.
Range of Motion Able to:
- Flex & extend
- Supination
- WRIST & HAND Inspection No deformity.
Palpation No tenderness.
Range of Motion Able to:
- Flex & extend
- Abduct & adduct
- THIGH Inspection No deformity.
Palpation No tenderness.
Range of Motion Not tested due to traction.
- KNEE Inspection No deformity.
Palpation No tenderness.
Range of Motion Able to:
- Flex & extend
- External & internal rotation
- ANKLE & FOOT Inspection - No deformity.
Palpation No tenderness.
Range of Motion Able to:
- Plantar Flex
- Dorsiflex
- Invert & evert
NEUROLOGIC EXAMINATION
MENTAL STATUS Patient was alert, relaxed, and cooperative. Thought process coherent. Oriented to three
spheres - person, place, and time.
CRANIAL NERVES
- I Able to identify odors.
- II Visual fields are full in all four quadrants by confrontation.
- III, IV, VI PERRLA, normal gaze, no strabismus or nystagmus.
- V Able to open and close jaw without difficulty, intact facial expression.
- VII Symmetric, no weakness or paralysis of facial muscle.
- VIII Able to hear whisper and normal voice.
- IX, X Able to swallow without difficulty.
- XI Able to shrug shoulder without weakness.
- XII No tongue deviation when protruding, no atrophy or dysarthria.
MOTOR Good muscle bulk and tone.
RUE - 5/5 RLE- 5/5 LUE - 5/5 LLE - 5/5
CEREBELLAR Rapid alternating movement and point to point movements are intact.
SENSORY Pinprick, light touch, position sense, vibration, and stereognosis intact.
(-) Romberg sign.
RUE - 5/5 RLE - 5/5 LUE - 5/5 LLE - 5/5
REFLEXES Biceps Triceps Brachioradialis Patellar Achilles Plantar
Right 2+ 2+ 2+ 2+ 2+ 2+
Left 2+ 2+ 2+ 2+ 2+ 2+