Sei sulla pagina 1di 5

General Data

E.T., 50 year old, G15P14 (14-01-14), Filipino, Roman Catholic, married, farmer,
born on August 4, 1964, residing at Samboan, Cebu, admitted for the first time at
Vicente Sotto, Memorial Medical Center on December 11, 2014 at 3pm.

OB History
Mode of
No. Date Place AOG Outcome Attended Weight/Sex Complication
Delivery
Samboan, 40 Birth
1 1989 Full Term NSVD M None
Cebu weeks Attendant
Samboan, 40 Birth
2 1990 Full Term NSVD M None
Cebu weeks Attendant
Samboan, 12 Spontaneous
3 1991 D&C Physician __ None
Cebu weeks Abortion
Samboan, 40 Birth
4 1992 Full Term NSVD F None
Cebu weeks Attendant
Samboan, 40 Birth
5 1993 Full Term NSVD M None
Cebu weeks Attendant
Samboan, 40 Birth
6 1994 Full Term NSVD F None
Cebu weeks Attendant
Samboan, 40 Birth
7 1995 Full Term NSVD M None
Cebu weeks Attendant
Samboan, 40 Birth
8 1996 Full Term NSVD F None
Cebu weeks Attendant
Samboan, 40 Birth
9 1997 Full Term NSVD F None
Cebu weeks Attendant
Samboan, 40 Birth
10 1998 Full Term NSVD F None
Cebu weeks Attendant
Samboan, 40 Birth
11 1999 Full Term NSVD F None
Cebu weeks Attendant
Samboan, 40 Birth
12 2000 Full Term NSVD M None
Cebu weeks Attendant
Samboan, 40 Birth
13 2001 Full Term NSVD M None
Cebu weeks Attendant
Samboan, 40 Full Term Full Birth
14 2002 NSVD M None
Cebu weeks Term Attendant
Samboan, 40 Birth
15 2003 Full Term NSVD F None
Cebu weeks Attendant
Contraceptive History
No history of contraceptive use.

Sexual History
Patient had her coitarche at age 20 with her husband as her sole partner with no
dyspareunia.

Past Health History


Childhood illness includes: mumps, measles and chicken pox at unrecalled age.
Patient claimed that she had complete immunization and also received TT1-TT5.
Previous hospitalization was obstetrical reason. No history of surgery and accidents.
She is non-hypertensive, non-diabtetic nor asthmatic. No known food and drug
allergies.

Personal and Social History


Patient was born and raised in Samboan, Cebu. She is a high school graduate and
currently works as a farmer. She is non-alcoholic and non-smoker.

Family History
Her father is 78 years old, alive and hypertensive with maintenance medication
while her mother is 77 years old, alive and well. Patient is the 3 rd among 12 siblings.
Her husband is a carpenter, 50 years old, alive and well. Heredofamiliar disease
includes hypertension and asthma on both sides.

REVIEW OF SYSTEMS
HEENT: HEAD - no headache, dizziness, EYES- no pain, blurring of vision, no flashing
lights, no diplopia EARS: no tinnitus, sensation of fullness, NOSE- no nasal
congestion nor discharges THROAT: no hoarseness of voice, no feeling of irritation.
Mouth: no dentures, no dryness
Neck : no pain, no stiffness
Chest: no difficulty in breathing, no chest pain, no palpitations, no orthopnea
Abdomen: no pain in all 4 quadrants, no diarrhea, constipation, no changes in bowel,
feeling of nausea for 1 month
Genitourinary: bleeding for 1 month, no hematuria, no dysuria, no foul smelling
urine, no changes in urination noted.
Musculoskeletal: no pain, no weakness, paresthesias, full ROM as claimed
Neurologic: no changes in sensorium noted, no changes in memory

PHYSICAL EXAMINATION
General Appearance:
Examined lying on bed awake, conscious, responsive, coherent, lethargic, afebrile,
eupneic, with the ff. v/s: BP=120/80 mmHg ; PR=62 bpm; RR=19 cpm;
T=37.1˚C/axilla

SKIN & NAILS:


Evenly colored brown skin without unusual prominent discoloration, even
distribution of hair, dry, warm to touch, (-) jaundice, (-) edema, and good skin
turgor, (+) sensation to light and touch, no nail clubbing noted, CRT < 2 sec

HEENT:
HEAD: Normocephalic with symmetrical facial features, no infestations, no lesions,
no swelling nor tenderness, no masses palpated. EYES: Eyeballs are symmetrical
without protrusion or sinking, pink and moist palpebral conjunctiva, symmetrical
eyelids, (+) corneal light reflex, (+) cardinal gaze, (+) PERRLA, (+) peripheral vision,
able to read the nameplate @ 2ft distance with squinting. EARS AND HEARING:
Ears are symmetrical, (-) lesions, (-) discharges, (-) tenderness upon palpation.
NOSE: Symmetrical nares, (-) discharges present, (-) nasal flaring, septum at midline
without perforation, patent, firm, no nodules, (-) masses nor tenderness upon
palpation
MOUTH AND PHARYNX: dry lips, pinkish oral mucosa without lesions, uvula at
midline, no dentures, no bleeding or swelling noted.

NECK: Symmetrical, midline, non-tender, trachea at midline, lymph nodes not


palpable, thyroid @ midline, (-) swelling.

THORAX AND LUNGS: Prominent thorax, symmetrical, no tenderness, no


deformities, equal chest expansion (ECE), no retractions, no adventitious breath
sounds upon auscultation.

HEART AND PERIPHERAL VASCULATURE: Distinct S1 and S2 sounds, no murmurs,


no chest pains noted, (+) JVD, symmetrical peripheral pulses, CRT <2 secs.

ABDOMEN: presence of intact dressing at midline, (-) masses, umbilicus is at


midline, bowel sounds (7 clicks/min).

EXTREMITIES: Symmetrical upper and lower extremities, scars on both legs with
different sizes, long toenails, full ROM on both extremities.

MUSCLE STRENGTH
L R
5/5 5/5

4/5 4/5

GENITOURINARY: not assessed.

LYMPH NODES: No swelling, no masses, no tenderness, non-palpable


NEUROLOGIC ASSESSMENT

Mental Status: oriented to time & place & person, awake, lethargic, responsive and
coherent, dressed appropriately for place and climate.

MEMORY: intact remote memory (recalls past events such as the birth year of her
1st child --2004), intact recent memory (24-hr diet recall)

Motor/Cerebellar Function: (+) finger to nose test, sluggish and clumsy on Left
hand, (+) finger to thumb test. Alternates pronation and supination of hands without
difficulty. No involuntary movements noted.

Sensory Function: (+) Stereognosis (pen was placed on hand), (+) Graphesthesia
(number 8 was drawn on palm), (+) Kinesthesia in all extremities.

Cranial Nerve Testing


I Olfactory – was able to identify the scent of alcohol
II Optic – Sensory: was unable to read the student’s nameplate at 2ft distance
III, IV, VI Occulomotor, Trochlear, Abducens – Motor: equal eye movement, (+)
PERRLA, (+) cardinal gaze
V Trigeminal – Sensory: (+) blink reflex, Motor: able to clench teeth, able to
masticate
VII Facial – Motor: able to frown, smile, show teeth, close both eyes, and raise
eyebrows
VIII Acoustic/ Vestibulocochlear – Sensory: was able to hear instructions at 2ft
distance.
IX, X, XII – able to protrude tongue, can move tongue from side to side
XI Spinal Accessory –able to shrug shoulders against resistance