IM - Patient 1
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Transcript of IM - Patient 1
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
F:\2012-13\FORMS\Normal_PE_Sample_write-up.doc 2 of 5 Revised 1/28/13
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
F:\2012-13\FORMS\Normal_PE_Sample_write-up.doc 3 of 5 Revised 1/28/13
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
F:\2012-13\FORMS\Normal_PE_Sample_write-up.doc 4 of 5 Revised 1/28/13
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)