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 Fundoscopyo Red Reflex: present o Disc: round, sharp margins, nl color o Vessels: nl caliber, A/V ratio ~ o Background: abn pigmentation, hemorrhages or exudates o Macula: visualized Ears: External Ear- lesions, masses, tenderness Auditory Canal- normal Eardrum- TMs 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 tendono 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 Fundoscopyo 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- TMs 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 Fieldstactile 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)