Beruflich Dokumente
Kultur Dokumente
Cardiac
1. health history
A Biographical data
Childhood Illness:
- Chickenpox, mumps, measles, colds, cough, fever.
Accident/Injuries
- no known accident
Serious or Chronic Disease
- Hypertension and CHF
Hospitalization
- Admitted at CHDC due to Hypertension
Obstetric History
-
Immunizations
- he had a complete immunization or vaccination in her childhood
Last Exam date (Dental,Vision,Hearing,EKG,Chest x-ray)
-Last November 2008
Allergies
-allergic in sea foods
Current medications
-Prozinc drops 2ml O.D, Metronidazole 250 mg / 5 ml q6, Tempra 80 mg q 1 PRN for fever
Habits
-Play basketball
Family History of illness
-Hes grandmother has an hypertension stage 2
Personal and social History
-
Economic History
- Patient relies to her daughter
1. Integument
- Darkish Brown in color, and has poor skin turgor
2.Head
-he had dandruff during adolescent and now her hair becomes thinner and grey white in color
3.Eye structures and visual acuity
- he had a difficulty in viewing small particles, and has a difficulty in reading
4.Ears and hearing.
-he had difficulty in hearing in her right ear.
5,Nose and sinuses.
-he was able to smell different kind of food.
6.Mouth and oropharynx.
-he had only 4 teeth, she never used any dentures due to lack of financial resources. She did not experience any
difficulties.
7.Neck
-he did not suffer any neck pains recently she never had felt any enlargement but she able to palpate some small
masses in her neck.
8.Thorax and lungs.
-he she recently experience difficulty in breathing, chest pain and cough w/ yellow colored sputum
9. heart and central vessels
-he didn’t experienced any heart attacks,, but she never experience any signs of cyanosis.
10. Peripheral vascular systems
-he noticed her veins where getting bigger on her upper and lower extremeties, sometimes she experience cramps.
And numbness.
11. Breast and axillae.
Breast are in symmetric position and the axillae has no masses or tenderness noted
12. Abdomen
- good in contour, symmetrical and no scars or abnormalities noted
13.Musculuskeltal system
- he cannot move hes arm well due to old age.
14.Neurological system.
-he can remember where he is. And he is oriented
A. Nose
- Nose is in midline placemaent. Shape symmetrical and consistent.
B. Facial Sinuses.
- No preorbital edema or discoloration in sinuses
Neck
A. Neck muscles
- are mobile, no signs of stiff neck
B. Lymph Nodes
- Lymph nodes normally not palpable especially the deep and clavicular nodes.
C. Trachea
- is midline placement.
D. Thyroid Gland
- consistency is firm, smooth, and meaty, with no nodularity, enlargement, or tenderness.
A Posterior Thorax
Inspection
- Skin is intact, no scars
Palpation
- nontender. No deformities or crepitus
Percussion
- Resonance to second intercostals space on left; slight dullness over third through fifth intercostals space over
heart.
Auscultation
-. With no adventitious sounds, lungs are clear to auscultation. No crackles, wheezes or rubs
B. Anterior Thorax
Inspection
- Skin is intact, no scars
Palpation
- nontender. No deformities or crepitus
Percussion
- Resonance to second intercostals space on left; slight dullness over third through fifth intercostals space over
heart.
Auscultation
-. With no adventitious sounds, lungs are clear to auscultation. No crackles, wheezes or rubs
Palpation
- Abdomen soft and nontender. No organomaly or masses, nontender.
Olfactory Nerve
- Patient is able to identify substances.
Optic Nerve
- EOM intact
Oculomotor Nerve
- brisk constriction of pupils in reaction to light, followed by dilation and constriction
Trochlear Nerve
- Eyes deviate to side opposite from way head is turned
Trigeminal Nerve
- Full range of motion in jaw,, patient perceive light touch and superficial pain bilaterally
Abducens Nerve
-
Facial Nerve
- facial nerve intact; able to make faces. Taste sensation on anterior tongue intact
Auditory
- can hear clearly
Glossopharyngeal Nerve
- Swallow nad cough reflex intact. Speech clear.
Vagus Nerve
- Taste on posterior intact.
Accesory Nerve
-Movement symmetrical, with patient moving against resistance without pain.
Hypoglossal Nerve
- can protrude tongue medially. No atrophy, tumors, or lesions.
G. Reflexes
Biceps Reflex
- +2
Triceps Reflex
- +2
Brachioradialis Reflex
- +2
Patellar Reflex
- +2
Achilles reflex
- +2
Plantar reflex
- flexion of all toes
H. Motor Function
March 5, 2009
Laboratory