PHYSICAL ASSESSMENT

DATE 03/02/10

PATIENT NAME:---------------Patient X------------------HB NO.---------------------------AGE: ----------36-------------SEX: ---------Female---------ROOM NO. --------212---------CHIEF COMPLAINT:

---------------Masakit ang tahi ko as verbalized by the patient------------------------------------------------------------------------------------------------------------------------------------PAST MEDICAL HISTORY (Previous Illnesses & Operation)
-------------------History of UTI-------------------------------------------------------------------------------------DOB & Palpitation-------------------------------------------------------------FAMILY HISTORY:
-----------Family history if asthma and lower respiratory diseases/ infection-------------OCCUPATIONAL ENVIRONMENT:
---Garment factory worker-------------ALCOHOL(gm/day)-------X--------------------------House wife----------------------------TOBACCO------------------X--------------------------------------------------------------------DRUG ALLERGIES-------X----------------------SYSTEM REVIEW:
GENERAL --------------------:---Coherent and conscious--------------------------SKIN:-------------------------------Pale and Cracking lips---------------------------EENT:-------------------------------NORMAL----------------------------------------MUSCULOSKELETAL:---------Muscle weakness due to post operative anesthesia
RESPIRATORY:------------------19 cpm Respiratory Rate------------------------CARDIOVASCULAR:-----------Normal Heart Rate of 69bpm and BP of 120/80
GASTROINTESTINAL:---------Abdominal cramps-------------------------------GENITOURINARY:--------------Hematuria, Dark colored urine-----------------FEMALE REPRODUCTIVE:---well contracted uterus---------------------------NERVOUS:-------------------------sensory motor responsive----------------------PAST DISEASE (Including treatment & its duration, hospitalizations & operation)
----History of UTI, 3 days confinement at Mendoza Hospital Sta. Maria Bulacan during
her first trimester of pregnancy (Aug.9,2009).