Angel’s part

PMH:
Arthritis (+)
Kidney dse (-)
Diabetes (-)
TB (-)
HPN (-)
Heart dse (-)
Previous hospitalizations (-)
Complete immunizations

Personal and social hx

Work as a traffic enforcer ( bgry)
Depressed area (4 members)
Smoking (+) – 1 pack/day, 7 months ago – stopped
One/week – emperador – 1 bottle
Nawasa
Isda, gulay, pork – sometimes
No softdrinks, (+) coffee

Family hx:
Mother – died of pancreatic ca
Father died of cardiac arrest
Father – dm, hpn, stroke

Andy’s part:
Physical Examination:
Mr. G. M. is a 5’5” tall, old aged-man, who responds quickly to questions. He is coherent, conscious and
with no respiratory distress. He is well groomed, hair is fixed neatly, and he lies flat/sit without discomfort.

Vital Signs:
BP: 140/90 (Left arm)
RR: 20 b/m
HR: 89 c/m
Temp: 36.7 C

Skin: No scars, cyanosis, sores, lumps

Head, Eyes, Ears, Nose, Throat (HEENT):
Head: Hair of average texture. Scalp without lesions and normocephalic skull.
Eyes: Visual fields full by confrontation. Pink conjunctiva, anicteric sclera. Extraocular muscles
are intact. Direct and consensual reflex is responsive to light.
Ears: No cerumen/discharge, scars, lumps, inflammation. Auditory is good to whispered voice.
Nose: No sinus tenderness, nasal congestion, obstruction, swelling, discharge.
Mouth: Pink oral mucosa. No ulcerations, patches, edema. Tongue and uvula midline. Pharynx
without exudate
Neck: No scars, mass, tenderness. Trachea midline. Thyroid gland moves with good deglutition.
Lymph Nodes: No lymphadenopathies.
Thorax and Lungs: No scars, mass, lumps. Thorax symmetric with good excursion. Lungs resonant.
Equal tactile fremitus. Vesicular breath sounds.
Cardiovascular: Adynamic precordium. No heaves and thrills. PMI: 5th ICS LMCL. S1 louder at the
apex,S2 louder at the base.
Abdomen: Globular. No scars/masses. No bruit. Normoactive bowel sounds. Tympanitic bowel
sounds. Liver span of 6.5 RMCL. Spleen and kidneys not felt. Pain on the left lower lumbar area.
Extremities: No scars, masses. Warm with no bipedal edema. Wound on the left knee area.
Peripheral Vascular: No trace edema at both ankles.
Musculoskeletal: No joint deformities. Good range of motion in hands, wrists,
elbows, shoulders & ankles.,