Biographical Data

Name: Cindy Guadamor

Address: Brgy.21, Boulevard, Davao City
Age: 25 years old
Marital status: Married
Religion: Roman Catholic
Occupation: none (housewife)
Educational attainment: Highschool graduate
Chief complaints: pain on the left tonsil, fever
Date of admission: January 20, 2010
Attending physician: Dr. Edgar Allan Piatos

PRESENT HEALTH HISTORY

5 years PTA, patient first experienced pain on her tonsils accompanied by fever,
dysphagia and headache. The fever usually last for more than 3 days or until the pain on her
tonsils subside. She had consultations and was advised to take Cefalexin, 3 x a day for 1 week.
When patient was asked about compliance, she answered “hindi ko inuubos yung gamot, kapag
mwala na ang sakit, i-stop ko na”. She also noticed exudative lesions on her tonsils.

The pain on her tonsils recurred since then. She takes Paracetamol for fever and
Cefalexin for her inflammed tonsils. She verbalized that it is usually aggravated when she eats
sweet foods.

On day of admission, the patient presents with inflamed tonsils and exudates on the left
tonsil accompanied by high-grade fever. She is dyspneic, shortness of breath which is unrelieved
by rest and dysphagia. She describes the pain as severe with an intensity of 9/10.

PAST HEALTH HISTORY

Childhood illnesses: chickenpox, measles and mumps.
Adult illnesses: none
Surgery: none
Psychiatric: none
Health maintenance: Ferrous Sulfate (anemia)
Immunizations: TT, BCG, DPT, OPV, Hepa BV

FAMILY HISTORY

There are no known familial diseases on his maternal and paternal side.

PERSONAL AND SOCIAL HISTORY

Born and raised at Boulevard Avenue, Davao City. Graduated highschool and was
married to Patricio Guadamor at age 24. They have 2 children. She rarely exercises. She prefers
to eat fruits, vegetables, sweets and pork meat. She is a non-smoker and admits to be an
occasional drinker, usually 1 bottle.
REVIEW OF SYSTEMS

General : She has gained about 8 lbs in the past 2 years.

Skin : No skin rashes and fair skinned.
HEENT : Head: No history of head injury. Has intermittent headache.
Eyes: Has reading glasses for 2 years and currently not using
it.
Ears : Hearing is good. No tinnitus and infection
Nose: No discharges noted and sinuses were not inflamed
Throat: No bleeding gums were seen and has tonsillitis.
Neck : Tender lymph nodes on the both tonsillar area. No
goiter
Breast : No lumps, discharges and nipple retractions
Respiratory : No cough, wheezing and history of TB
Cardiovascular : No heart diseases and hypertension.
GI : Appetite is good. Experienced nausea and vomiting
prior to admission. Bowel movement about once daily,
no diarrhea and bleeding. No jaundice and liver problems
Urinary : No frequency, dysuria, hematuria or recent flank pain.
Genital : No vaginal or pelvic infection. No dyspareunia
Peripheral Vascular : No history of leg pain
Psychiatric : No history of depression or psychiatric treatment
Neurologic : Memory is good. Had dizziness recently
Hematologic : Has anemia

Physical Examination

Mr. Sigampong is a medium built man who responds quickly to questions.

He is in pain and anxious on the medications given. His hair is fixed and neat. He
is more comfortable in sitting position.

Vital signs
BP : 80/60 mmHg
HR : 72 bpm
RR : 24 cpm
Temp. : 36.0 C
Skin : Fair – skinned and palms are cold. Nails without cyanosis
and clubbing
Head : Hair – of average texture;
Scalp – no lesions and normocephalic
Eyes : Visual acuity of 20/30 on the left eye; 20/25 on the right
Visual fields full by confrontation
Conjunctiva pink; sclerae are white.
Pupils are round, regular and equally reactive to light.
Ears : Waxes partially obscure both tympanic membranes. Good
acuity to whispered voice. AC BC. Weber is on the midline.
Nose : No mucosal discharges and sinus tenderness
Throat : Tongue in midline position, inflamed left tonsils with exudates
Neck : Trachea is midline. No palpable mass.
Lymph nodes : Lymph node tenderness on left tonsillar and
both periauricular areas
Thorax & : Inspection: No skin retractions and thorax is
Lungs symmetric with good excursion
Palpation: No palpable masses.
Percussion: Right lung is more resonant than the left.
Auscultation: No wheezing
Cardio : Inspection: No irregular bulging.
Palpation: Apical impulse discrete and tapping, barely
palpable in the 5th left interspace midclavicular line
Auscultation: It is dynamic without heaves and thrills. Normal
S1 & S2 and no murmurs heard.
Breast : Inspection: No skin retractions, breast is symmetrical, no
nipple discharges.
Palpation: No masses and lymph nodes were palpated.
Abdomen : Inspection: No surgical scars were seen and abdomen is flat.
Auscultation: No irregular bowel sounds were heard.
Percussion: Dull on the right upper quadrant where liver is
located and most of the areas are tympanitic.
Palpation: Spleen and liver are not palpable.
Extremities : No varicosities, edema and it is warm to touch. Calves are non
Tender
Diagnosis : Tonsillitis

Neurologic Examination

GENERAL : The patient is oriented to time, space and location

CN-I : she is able to identify the smell of coffee
CN-II : Visual acuity on left eye is 20/30 and on the
right 20/25
CN-III, IV & VI : PERRLA, good convergence and was able to follow
hand movements. No nystagmus and lidlag are seen.
CN-V MOTOR : Masseter and temporal muscles has good strength
CN-V SENSORY : identifies sharp from dull objects; hot and cold
things and has good corneal reflex
CN-VII : Nasolabial folds are symmetrical; can raise both
eyebrows; can smile and frown. She can puff both cheeks
CN-VIII : Can hear normally. Weber in the midline. AC BC
CN-IX & X : Has good gag reflex and uvula is in midline position
CN-XI : No fasciculations and atrophy of trapeziues. Can
turn her head left and right with no pain.
CN-XII : Has good articulations. No tongue atrophy, deviation
and fasciculations. Can move her tongue left and right.
MOTOR : She has no pronator drift, can perform pronation
and supination. Good patellar reflex.