Fatima University Medical Center

Mc Arthur Highway, Valenzuela City

Department of Otolaryngology, Head and Neck Surgery
CLINICAL HISTORY
______________________________________________________________

Name: JUERA, Joshua Cupillo

Age/sex: 21 years old/male
Date of admission: January 14, 2019
Attending physician: Jim Caluag , MD
Admitting diagnosis: lacerated wound; r/o cerebral concussion; r/o nasal bone fracture

Chief complaint: Industrial Accident

History of present Illness:

3 days PTC, the patient had an accident at work while delivering motorcycle in Marinduque.
Patient was riding on motorcycle with no helmet then he pulled the break, a part of motorcycle was
hinged accidentally on the ramp. Patient fell at a height of approximately 2 meters. His co – workers
seen him laid unconscious and immediately call for help. Then the patient was rushed to the
hospital. He vomited with watery , non-projectile. Xray was done and the patient vomited again,
non-projectile. Then the lacerated wound in his parieto- occipital area measured 5-6cm was sutured.
The patient was still in pain when walking with a pain scale of 9/10. Then he was prescribed with
Co-Amoxiclav 625mg/tab BID and Celecoxib 250mg BID and was discharged around 10:30AM.

2 days PTC, the patient experienced dizziness with associated vomiting twice, non-
projectile of previously ingested food. The patient still in pain while walking but now with pain scale
of 7/10. The patient claimed that he is compliant with his medications. No consult was done.

1 day PTC, still with the above symptoms, patient was compliant with his medications. No
consult was done.

Few hours PTC, due to persistence, patient sought consult here in our institution, hence
admitted.

Past Medical History:

(-) Surgeries
(-)HPN
(-) DM
(-) Asthma
(-) Thyroid dse
(-) Surgeries
(-) Allergy to food and drugs

Family Medical History:

(-) Diabetes Mellitus
(+) HPN – mother
(-) Asthma
(-) Kidney disease
(-) Allergy to food and drugs
(-) Malignancies

Personal/ Social History:

(-) smoker
(-) alcoholic beverage-drinker
PHYSICAL EXAMINATION:

GENERAL: Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress

BP: 100/80 mmHg HR:86 bpm RR: 20 cpm Temp: 36.4 °C

Skin: brown in color, soft, warm to touch

Head: Normocephalic, (+) lacerated wound at parieto- occipital measuring 5-6cm, (-) mass

EAR

(-) Discharge
Patent ear canal
Intact tympanic membrane
(+) Cone of light

NOSE
(+) nasal discharge
(-) lesion
(-) Mass
(-) Obstruction

THROAT

(-) Tonsillopharyngeal congestion

(+) Grade 3 tonsils bilateral, hyperemic,
enlarged tonsils
(-) Edematous, erythematous uvula

NECK

(-) Cervical lymphadenopathy

(-) No lesion

HEART: Adynamic precordium, normal rate, regular rhythm, (-) murmur

CHEST & LUNGS: Symmetrical chest expansion, (-) retractions, (-) lagging, equal vocal and
tactile fremitus, with clear breath sounds
ABDOMEN: Globular, normoactive bowel sounds, soft, tympanitic, (-) tenderness on deep and
light palpation
EXTREMITIES: Grossly normal extremities, no cyanosis, no edema, full equal pulses,
(+) lacerated wound on left elbow
NEUROLOGIC EXAM: (-) Seizure, (-) involuntary movements, GCS 15

_____________________ Jim Caluag , M.D.

Clerk- in-charge Attending Physician