CLINICAL RECORD

FIRST NAME SURENAME

AGE SEX FEMALE
ADDRESS
CONTACT NOS. RELIGION
DATE SEEN FM RESIDENT

History of Present Illness:

Review of System:
(-) headache, (-) dizziness, (-) ear pain, (-) sore throat, (-) chest pain, (-) difficulty of breathing, (-) abdominal pain,
(-) changes in bowel movement, (-) dysuria, (-) easy bruisability,

Past Medical History

Non-Hypertensive
Non-Diabetic
No history of Surgery or Hospitalization

Personal and Social History

- Non-alcoholic beverage drinker. Non-Smoker
- Denies any substance abuse

Immunization History
N/A

Obstetrics/Menstrual History
- Menarch at age of 13 yo, Regular Cycle, 4-5 days, 4-5 pads per day, (-) Dysmenorrhea

Physical Examination
- Alert, awake, not in cardiorespiratory distress.
- BP 120/70 mmHg HR 89 bpm RR 21 cpm T37.5 oC
- Warm, moist skin, no active dermatoses.
- Conjunctivae pink, sclerae white, without jaundice. No en- or exophthalmos.
- Moist lips, no tonsillopharyngeal congestion, no cervical lymphadenopathy.
- Symmetrical chest expansion, (+) harsh breath sound on right upper lobe, no retractions, no wheezing.
- Adynamic precordium, regular cardiac rate and rhythm.
- Soft abdomen, normoactive bowel sounds, non-tender.
- Full and equal pulses.
- Neurologic Examination: Unremarkable

Assessment
- Dog Bite,2nd Digit Right Hand, Category II
Plan
- Diagnostics
o CBC PC, UA, Chest X-Ray, Rapid Test, Covid19 (RT-PCR)
- Therapeutics
o Paracetamol 500mg/tab, 1 tablet every 4 hours as needed for temperature equal or more than 37.8C.
o Vitamin C Oral Tablets, 1 tablet OD.
o For Repeat RT-PCT after 14 days of Home Isolation.
- Follow-up
o Follow up after completion of 14 days of home isolation.
- Referral
o Refer to Cainta Health Office (Contact tracing. Patient).
o May call Cainta Covid19 Hotline anytime if with problem.
- Health Education and Advice
o DAT.
o Transmission-Based Precaution.
o Increase Oral Fluid Intake.