Valdez, Aldrey, 19 years old, male, single,

Filipino, Roman Catholic, Born on April 8, 2000

currently residing at Balaoan, La Union,
admiited for the second time last February 22,
2020.

Informant: Patient
Reliability: 90%
Chief Complaint: Facial Asymmetry

Nature of Injury: Motor Vehicular Accident(motorcycle vs

motorcyclez)
Time of Injury: 2:00 AM
Date of Injury: January 9, 2020
Place of Injury: Balaoan, La Union

(+)loss of consciousness
(+) Alcohol Breath
 Past Medical History
• Patient was admitted last January 9, 2020 due
to Multiple Physical Injury secondary to
vehicular accident at ITRMC.
• No known hypertension, diabetes mellitus,
asthma.
Family History
(-)hypertension
(-) Diabetes Mellitus
(-)Asthma
(-) Cancer

Personal and Social History

(-)smoker
(+) alcohol beverage drinker-occassionally
(-) illicit drug use
REVIEW OF SYSTEM:
General: (-)weight loss, (-)febrile episodes, (-)chills, (-)sweat, (-)irritability, (-) lethargy.
Integumentary: (-) cyanosis, (-) pallor, (-) jaundice, (-) lesion, (-)rash, (-) dry skin
 
Head, Eyes, Ears, Nose, Throat (HEENT):
Head: (-) history of head injury, (-) Headache
Eyes: (+) blurring of vision, (-)pain, (-)redness, (-)spots, (-)specks, & (-) sunkeneyeballs.
Ears: (-)earaches,(-)tinnitus,(-)discharges
Nose: (-) cold, (-)nasal stuffiness,(-)discharge,(-)itching,(-)nosebleed (-) smell
Mouth And Throat:(-) bleeding of gums,(-) sore throat ,(-)ulcer, (-) hoarseness, (-) soreness , (-) dental caries, (-)
enlarging tonsils.
Neck: (-) swollen glands.(-) lumps,(-)goiter,(-)pain and(-)stiffness of the neck.

Respiratory: (+) sputum, (-) haemoptysis, (-)dyspnea, (-)shortness of breath.

Cardiovascular: (-)adynamic precordium, (-)NRRR , (-)murmurs (-) palpitations
Gastrointestinal: (-)vomiting, (-)diarrhoea, (-) abdominal pain, (-)bleeding, (-) GOOD Appetite, (-) Hematochezia
Urinary: (-) oliguria, (-)nocturia, (-)urgency, (-) hematuria.
Genital: (-) discharge, (-) pain, (-) swelling, (-) tenderness, (-) itchiness
Musculoskeletal: (-) stiffness, (-)deformities, (-) tenderness,
Neurologic: (-) Irritable, (-)changes in orientation, (-)memory loss, (-)fainting, (-)seizures, (-)motor or sensory
loss.
Extremities: (-) numbnesss
 
 PHYSICAL EXAMINATION
• General Survey: Conscious , oriented , conversant, not in respiratory distress
• Vital Signs: BP 100/70, CR 95, RR 20, SPO2 99, T 37.1
• Skin: No pallor , no jaundice, no cyanosis warm to touch
•  

•  
• Chestand Lung: SCE,(-)lagging, (-)retraction, (+) crackles, left bibasal, (-)
diffuse wheezing,
• Heart: Irregular heart beat, (-) thrills , AP (-) murmur
• Abdomen: flat, soft, (-) hypogastric tenderness, normoactive bowel sounds,
globular.
• Genitalia: not assessed
• Extremities: full and equal pluses, no edema
 HEENT
HEAD: (+)facial asymmetry, (+) swelling on left
maxillomandibular area
EYES: anicteric sclera, pink palpebral conjunctiva, pupils
equally reactive to light, intact extraocular muscles,
(+)left periorbital contusion
EARS: no discharges, clear external auditory canal, intact
tympanic membrane on both ears
NOSE: midline septum, no lesions, no dicharges
THROAT/NECK: trachea midline, no cervical
lymphadenopathy
• Chestand Lung: Symmetric chest wall
expansion, no retractions, clear breath sounds
• Heart: Adynamic precordium, Normal Rate
and Regular Rhythm, No murmur
• Abdomen: flat, normoactive bowel sounds,
soft, non tender abdomen
• Extremities: full and equal pluses, no edema