Professional Documents
Culture Documents
Respiratory
1. health history
A Biographical data
Childhood Illness:
- Dengue fever.
Accident/Injuries
- fall hazard
Serious or Chronic Disease
- Hypertension and Type 2 DM
Hospitalization
- Admitted at BIHMI due to Type 2 DM
Obstetric History
-
Immunizations
- he had a complete immunization or vaccination in her childhood
Last Exam date (Dental,Vision,Hearing,EKG,Chest x-ray)
-Last November 1992
Allergies
-No know allergies
Current medications
-Losartan 50Mg 1 tab OD, Metformin 500Mg/1 tab OD
Habits
- Cleaning house
Family History of illness
-Her mother was diagnose of hypertension and her father was diagnosed of DM
Personal and social History
- NON smoker, Retired office Employee
Economic History
- Patient relies to her Daughter and son
A. Nose
- Nose is in midline placemaent. Shape symmetrical and consistent.
B. Facial Sinuses.
- No preorbital edema or discoloration in sinuses
Neck
A. Neck muscles
- are mobile, no signs of stiff neck
B. Lymph Nodes
- Lymph nodes normally not palpable especially the deep and clavicular nodes.
C. Trachea
- is midline placement.
D. Thyroid Gland
- consistency is firm, smooth, and meaty, with no nodularity, enlargement, or tenderness.
A Posterior Thorax
Inspection
- Skin is intact, no scars
Palpation
- nontender. No deformities or crepitus
Percussion
- Resonance to second intercostals space on left; slight dullness over third through fifth intercostals space over
heart.
Auscultation
-. With no adventitious sounds, lungs are clear to auscultation. No crackles, wheezes or rubs
B. Anterior Thorax
Inspection
- Skin is intact, no scars
Palpation
- nontender. No deformities or crepitus
Percussion
- Resonance to second intercostals space on left; slight dullness over third through fifth intercostals space over
heart.
Auscultation
-. With no adventitious sounds, lungs are clear to auscultation. No crackles, wheezes or rubs
Palpation
- Abdomen soft and nontender. No organomaly or masses, nontender.
Olfactory Nerve
- Patient is able to identify substances.
Optic Nerve
- EOM intact
Oculomotor Nerve
- brisk constriction of pupils in reaction to light, followed by dilation and constriction
Trochlear Nerve
- Eyes deviate to side opposite from way head is turned
Trigeminal Nerve
- Full range of motion in jaw,, patient perceive light touch and superficial pain bilaterally
Abducens Nerve
-
Facial Nerve
- facial nerve intact; able to make faces. Taste sensation on anterior tongue intact
Auditory
- can hear clearly
Glossopharyngeal Nerve
- Swallow nad cough reflex intact. Speech clear.
Vagus Nerve
- Taste on posterior intact.
Accesory Nerve
-Movement symmetrical, with patient moving against resistance without pain.
Hypoglossal Nerve
- can protrude tongue medially. No atrophy, tumors, or lesions.
G. Reflexes
Biceps Reflex
- +2
Triceps Reflex
- +2
Brachioradialis Reflex
- +2
Patellar Reflex
- +2
Achilles reflex
- +2
Plantar reflex
- flexion of all toes
H. Motor Function
Laboratory
Urinalysis