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    Homura Ch.
    1) The patient has a history of diabetes, stroke, and hypertension. She presented with weakness, low blood pressure, and a history of recent hospitalizations for diabetic ketoacidosis, lung mass, and fluid in the lungs. 2) On physical examination, the patient was irritable and uncooperative. Examination of heart, lungs, abdomen, and extremities was unremarkable. 3) The document contains a physician's assessment record from Fatima University Medical Center, providing details of the patient's history, review of systems, past medical history, physical examination, and vital signs.

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    Ana PDF

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    1) The patient has a history of diabetes, stroke, and hypertension. She presented with weakness, low blood pressure, and a history of recent hospitalizations for diabetic ketoacidosis, lung mass, and fluid in the lungs. 2) On physical examination, the patient was irritable and uncooperative. Examination of heart, lungs, abdomen, and extremities was unremarkable. 3) The document contains a physician's assessment record from Fatima University Medical Center, providing details of the patient's history, review of systems, past medical history, physical examination, and vital signs.

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    1) The patient has a history of diabetes, stroke, and hypertension. She presented with weakness, low blood pressure, and a history of recent hospitalizations for diabetic ketoacidosis, lung mass, and fluid in the lungs. 2) On physical examination, the patient was irritable and uncooperative. Examination of heart, lungs, abdomen, and extremities was unremarkable. 3) The document contains a physician's assessment record from Fatima University Medical Center, providing details of the patient's history, review of systems, past medical history, physical examination, and vital signs.

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    15 views4 pages

    Ana PDF

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    Homura Ch.
    1) The patient has a history of diabetes, stroke, and hypertension. She presented with weakness, low blood pressure, and a history of recent hospitalizations for diabetic ketoacidosis, lung mass, and fluid in the lungs. 2) On physical examination, the patient was irritable and uncooperative. Examination of heart, lungs, abdomen, and extremities was unremarkable. 3) The document contains a physician's assessment record from Fatima University Medical Center, providing details of the patient's history, review of systems, past medical history, physical examination, and vital signs.

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    of 4

    FATIMA UNIVERSITY MEDICAL CENTER CORP.

    120 McArthur Highway, Marulas, Valenzuela City


    Philippines, 1440

    DEPARTMENT OF INTERNAL MEDICINE


    PHYSICIAN’S ASSESSMENT RECORD
    Private/Suite/Semi-Private
    Ward
    Intensive Care Unit
    Delivery Room

    SERVICE: Internal Medicine Surgery Ophtha ENT OB-GYNE Others:

    PATIENT’S NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH SEX /AGE STATUS
    (Month/Date/Year)

    Address Occupation

    CHIEF COMPLAINT: INFORMANT: RELIABILITY

    INITIAL VITAL SIGNS PR: RR TEMP:


    BP:
    Sitting Lying Sat %02 ORAL AXILA RECTAL TYMPANIC
    WT. (kg) Standing Bed Percentile BMI
    Normal Underweight Obese Overweight
    HT. (cm)
    Percentile Normal Stunted

    Weight loss mild< 10% of usual weight moderate > 10 % of usual weight
    PAIN SCORE: LOCATION: TIME/DURATION: FREQUENCY: CHARACTER: TRIGGER FACTOR:

    HISTORY OF PRESENT ILLNESS:

    5 months prior to admission ( May 17 ) patient was brought to our institution ( FUMC ) due to abdominal pain and was found
    out very septic and was diagnosed with Diabetic Ketoacidosis. Admitted and was discharged on May 27 Medication were
    unrecalled ( Prescription was not handed ).

    3 months prior to admission ( July 17th ) patient was brought to another private institution ( Manila Doctors Hospital ) because
    she was very dyspneic with a very low O2 saturation upon checking ( value was not reported ) and a BP of 60/40 mmhg. Later
    on was diagnosed with a lung Mass on the left side and fluid on both lungs ( 80 ml on the Right, 100 ml on the Left ). The
    patient had undergone thoracentesis and eventually was discharged on July 27th.

    4 days prior to admission the patient’s informant reported that the patient was showing signs of weakness and had no energy to
    walk. Eventually the informant decided to take the blood pressure of the patient, recorded 68 / 40 and right away with no time
    to waste the patient was brought to our institution.

    Copy Distribution (1): Copy 1 - Chart Page 1 of 6


    Document No. NSO-07 / Effective October 1, 2018 / Revision No. 0
    REVIEW OF SYSTEMS:
    CONSTITUTIONAL Fever Chills Weight loss Fatigue Night Sweats Weight gain
    Change in appetite Somnolence
    Changes in skin color Sores Rashes Hair loss Pruritus Scaling Bleeding
    SKIN
    Acne Abnormal nails Excessive Sweating

    EYES Eye Pain Double Vision Diplopia Photophobia

    Difficulty Hearing Ear Pain Tinnitus Vertigo Loss of Sense of Smell


    EARS, NOSE & THROAT
    Colds Epistaxis Postnatal Discharge Sinus Pain Hoarseness Change in voice
    Sore Throat Bleeding gums Swelling gums Tooth Decay Tooth Extraction Ulcers
    Disturbance of Taste Tender nodes

    ALLERGIC OR Seasonal allergies or environmental allergies Urticaria


    IMMUNOBLOC
    Chest pain Palpitations Dyspnea Orthopnea Easy Fatigability
    CARDIOVASCULAR
    Paroxysmal Nocturnal Dyspnea Cramping in Legs Leg Swelling (Ederna) Leg Pain with walking (Claudication)

    Cough: Productive Non-Productive


    RESPIRATORY
    Snoring Shortness of Breath: with activity (Dyspnea on exertion) while lying flat (Orthopnea)

    GASTROENTISTINAL Anorexia Dysphagia Hematemesis Nausea Vomiting Hematochezia Melena Diarrhea

    Dysuria Hematuria Nocturia Frequency Retention Incontinence Urgency


    GENITOURINARY
    Discharge if Males: Testicular pasin Scrotal enlargement Erectile dysfunction

    MUSCULOSKELETAL Pain Weakness Tenderness Cramps Joint Pain

    ENDOCRINE Polyuria Polydipsia Polyphagia Heat intolerance Cold intolerance

    HEMATOLOGIC Pallor Easy Fatigability

    Senses Language Writing Memory Concentration Orientation


    NERVOUS
    Judgement Syncope Seizure Dizziness Tremor

    PSYCHIATRIC Depression Suicidal/homicidal Ideation Hallucination

    PAST MEDICAL HISTORY


    Check here if biological family history unknown
    Diabetes ( 2010 )
    Stroke
    Heart Disease/Heart Attack
    High cholesterol
    Hypertension (2010 )
    Cancer
    Alcohol problem
    Major depression
    Drug problem
    PTB
    Previous surgery
    Others

    FAMILY HISTORY
    Diabetes
    Stroke (CVA)
    Heart Disease/Heart Attack
    High cholesterol
    Hypertension
    Cancer

    Alcohol problem
    Major depression
    Drug Problem
    Others
    Unremarkable

    Copy Distribution (1): Copy 1 - Chart Page 3 of 6


    Document No. NSO-07 / Effective October 1, 2018 / Revision No. 0
    PERSONAL AND SOCIAL HISTORY
    Alcohol Drinker Amount: Duration:
    Smoker Pack Years:
    Occupation:
    DETAILS OF PHYSICAL EXAMINATION
    PHYSICAL EXAMINATION
    GENERAL APPEARANCE

    Level of Consciousness:
    SKIN Color: Lesion: Skin Turgor: Capillary Refill:
    Less than 2 secs
    More than 2 secs
    HEAD, EYES, EARS, NOSE, THROAT:

    CHEST/LUNGS :
    Inspection
    Unremarkable

    Palpation

    Percussion

    Auscultation

    HEART

    Inspection Unremarkable

    Palpation

    Auscultation

    ABDOMEN
    Inspection
    Unremarkable

    Auscultation

    Percussion

    Palpation

    Special Exam
    (please specify)

    Digital Rectal
    Exam

    Pelvic
    Examination Unremarkable

    Copy Distribution (1): Copy 1 - Chart Page 4 of 6


    Document No. NSO-07 / Effective October 1, 2018 / Revision No. 0
    EXTREMITIES
    Unremarkable
    OB-GYNE
    Not anymore asked because the patient was quite irritable and uncooperative

    DETAILS OF PHYSICAL GLASGOW COMA SCORE MOTION SENSORY


    EXAMINATIONS

    CN I- CEREBRAL:

    CN II,III- 5/5
    5/5

    CN III, IV,VI-
    CEREBELLAR:

    CN VII-
    5/5 5/5
    CN VIII-

    CN IX,X-

    CN XII-

    ADMITTING IMPRESSION

    PLAN OF CARE

    PREPARED BY:
    Signature Over Printed Name Date/Time

    VALIDATED BY: Dr. Dianna Manalili


    Signature Over Printed Name Date/Time

    Copy Distribution (1): Copy 1 - Chart Page 5 of 6


    Document No. NSO-07 / Effective October 1, 2018 / Revision No. 0

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