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General : She has gained about 8 lbs in the past 2 years.

Skin : No skin rashes and fair skinned.
HEENT : Head: No history of head injury. Has intermittent headache.
Eyes: Has reading glasses for 2 years and currently not using
Ears : Hearing is good. No tinnitus and infection
Nose: No discharges noted and sinuses were not inflamed
Throat: No bleeding gums were seen and has tonsillitis.
Neck : Tender lymph nodes on the both tonsillar area. No
Breast : No lumps, discharges and nipple retractions
Respiratory : No cough, wheezing and history of TB
Cardiovascular : No heart diseases and hypertension.
GI : Appetite is good. Experienced nausea and vomiting
prior to admission. Bowel movement about once daily,
no diarrhea and bleeding. No jaundice and liver
Urinary : No frequency, dysuria, hematuria or recent flank pain.
Genital : No vaginal or pelvic infection. No dyspareunia
Peripheral Vascular : No history of leg pain
Psychiatric : No history of depression or psychiatric treatment
Neurologic : Memory is good. Had dizziness recently
Hematologic : Has anemia

Physical Examination

Mr. Sigampong is a medium built man who responds quickly to

questions. He is in pain and anxious on the medications given. His hair is fixed
and neat. He is more comfortable in sitting position.

Vital signs
BP : 80/60 mmHg
HR : 72 bpm
RR : 24 cpm
Temp. : 36.0 C
Skin : Fair – skinned and palms are cold. Nails without cyanosis
and clubbing
Head : Hair – of average texture;
Scalp – no lesions and normocephalic
Eyes : Visual acuity of 20/30 on the left eye; 20/25 on the right
Visual fields full by confrontation
Conjunctiva pink; sclerae are white.
Pupils are round, regular and equally reactive to light.
Ears : Waxes partially obscure both tympanic membranes. Good
acuity to whispered voice. AC BC. Weber is on the midline.
Nose : No mucosal discharges and sinus tenderness
Throat : Tongue in midline position, inflamed left tonsils with exudates
Neck : Trachea is midline. No palpable mass.
Lymph nodes : Lymph node tenderness on left tonsillar and
both periauricular areas
Thorax & : Inspection: No skin retractions and thorax is
Lungs symmetric with good excursion
Palpation: No palpable masses.
Percussion: Right lung is more resonant than the left.
Auscultation: No wheezing
Cardio : Inspection: No irregular bulging.
Palpation: Apical impulse discrete and tapping, barely
palpable in the 5th left interspace midclavicular
Auscultation: It is dynamic without heaves and thrills. Normal
S1 & S2 and no murmurs heard.
Breast : Inspection: No skin retractions, breast is symmetrical, no
nipple discharges.
Palpation: No masses and lymph nodes were palpated.
Abdomen : Inspection: No surgical scars were seen and abdomen is flat.
Auscultation: No irregular bowel sounds were heard.
Percussion: Dull on the right upper quadrant where liver is
located and most of the areas are tympanitic.
Palpation: Spleen and liver are not palpable.
Extremities : No varicosities, edema and it is warm to touch. Calves are non

Diagnosis : Tonsillitis
Neurologic Examination

GENERAL : The patient is oriented to time, space and location

CN-I : she is able to identify the smell of coffee

CN-II : Visual acuity on left eye is 20/30 and on the

right 20/25

CN-III, IV & VI : PERRLA, good convergence and was able to follow

hand movements. No nystagmus and lidlag are seen.

CN-V MOTOR : Masseter and temporal muscles has good strength

CN-V SENSORY : identifies sharp from dull objects; hot and cold
things and has good corneal reflex

CN-VII : Nasolabial folds are symmetrical; can raise both

eyebrows; can smile and frown. She can puff both

CN-VIII : Can hear normally. Weber in the midline. AC BC

CN-IX & X : Has good gag reflex and uvula is in midline position

CN-XI : No fasciculations and atrophy of trapeziues. Can

turn her head left and right with no pain.

CN-XII : Has good articulations. No tongue atrophy, deviation

and fasciculations. Can move her tongue left and right.

MOTOR : She has no pronator drift, can perform pronation

and supination. Good patellar reflex.