Professional Documents
Culture Documents
I- General Data
Patient R.R.M., 41 year old, male, single, and residing at Batac, Ilocos Norte. He is
an affiliate of Iglesia Filipina Independiente and a herdsman. He was admitted on April 12,
2018 and this is his first time admission.
B. Vital Signs
BP = 120/90mmHg
RR = 33bpm
PR = 87bpm
T° = 37.1°C
O2 Sat = 93%
Wt. = 64kg
Ht. = 170.5cm
BMI = 21.99
D. HEENT
1. Head
Skull is symmetrical in contour.
2. Eyes
Symmetrical. Jaundice sclera. Palpebral conjunctiva is pinkish. No ptosis
or nystagmus. No discharge. Bilaterally positive ROR.
3. Ears
Symmetrical without swelling. Both ears have minimal wet yellowish-
brownish earwax partially occluding the tympanic membrane. positive cone of light.
No mass, lesion, or deformity. No tenderness.
4. Nose
Nasal mucosa is moist and pink. No swelling, bleeding, or exudates.
Septum is midline. Whitish discharge noted. No tenderness and negative
transillumination on sinuses.
5. Throat and Mouth
Oral mucosa is moist and pale. Tongue has no lesions. Pharynx has no
swelling, bleeding, or exudates. Tonsil is grade II. 1st and 2nd lower right and left
molars and upper right central incisor are missing. Teeth have dental carries.
Uvula is in the midline.
E. Neck
Trachea is in midline. Thyroid isthmus is palpable and mobile. No mass. With
2cm horizontal scar on left sternocleidomastoid area.
Pakidagdag na lang sa neuro guys:
CN II
Visual fields:
Central and peripheral visions are intact in all fields by confrontation test.
Visual acuity:
OD: 20/20
OS: 20/30 + 1
CN II and III
Pupils are equally round and reactive to light and accommodation (constrict from 3mm
to 2mm).
CN III, IV, VI
Extraocular movement (EOM) intact in six directions
No nystagmus.
CN VIII
Weber Test: lateralizes midline
Rinne Test:
AU: AC > BC