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MP
64 years old, female, married
Filipino, Roman Catholic
Housewife
Residing in Tinago, Cebu City
Admitted for the 1st time at VCMC
CC: Chest Pain
Family History
Hypertension: paternal
Diabetes Mellitus Type 2: maternal
Physical Examination
On admission, patient was conscious, coherent,
afebrile, not in respiratory distress & with the
following vital signs:
BP: RR: 20 cpm
HR: 72 bpm T: 36C/axilla
PS: 5/10 Ht: 160cm
Wt: 66kg
O2 sat: 97%
Physical Examination
Skin: warm, good turgor, no lesions
HEENT: anicteric sclerae, pinkish palpebral
conjunctivae, no nasoaural discharges, no
tonsillopharyngeal congestion
Neck: supple, trachea at midline, no cervical
lymphadenopathy, no neck vein engorgement,
thyroid gland not enlarged
Physical Examination
C/L: equal chest expansion, equal tactile
fremitus, resonance on both lung fields,
clear breath sounds, no rales, no wheezes
CVS: adynamic precordium, PMI at the 5th
LICS MCL 2cm, distinct S1 and S2, normal
rate, regular rhythm, no audible murmurs
Physical Examination
Abdomen: flabby, normoactive bowel sounds, generally
tympanitic except at area of liver dullness, no palpable
masses, no organomegaly, no tenderness
GUT: no costovertebral angle tenderness, bilaterally
Extremities: warm, strong and equal peripheral pulses,
pinkish nailbeds, CRT of < 2 seconds, no peripheral
edema
Physical Examination
Abdomen: flabby, normoactive bowel sounds, generally
tympanitic except at area of liver dullness, no palpable
masses, no organomegaly, no tenderness
GUT: no costovertebral angle tenderness, bilaterally
Extremities: warm, strong and equal peripheral pulses,
pinkish nailbeds, CRT of < 2 seconds, no peripheral
edema
Physical Examination
CN7: good facial expression, no facial
asymmetry
CN8: able to hear spoken words at 2 feet
distance
CN9, 10: (+) gag reflex
CN11: able to shrug shoulders against
resistance
CN12: tongue midline at rest and upon
Physical Examination
Cerebellar: well-coordinated movements by
rapid alternating hand test, (+) finger to nose
test, heel to shin test
Motor: good muscle tone, no atrophy
5/5 5/5
5/5 5/5
Sensory: intact pain and touch sensation
Reflexes: +2 DTRs