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orson-clemons

History of Present Illness - PowerPoint PPT Presentation

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History of Present Illness
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  1. History of Present Illness

  2. Review of Systems • GENERAL: Undocumented weight loss, (+) decrease in appetite • SKIN: No jaundice, no rashes • HEENT: No eye pain, no blurring of vision, no ear discharge, no nasal discharge, no sore throat, no mucosal ulcers • LUNGS: No dyspnea, no hemoptysis • CARDIOVASCULAR: No cyanosis, no palpitations, no chest pain, no easy fatigability; • GIT: No vomiting, no diarrhea, no constipation • GUT: see HPI • ENDOCRINE: No heat/cold intolerance, no polydipsia, no polyuria, no polyphagia • HEMATOPOIETIC: no pallor, no bleeding manifestations, no easy bruisability • EXTREMITIES: No muscle, bone and joint swelling, no limitation of range of motion, no joint pains • NERVOUS: No convulsions, no mood/behavioral changes, no headache

  3. Physical Examination • General Survey: awake, alert, ambulatory, irritable, mild PEM, moderate wasting • Anthropometric data: Wt 16.6 kg ;Ht 93 cm; BMI 19.2 ; BSA 0.65 • Vital Signs: BP 90/50 PR 92 bpm, regular, RR 24cpm, T 37.0C • Skin: warm, moist skin; no active dermatoses • HEENT: Normocephalic head, no scalp lesions, closed fontanels; not sunken eyeballs, no swollen eyelids, no matted lashes, pink palpebralconjunctiva, anicteric sclera, 2-3mm ERTL, isocoric; no tragal tenderness, non-hyperemic external auditory canal, TM intact, AU (+) cerumen, AU; Midline nasal septum, turbinates not congested, no nasal discharge; Moist buccal mucosa, non-hyperemic posterior pharyngeal wall, tonsils not enlarged • Neck: supple neck, thyroid gland not enlarged, (-) palpable lymph nodes • Lungs/Chest: symmetric chest expansion, (-) retractions, clear breath sounds • Cardiovascular: adynamicprecordium, AB 4thLICS left MCL, S1>S2 at apex, S1<S2 at base, (-) murmurs • Abdomen: Globular, soft, no scars, no striae, normoactive bowel sounds, no palpable mass, non tender, no hepatomegaly, no splenomegaly • GUT: (-) CVA tenderness; SMR Tanner stage 1 • Extremities: pulses full and equal, no edema, no cyanosis, no clubbing

  4. Please Read • Medyomaraming inconsistencies. I collated all the records. Yung huling entry ay mod wasting with mild PEM pero BMI nya ay pasoksa normal. • Yung mga data na pertinent, katuladna CVA tenderness, frequency, hesitancy, I assumed nawalakasiwalangnakasulat. • Yung regarding sa history nyang GERD, walangnakalagayng pertinent na data, katuladnghypermic PPW, burning epigastric pain, etc… • walangnakalagaynamga laboratory results ngmga DMSA scan, VCUG, EEG….