SILLIMAN UNIVERSITY MEDICAL SCHOOL
ADMITTING NOTES
Name: AMBA, RAZINITA Attending Physician: Dr.
Date and Time of Admission: 07/09/2024 Room Number:
GENERAL DATA: REVIEW OF SYSTEMS
This is case of R.A., a 60-year-old, female, married, Roman ⮚ GENERAL: (-) weight loss, (-) night sweats, (-) sleep
Catholic, from Tanjay, Negros Oriental who was admitted due disturbance, (-) overall weakness, (-) fever, (-) chills, (-)
to….. fatigue/malaise, (-) increased thirst.
⮚ SKIN: (-) Itching, (-) Skin Color change, (-) Rash, (-)
CC: HEMATURIA dryness
Informant: Patient herself (95% reliability) ⮚ HEAD and NECK: (-) Headache, (-) Neck stiffness, (-)
lightheadedness, (-) Dizziness, (-) Goiter, (-) lumps
HISTORY OF PRESENT ILLNESS: ⮚ EYES: (-) Visual disturbances, (-) Red, Painful eyes, (-)
tearing, (-) Cataract/ Glaucoma
1 day PTA, sudden onset of dysuria associated with gross ⮚ EARS, NOSE, SINUSES, MOUTH, THROAT: (-) Sore
hematuria noted to be bright red in color, mild hypogastric pain throat, (-) nasal stuffiness, (-) nasal discharges, (-)
was also noted. Patient sought consultation at a local clinic and nosebleed, (-) bleeding gums, (-) dry mouth, (-) tinnitus,
was prescribed TRANEXAMIC ACID 500mg and CEFUROXIME (-) earaches
500 mg with mild relief, thus admission. ⮚ RESPIRATORY: (-) Cough, (-) hemoptysis, (-) SOB, (-)
chest tightness
PAST MEDICAL HISTORY: ⮚ CARDIOVASCULAR: (-) palpitations, (-) edema, (-)
⮚ Past admissions: dyspnea (w/ or w/out exertion), (-) orthopnea, (-) chest
o none pain/discomfort
⮚ Past surgeries: ⮚ GASTROINTESTINAL: (-) Vomiting, (-) nausea, (-)
o none Diarrhea, (-) Constipation, (-) Abdominal pain, (-) Loss of
⮚ Comorbidities: appetite,
o Hypertension ⮚ URINARY: (-) Hematuria, (-) Dysuria, (-) Oliguria, (-)
o UBP - 130/90 mmHg Flank pain, (-) Suprapubic pain, (-) Nocturia
o HBP - 170/100 mmHg ⮚ MUSCULOSKELETAL: (-) Weakness, (-) Cramps, (-)
o Diabetes Mellitus Swelling, (-) Limitation in movement
⮚ Maintenance Medications: GOOD COMPLIANCE ⮚ ENDOCRINE: (-) Polyuria, Polydipsia, Polyphagia, (-)
1. LOSARTAN 50 MG Cold/Heat intolerance
2. ROSUVASTATIN 10MG ⮚ NEUROLOGIC: (-) Seizures, (-) Loss of consciousness,
3. SITAGLIPTIN 50 MG (-) Dizziness
⮚ Blood Transfusion: none ⮚ HEMATOLOGIC: (-) Abnormal bleeding, (-) Poor wound
⮚ Food/Drug Allergy: None healing
⮚ Immunizations: None
PHYSICAL EXAMINATION:
FAMILY HISTORY:
⮚ Maternal: HTN GENERAL SURVEY: Awake, alert, afebrile, coherent,
⮚ Paternal: DM ambulatory and NIRD
PERSONAL AND SOCIAL HISTORY: VITAL SIGNS:
⮚ Patient is a non smoker, a non alcoholic beverage BP: 170/100 mmHg
drinker, and denies illicit drug use. HR: 116
⮚ Diet: Unrestricted 02: 100% at RA
⮚ Physical Activity: zumba RR: 20
⮚ Vitamins/ Supplements: none T: 36.9
Anthropometrics:
Weight: 151
Height: 51.5 Motor
BMI: 22.6
Skin: no pallor, no jaundice, no pruritus, no rash, no active
lesions, warn to touch, good skin turgor and mobility Sensory
HEENT: normocephalic, atraumatic, anicteric sclerae, pink
palpebral conjunctiva, nosunken eyeballs, PERRLA, no sinus
tenderness, ears with minimal cerumen, pearly white tympanic
membrane, moist lips and oral mucosa, no tonsillopharyngeal
congestion Reflexes:
Neck: supple, trachea midline, no cervical lymphadenopathies,
no distend neck vein, thyroid not palpable
C/L: symmetric with good expansion, equal tactile fremitus, (-)
retractions, (-) crackles, (-) inspiratory wheezing upper lobes
CVS: adynamic precordium, PMI at 5th left intercostal space
midclavicular line, no heaves or thrills, regular heart rate and Cerebellar: Well-coordinated movements by finger-to-nose test
rhythm, distinct heart sound, no murmurs and heel-to-shin test, right upper and lower extremities; no
dysdiadochokinesia
Abdomen: flabby, normoactive bowel sounds, tympanitic on all
quadrants except over area of liver dullness, soft, no palpable Meningeal: (-) nuchal rigidity, (-) Kernig, (-) Brudzinski (-)
mass, nontender upon light and deep palpation (+) Hypogastric Babinski
Discomfort
Primary Working Impression:
GUT: (-) KPS, bilateral 1. t/c Nephrolithiasis
2. Type II DM
Extremities: no gross deformity, no edema, CRT <2 seconds, 3. HCVD
strong peripheral pulses, no limitations in the range of motion
Neurologic:
MSE: patient is conscious, coherent, oriented to time, place and
person
GCS 15 (E4V5M6)
Cranial Nerves
CN I - no anosmia (able to smell)
CN II – PERRLA, direct and consensual PLR (pupils 2mm,
equally reactive to light and accommodation)
CN V – facial sensations intact, (+) corneal reflex, intact muscles
of mastication
CN VII – good and symmetrical facial expressions
CN VIII - able to hear spoken voice test, both ears; Rinne Test
AC>BC
CN IX, - uvula at midline, able to swallow, (+) gag reflex
CN XI - able to turn head and shrug shoulders and turn head
against resistance, both sides
CN XII - tongue at midline upon rest and protrusion, no atrophy or
fasciculations
