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yChief Complaint:Abdominal pain

y Admitting Diagnosis: UTI t/cUrolithiasis.

y Attending Physician: Dra. BaguiyDate of admission: Nov 72009

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:Past Health History:

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Family History:

yHe has their own house. He is the

oldest in all of his siblings. Hehas

one sibling, a 18 year- old daughter.His family is a traditional family. His

family belongs to the middle class.

His family has no diagnosed mentaldisorders and Cardiovascular

Diseases but has a history of 

asthma.

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Social History:

yHe is a graduate of Bachelor in

Sceince in Nursing. His currently

enrolled on a review program in

lipa.He is an active member of an

organization in their Institution untilnow.

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Physical Assessment

Performed: Nov. 11 , 2009;8:00am

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Body parts Methods Findings Analysis

Ski

Hair

ails

Hea

i s ecti

al ati

i s ecti

i s ecti

al ati

i s ecti

al ati

no skin lesions no e e a

te erat re was wit in nor al range= 36.1 no infection orinfestation after lanc test,

s al color ret rn romt ly 

rounded a sence of nodulesor masses

normal

normalnormal

normal

normal

normal

normal

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Body Parts Methods Findings Analysis

E yes:

eye ro ws

eyelas es

eyelids

upils

Ears

ose

inspection

inspection

inspection

inspection

inspection

palpation

inspection

hair evenly distri uted equally distri uted no discoloration pupil constricts when illuminated

sy mmetrically aligned firm, smooth no lesions sy mmetric midline of the face

no discharge

normal

normal

normal

normal

normal

normalnormalnormalnormal

normal

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Bod y parts Methods Finding Analysis

Mouth lips

teeth and gums

eck

hest and Lungs

inspection

palpationinspection

inspection

inspection

inspection

 withoutinflammation smooth properly aligned teeth pink gums central position no lesions

no enlargementof ly mph nodes

thorax rises and fall. 21 pm

normal

normalnormal

normalnormal

normal

normalnormalnormalnormal

normal

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Body parts Methods Findings Analysis

Heart

domen

Musculoskeletal

S ystem muscles

Extremities upper lo wer

auscultation

auscultation

inspection

auscultation

palpation

inspection

inspection

inspection palpation

normal reathsound 

1 6 pm

unblemished skin audible bo welsound no tenderness

equal size on 

both sides of thebod y  no def ormities

no lesions no edema

normal

normal

normal

normal

normal

normal

normal

normalnormal

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oentgenological findings:

Both lung fields are clear. heheart is not enlarged. he

 visualized bon y thorax, hemi

diaphragms and sulci are negative.

onclusion: Essentially  ormalhest

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Interpretation:y A ll the findings were normal were

all normal.

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