Medical History

II. MEDICAL HISTORY

HISTORY OF PAST ILLNESS : none HISTORY OF PRESENT ILLNESS: Pre-operative Dx: Epidural Hematoma Propose Operation: Craniectomy PAST MEDICAL HISTORY: (-) (-) (-) (-)

Previous Drug Therapy Previous operations previous hospitalization previous illness: (-) Heart Disease (-) HPN (-) COPD, Asthma, PTB (-) Coagulopathies (-) Hepatic Disease

FAMILY HISTORY: (-) Heart Disease (-) CANCER (-) DM

(+) HPN (-) PTB (-) BA

SOCIAL ENVIRONMENTAL HISTORY: (+) Hisotry of Smoking (+) History of Alcoholic Bev. (-) History of Drug Intake

REVIEW OF SYSTEMS PHYSICAL EXAMINATION: General Survey: Awake Vital signs: BP: 100/70 mmHG Temp: 36.5 ⁰C Skin: (-) Pallor

PR: 58 bpm RR: 17 bpm

(-) Cyanosis (-) Rashes

HEENT: (-) Head mass (-)Icteric Sclerae (-) Neck Masses

(-) Jaundice (+) Lesions

(-) Alar Flaring (-) Ear Discharge

Airway Examination: Dentition: Malampati Classification: Neck Mobility: Good

Mouth Opening: Good Thyromenta Distance:

CHEST and LUNGS: (+) Equal Symmetrical chest expansion (-) Retractions (-) Rales HEART: (-) Murmurs

(-)Heave

ABDOMEN: (-) Globular

(-)Organomegaly

EXTREMITIES: (-)Deformities

(-)Edema

MUSCULOSKELETAL: (-)Lordosis (-)scoliosis

(-) Wheezes (-) Rhonchi (-) Chest Deformities

(-)Lift

(-)thrills

(-)Flat (-)Cyanosis (-)kyphosis

(-)Tenderness (+)Lesions (-)infection/lesions