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I. PATIENTS PROFILE
 Name: Alfredo Ortiz Perida Case No: 336059Age: 57 years oldSex: MaleCivil status: MarriedAddress: Brgy. Guindapunan Carigara, LeyteOccupation: Fish Vendor Religion: Roman CatholicNationality: FilipinoBirthday: March 14, 1950Birthplace: Barugo, LeyteDate of Admission: April 26, 2007Time: 1:15PMFather: DeceasedMother: Lucena OrtizWife: Rufina PeridaAttending Consultant: Dr. ZetaChief Complaint: “Nanluya ak, namusag, nagsirom an pangitaan ngan sumakit an akondughan.”Diagnosis: Hyperglycemia, Diabetes Milletus Type II
II. History Present Illness
Few hours on the day of the admission, the patient woke up with dizziness and body malaise. Then when he was putting ice on the fishes that he is going to sell that day,his dizziness worsened. Not only that, the dizziness was accompanied by blurring of vision, diaphoresis and fainting or syncope. So the patient immediately consulted a private doctor but was not accepted. Then he was brought to the emergency room of theCarigara District hospital. According to the patient, his BP at that time was 50/30mmhgand then increased to 90/70mmhg. Finally the patient was refereed to this institution.
III. Past History
•
The patient had experienced measles during his childhood years.
•
As far as the patient can remember, he had completed his immunization.
•
The patient is not allergic to any drug, food, plants and others.
•
In the past, the patient did not encounter any accident or injury.
•
The patient was hospitalized last 2004 still for the same reason, DM.
•
The patient had a maintenance drug, which is Diamicron. He usually takes thedrug every morning and afternoon. This was for three years but he stopped for amonth now.
IV. Family History
According to the patient, his family has no history of Diabetes Milletus,hypertension, asthma, arthritis or even cancer.
V. Lifestyle
•
Before, when the patient was not yet diagnosed with DM, he admitted that he wasa strong alcoholic and smoker. But because of his condition, he minimized hisdrinking and smoking habits. If before almost everyday he drinks alcoholic beverages, now he tries very hard to drink only about 2-3 times a week and nowhe also smoke sometimes.
•
According to the patient, he has no difficulty sleeping.
•
The patient is a fish vendor, so his usual activities is of course going to the marketand selling his fishes.
•
The patient does not have any exercise regimen. One of his hobby is playing cardsespecially
tong-its.
VI. Social Data
•
In times of stress, his family is very much supportive of him, not only financially but especially emotionally.
•
Before he became a fish vendor, he was first a driver. Then after he changed his job to selling fish in the market.
 
REVIEW OF SYSTEMS
General: No weight loss, no fever and chills.Skin: Wound on the left big toe, scars on the lower extremitied, hyperpigmented shinyskin on the feet, no rashes and pruritus.Head: No headache, injur or tenderness.Eyes: Blurring of vision, no excessive tearing or no discharges.Ears: Dizziness, no discharges, no pain Nose: No sneezing, epistaxis or no change in sense of smellThroat: No bleeding gums, no lesionsRespiratory: No cough, chest pain, no hemoptysis, diaphorsis.Cardiovascular: Chest painGastrointestinal: PolyphagiaGenitourinary: PolyuriaEndocrine: FatigueMusculoskeletal: No stiffness or limitation of movement.
PHYSICAL EXAMINATION
General: The patient is an adult, 57 years old male. He is not assuming any usual position. He is also cooperative, pleasant and easy to talk with.Vital Signs:
•
Temperature= 37°C
•
Respiratory rate: 22 breaths per minute
•
Blood Pressure: 100/60mmgh
•
Pulse rate: 50 beats per minuteHead: No tenderness or mass, symmetrical, absence of nodules and symmetrical facialmovements.Skin: Ski color ranges from light to dark brown, hyperpigmented shiny skin on the feet,no edema, wound on the left big foot, moist skin folds, good skin turgor.Hair: Evenly distributed, no infection or infestation.Eyes: No blurring of vision at the momentEars: no tenderness and no hearing impairments Nose: symmetrical, no lesions, inflammation, or congestion.
DIAGNOSTIC EXAMS
I. Ultrasound Report (April 26, 2007)Findings: Chest x-ray PA viewUpright film shows no definite lung parenchymal infiltrates. Trachea at midline,heart is not enlarged. Intact both hemidiaphragms with sharp skull. The visualized softtissues and osseous structures shows no identifiable abnormalities.Impressions: Normal chest findings.II. Urinalysis (April 26, 2007)
ExamResultNormal FindingsSignificance
ColorYellowColorless to dark yellow NormalTransparencyTurbid pH6.04.6-8.0NormalSpecific gravity1.0251.006-1.030NormalAlbuminNegativeNegativeNormalSugar(+)NegativeDiabetesPus cells0-2/hpf Red blood cells0-2/hpf Epithelial cellsSomeBacteriaFewNoneA.uratesFewMucus threadsModerateKetonesNegativeNegativeNormal
 
III. Laboratory Report
ExamResultNormal ValuesSignificance
GlycosylatedHemoglobin8.4%3.9-6.2%Increased inDiabetes MilletusIV. Clinical Chemistry (April 26, 2007)
ExamResultNormal ValuesSignificance
Sodium135mmol/l135-148mmol/LNormalPotassium4.25mmol/L3.5-5.3mmol/LNormalChloride102.5mmol/L98-107mmol/LNormalV. Hematology (April 26, 2007)
ExamResultNormal ValuesSignificance
Hemoglobin123g/LMale: 135-170g/LFemale: 120-160g/LDecreased inhemodilution(fluidoverload), anemia,recent hemorrhageHematocrit0.37Male: 0.40-0.54Female: 0.36-0.47Decreased inhemodilution, anemia,and acute massive bloodloss.Erythrocytes4.33x10
12
/LMale:4.6-6.2x10
12
/LFemale:4.2-5.4x10
12
/LDecreased in anemia,fluid overload, recenthemorrhage, leukemia.Leukocytes10.60x10
9
/L4.5-10.0x10
9
/LIncreased in infection,leukemia, tissuenecrosis.Granulocytes0.79%0.500-0.750%Increased ininflammatory disease,tissue necrosis, anemia,allergic reactions.Lymphocytes0.18%0.200-0.350%Decreased in AIDS,corticosteroids,immunosuppressivedrugs.Monocytes0.03%0.20-0.060%Decreased in drugtherapy and prednisone.MCV86 fl80-96 flNormalMCH28.40 pg27-31 pgNormalMCHC330320-360Normal
I. PATIENTS PROFILE
 Name: Bernabe Rañin Petallana Sr. Case No: 336375Age: 38 years oldSex: MaleCivil status: MarriedAddress: Cutay, Carigara, LeyteOccupation: Motorcycle Driver Religion: Roman CatholicNationality: FilipinoBirthday: October 8, 1970Birthplace: Carigara, LeyteDate of Admission: April 30, 2007Time: 11:30 AMFather: DeceasedMother: Milagros PetallanaWife: Liza PetallanaChief Complaint: “Hataas an akon hiranat ngan naglagdos an akon sorok-sorok.”
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