You are on page 1of 133

I.

PATIENTS PROFILE Name: Alfredo Ortiz Perida Case No: 336059 Age: 57 years old Sex: Male Civil status: Married Address: Brgy. Guindapunan Carigara, Leyte Occupation: Fish Vendor Religion: Roman Catholic Nationality: Filipino Birthday: March 14, 1950 Birthplace: Barugo, Leyte Date of Admission: April 26, 2007 Time: 1:15PM Father: Deceased Mother: Lucena Ortiz Wife: Rufina Perida Attending Consultant: Dr. Zeta Chief Complaint: “Nanluya ak, namusag, nagsirom an pangitaan ngan sumakit an akon dughan.” 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 the Carigara District hospital. According to the patient, his BP at that time was 50/30mmhg and 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 the drug every morning and afternoon. This was for three years but he stopped for a month 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 was a strong alcoholic and smoker. But because of his condition, he minimized his drinking 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 now he 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 market and selling his fishes. • The patient does not have any exercise regimen. One of his hobby is playing cards especially 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 shiny skin 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 smell Throat: No bleeding gums, no lesions Respiratory: No cough, chest pain, no hemoptysis, diaphorsis. Cardiovascular: Chest pain Gastrointestinal: Polyphagia Genitourinary: Polyuria Endocrine: Fatigue Musculoskeletal: 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 minute Head: No tenderness or mass, symmetrical, absence of nodules and symmetrical facial movements. 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 moment Ears: 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 view Upright film shows no definite lung parenchymal infiltrates. Trachea at midline, heart is not enlarged. Intact both hemidiaphragms with sharp skull. The visualized soft tissues and osseous structures shows no identifiable abnormalities. Impressions: Normal chest findings. II. Urinalysis (April 26, 2007) Exam Color Transparency pH Specific gravity Albumin Sugar Pus cells Red blood cells Epithelial cells Bacteria A.urates Mucus threads Ketones Result Yellow Turbid 6.0 1.025 Negative (+) 0-2/hpf 0-2/hpf Some Few Few Moderate Negative Normal Findings Colorless to dark yellow 4.6-8.0 1.006-1.030 Negative Negative Significance Normal Normal Normal Normal Diabetes

None Negative Normal

III. Laboratory Report Exam Glycosylated Hemoglobin Result 8.4% Normal Values 3.9-6.2% Significance Increased in Diabetes Milletus

IV. Clinical Chemistry (April 26, 2007) Exam Sodium Potassium Chloride Result 135mmol/l 4.25mmol/L 102.5mmol/L Normal Values 135-148mmol/L 3.5-5.3mmol/L 98-107mmol/L Significance Normal Normal Normal

V. Hematology (April 26, 2007) Exam Hemoglobin Result 123g/L Normal Values Male: 135-170g/L Female: 120-160g/L Male: 0.40-0.54 Female: 0.36-0.47 Male:4.6-6.2x1012/L Female:4.25.4x1012/L 4.5-10.0x109/L 0.500-0.750% Significance Decreased in hemodilution(fluid overload), anemia, recent hemorrhage Decreased in hemodilution, anemia, and acute massive blood loss. Decreased in anemia, fluid overload, recent hemorrhage, leukemia. Increased in infection, leukemia, tissue necrosis. Increased in inflammatory disease, tissue necrosis, anemia, allergic reactions. Decreased in AIDS, corticosteroids, immunosuppressive drugs. Decreased in drug therapy and prednisone. Normal Normal Normal

Hematocrit

0.37

Erythrocytes Leukocytes Granulocytes

4.33x1012/L 10.60x109/L 0.79%

Lymphocytes

0.18%

0.200-0.350%

Monocytes MCV MCH MCHC

0.03% 86 fl 28.40 pg 330

0.20-0.060% 80-96 fl 27-31 pg 320-360

I. PATIENTS PROFILE Name: Bernabe Rañin Petallana Sr. Case No: 336375 Age: 38 years old Sex: Male Civil status: Married Address: Cutay, Carigara, Leyte Occupation: Motorcycle Driver Religion: Roman Catholic Nationality: Filipino Birthday: October 8, 1970 Birthplace: Carigara, Leyte Date of Admission: April 30, 2007 Time: 11:30 AM Father: Deceased Mother: Milagros Petallana Wife: Liza Petallana Chief Complaint: “Hataas an akon hiranat ngan naglagdos an akon sorok-sorok.”

Diagnosis: Typhoid Fever with Ileitis II. History Present Illness 15 days prior to admission, the patient experienced abdominal distention which was accompanied by fever. He did not consult to any doctor. He took Paracetamol for relief of fever. 3 days later, he decided to consult a doctor in their area. His doctor told him take antibiotic. The symptoms of the patient started 15 days PTA. Often his fever occurs in the afternoon. He experiences pain in his abdomen especially in RUQ. In a scale of 1-10 wherein 10 is most painful, the patient described the intensity of the pain he is experiencing as 8. He felt the symptoms when he was driving the motorcycle. Other than fever, there are no other symptoms associated with abdominal distention. According to the patient, the pain becomes severe when he is eating. On the other hand, it dos not have an effect whether he sits, stands or lie down. III. Past History • The patient is negative for childhood illnesses. • The patient can no longer remember about his immunizations. • 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 never hospitalized in the past. This is the first time he was admitted to the hospital. • When the patient had fever, he took Paracetamol and antibiotics that was recommended by the doctor. IV. Family History According to the patient, his family has no history of Diabetes Milletus, hypertension, asthma, arthritis or even cancer. V. Lifestyle • Before, the patient drinks about 2 liters of tuba. He also smokes in the past. But at the moment, he admitted that he now drinks whenever there is an occasion and he seldom smokes. • The patient verbalized that he usually eats fish and vegetables everyday, and he doest not eats street foods. • According to the patient, he has no difficulty sleeping. • The patient is a motorcycle driver. He usually wakes up at around 7 in the morning and goes to work and goes home at around 4 in the afternoon. • The patient does not have any exercise regimen. VI. Social Data • In times of stress, his family is very much supportive of him, not only financially but especially emotionally. • The patient’s highest educational attainment is 3rd year high school. • Before he was a farmer. And when he got married, he became a motorcycle driver, about 14 years now. • The patient does not have any medicare. • The patient lives in a semiconcrete house in Carigara, leyte with 2 rooms. He also lives with his wife and 5 children. Their house is located near the main road. They have a water sealed toilet and deep well as a source of water. REVIEW OF SYSTEMS General: Weight loss, fever and chills. Skin: No rashes, bruising, pruritus and no hypo or hyperpigmented skin. Head: No headache, injury or tenderness. Eyes: No excessive tearing or no discharges and blurring of vision. Ears: No discharges, no pain Nose: No sneezing, epistaxis or no change in sense of smell Throat: No bleeding gums, no lesions Respiratory: No cough nand colds, diaphoresis. Cardiovascular: No chest pain, palpitations nor dyspnea. Gastrointestinal: Abdominal distention, passage of yellow watery stool.

Genitourinary: No dysuria, polyuria and no oliguria. Endocrine: Fatigue PHYSICAL EXAMINATION General: The patient is conscious, coherent, and oriented to time, place and person. He is cooperative and does not assume any unusual position. He is febrile but not in respiratory distress. Vital Signs: • Temperature= 37.3°C • Respiratory rate: 32breaths per minute • Blood Pressure: 90/60mmgh • Pulse rate: 81 beats per minute Head: No tenderness or mass, symmetrical, absence of nodules and symmetrical facial movements. Skin: Skin color ranges from light to dark brown, no edema, good capillary refill and good skin turgor. Hair: Evenly distributed, no infection or infestation. Eyes: No blurring of vision at the moment and pink palpebral conjunctiva. Ears: no tenderness and no hearing impairments Nose: symmetrical, no lesions, inflammation, or congestion. Chest and Lungs: No crackles or wheeze, resonant bronchovesicular breath sounds Heart: No palpitations. Abdomen: Distended, Tympanic sound, globular, no shifting dllness, hypoactive bowel sounds. Extremities: Symmetrical, equal and no edema. DIAGNOSTIC EXAMS I. Urinalysis (April 30, 2007) Exam Color Transparency pH Specific gravity Albumin Sugar Pus cells Red blood cells Epithelial cells Bacteria A.urates Mucus threads Coarse Granular Cast Result Dark yellow Slight turbid 6.0 1.030 Trace Negative 0-2/hpf 0-1/hpf Occasional Few Moderate Few 0-1/lpf Normal Findings Colorless to dark yellow Clear 4.6-8.0 1.006-1.030 Negative Negative 3-5/hpf 2-4/hpf No significance Rare/Few/None No significance No significance Significance Normal Due to presence of pus cells Normal Normal Normal Normal Normal Normal Normal Normal Normal

II. Hematology (April 30 2007) Blood Type: “O” Rh Positive Exam Hemoglobin Result 100g/L Normal Values Male: 135-170g/L Female: 120-160g/L Male: 0.40-0.54 Female: 0.36-0.47 Significance Decreased in hemodilution(fluid overload), anemia, recent hemorrhage Decreased in hemodilution, anemia, and acute massive blood

Hematocrit

0.32

loss. Erythrocytes Leukocytes Granulocytes 4.15x10 /L 7.60x109/L 0.78%
12

Male:4.6-6.2x10 /L Female:4.25.4x1012/L 4.5-10.0x109/L 0.500-0.750%

12

Normal Normal Increased in inflammatory disease, tissue necrosis, anemia, allergic reactions. Decreased in AIDS, corticosteroids, immunosuppressive drugs. Decreased in drug therapy and prednisone. Decreased in Microcytic anemia, iron deficiency anemia, hypochromic anemia, thalassemia, lead poisoning. Decreased in Microcytic anemia Decreased in Microcytic anemia, iron deficiency anemia, hypochromic anemia, thalassemia. Normal

Lymphocytes

0.16%

0.200-0.350%

Monocytes MCV

0.06% 76 fl

0.20-0.060% 80-96 fl

MCH MCHC

24.10 pg 315

27-31 pg 320-360

Platelet Count

347x109/L

150-450x109/L

I. PATIENTS PROFILE Name: Kimuel Carit Yobia Case No: 337033 Age: 5 months old Sex: Male Address: Tunga, Leyte Religion: Roman Catholic Nationality: Filipino Birthday: November 11, 2006 Birthplace: Tunga, Leyte Date of Admission: May 10, 2007 Time: 7:15 AM Father: Abraham Yobia Occupation: Farmer Mother: Rogenia Yobia Occupation: Housewife Attending Consultant: Dr. Aspirin Chief Complaint: Mother verbalized “Naguro-uro hiya ngan nagsuka hin makadamu.” Diagnosis: Inguinal Hernia II. History Present Illness The patient was referred from Carigara Hospital. Four days before his admission to Carigara Hospital, he experienced diarrhea and vomiting occurring 2-3x a day. The onset of the symptoms was sudden. The patient was eating before the symptoms started. This was also associated with low-grade fever and mild cough. If the patient eats, it triggers the occurrence of the symptoms. 1 day PTA, the patient had onset of abdominal enlargement and was associated with tenderness. Still there was diarrhea and vomiting 2-3 x a day and low-grade fever. III. Past History • The patient had experienced chicken pox last month.. • The patient had been vaccinated with BCG, Hepa and anti-Measles. • The patient is not allergic to any food, animals and plants but he is allergic to some drugs. • The patient had not experienced any accidents and injuries. • This is the first time the patient was hospitalized. IV. Family History

Both the father and the mother of the patent are apparently well with no family history of asthma, DM, hypertension, and cancer. They also have no allergies to any food, drug and animals. V. Psychosocial History The patient was born to a G4P4, 41 years old mother who had completed his prenatal check up. The patient was delivered thru NSVD at their home in Tunga, Leyte with the help of the traditional birth attendant. According to the mother, he was exclusively breastfed for the first 3 months and at the 4th month, the mother started bottlefeeding, specifically BONA, about 3-4 bottles a day. REVIEW OF SYSTEMS General: Weight loss, fever, fatigue Skin: Red rashes on the inguinal area. Head: No headache, injury or tenderness. Eyes: No excessive tearing or no discharges. Ears: No discharges, no pain Nose: No sneezing, epistaxis or no change in sense of smell Throat: No bleeding gums, no lesions Abdomen: Enlarged with tenderness, Gobular Respiratory: Mild cough, dyspnea Cardiovascular: Dyspnea and mild cough Gastrointestinal: Vomiting and diarrhea Genitourinary: No hematuria or polyuria Musculoskeletal: No stiffness or limitation of movement.

DIAGNOSTIC EXAMS I. Ultrasound Report (May 11, 2007) Findings: Chest APL and FPU Slightly distended abdomen, gas-filled loops of bowel are noted without differential fluid levels. Bowel wall is not thickened. Visceral margins are intact. No unsual intraabdominal calcifications are seen. The liver shadow appears not enlarged. There is no evidence of portal gas air. No sub diaphragmatic air collection is appreciated. Air is present in the rectum. Impressions: Ileus pattern. No evidence of pneumoperitoneum. Absent air in the portal tract. Incidental note of hilar lymphadenopathy. II. Abdominal Ultrasound (May 11, 2007) Findings: The liver is not enlarged, homogenous parenchymal, echogenecity and no focal mass is noted. The intra-hepatic bile ducts are not obstructed. Vessels are intact. CBD measures 1.7mm (Normal is up to 6.6mm). Gallbladder measures 3.6x1.1cm without stones nor sludge. Wall is not thickened, less than 3.0mm. There is no pericholecystic fluid collection. The pancreas appears unremarkable without mass. A-P diameter of the pancreatic head is 1.0cm, the body is 0.6cm and tail is 0.5cm. Pancreatic duct is not dilated. The spleen appears not enlarged 5.5cm in length. Normal excursion of the diaphragm is observed. The right kidney measure 6.1x3.1x2.1cm (CT 0.6cm), while the left kidney measures 6.0x2.9x2.3cm (CT 0.7cm). No mass. Ectasia nor stone is noted. Well- differentiated corticomedullary junction. Ureters are not obstructed. Adequately filled urinary bladder without mass or stone is seen. Wall is not thickened. No paravesical mass is noted. Impression: Normal liver, gallbladder, pancreas, spleen and non-obstructed biliary tree. Normal kidneys and urinary bladder. Increased bowel air which limits the sensivity of the exam for mass. No evidence of intra-peritoneal fluid. III. Ultrasound Report (May 13, 2007) Findings: Chest xray APL view

Chest films show no demonstrable lung parenchymal infiltrates. Trachea at midline. No atelectatic densities noted. Cardiac silhouette is not enlarged with normal shape and orientation. Intact both hemidiaphragms with sharp and clear sulci. The visualized soft tissues and osseous structures appear normal. Impression: Normal radiographic chest findings. IV. Urinalysis (May 10, 2007) Exam Color Transparency pH Specific gravity Albumin Sugar Pus cells Red blood cells Epithelial cells Bacteria A.urates Mucus threads Cast: CGC Result Yellow Slight Turbid 6.0 1.015 Trace Negative 0-2/hpf 0-2/hpf Some Few Some Few 1-2/hpf Normal Findings Colorless to dark yellow Clear 4.6-8.0 1.006-1.030 Negative Negative 3-5/hpf 2-4/hpf No significance None/Rare/Few No significance No significance Significance Normal Due to presence of pus cells Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal

V. Clinical Chemistry (April 26, 2007) Exam Sodium Result 132.3mmol/l Normal Values 135-148mmol/L Significance Decreased in alkali deficit, Addison’s disease and Myxedema. Normal Normal

Potassium Chloride

4.13mmol/L 104.5mmol/L

3.5-5.3mmol/L 98-107mmol/L

VI. Hematology (May 10, 2007) Exam Hemoglobin Result 101g/L Normal Values Male: 135-170g/L Female: 120-160g/L Significance Decreased in hemodilution(fluid overload), anemia, recent hemorrhage Decreased in hemodilution, anemia, and acute massive blood loss. Decreased in anemia, fluid overload, recent hemorrhage, leukemia. Decreased by bone marrow depression

Hematocrit

0.27

Male: 0.40-0.54 Female: 0.36-0.47 Male:4.6-6.2x1012/L Female:4.2-5.4x1012/L 4.5-10.0x109/L

Erythrocytes

3.62x1012/L

Leukocytes Segmenter

3.2x109/L 0.38

Lymphocytes

0.53%

0.200-0.350%

Monocytes MCV

0.06% 75 fl

0.20-0.060% 80-96 fl

MCH MCHC Platelet

28 pg 375 35x109/L

27-31 pg 320-360 150-450x109/L

Eosinophils

0.03%

1.4%

Clotting time

2mins and 35 seconds

7-120 seconds

Increased in infectious mononucleosis, chronic bacterial infections, tuberculosis, pertussis, lymphocytic leukemia. Normal Decreased in Microcytic anemia, IDA, hypochromic anemia, thalasssemia and lead poisoning. Normal Increased in spherocytosis. Decreased in prolonged bleeding time, and impaired clot retraction. Decreases in Stress response and cushing syndrome. Increased in severe coagulation problems and therapeutic administration of heparin.

Bleeding time

45 seconds

3-8 mins

VII. Hematology (May 13, 2007) Exam Hematocrit Result 0.26 Normal Values Male: 0.40-0.54 Significance Decreased in hemodilution, anemia, and acute massive blood loss. Normal Increased in infectious mononucleosis, chronic bacterial infections, tuberculosis, pertussis, lymphocytic leukemia. Decreases in Stress response and cushing syndrome.

WBC Segmenter Lymphocyte

6.40x109/L 0.61 0.36

4.5-10.0x109/L 0.200-0.350%

Eosinophils

0.03

1.4%

VIII. Hematology (May10,2007)

Exam

Result

Normal Values

Significance

Platelet

420x109/L

150-450x109/L

Normal

IX. Fecalysis (May 10,2007) Exam Color Consistency Ova or parasite Result Brown Soft None found Normal Values Significance

I.

Patient’s Profile Name: Purog, Ramil Apurillo Age: 33 y.o Sex: Male Address: Blk 9, Lot 31, Ilang-ilang St. V&G Tac. City Religion: Catholic Occupation: Teacher Date of birth: 04-18-74 Birthplace: Cebu city Mother: Fe April Purog Father: Jose Purog Date Admission: 06-16-07 Time of Admission: 10:59 PM Chief coplaint: LBM Physician: Dr. C. Baligod

II.

History >Morning prior to admission, the patient experienced severe abdominal pain on the umbilical and hypogastric region, he had more than 3 episodes of LBM and passed out watery, pus bloody and non-mucoid stool, scanty in amount associated with scarring abdominal pain. Other symptoms he experienced were numbness, cold clammy, and diaphoresis. No vomiting was noted. When asked about what may have caused the illness, patient stated that he ate food which he bought and mixed it with some vegetables which probably precipitated his condition. Medications taken during the onset of the disease were metronidazole, ofloxacin, hydrite and vitamins, however these medications did not relieved the condition of the patient. His LBM persisted for about 9 episodes which prompted consult and admission. III. Past History: >The patient has had complete immunizations when he was still a child. >Patients had many hospitalizations a few of them which he can still remember are back when he was in high school when he was bitten by a dog, another was when he was operated because of abscess on his lower head, and the most recent was last September 6, 2006 because of amoebiasis. >Patient did not experienced any serious accidents that lead to fractures and major injuries, though he claimed that he had a very minor accident when he was playing with his bicycle and accidentally fell. >Patient has allergies in foods with MSG, especially junk foods and “dagmay”. He said whenever he eats these foods he would develop a lesion which heals poorly. >Patient claimed that he had a history of asthma when he was a child, and a pulmonary infection when he aged 23 and the patient said that the cause probably was because of chalk dust that irritated his lungs. >He did not had any blood transfusions in the past. IV. Lifestyle: >The patient experienced smoking back when he was in his high school years but claimed that he only tried few times only because of peer pressure but did not continue on this vice because he knew that it would be bad for his health. The patient at present is an occasional alcoholic beverage drinker but he revealed that when he was in his 4th year high school he drank alcohol almost weekly with his friends and it was only during 1st yr college that he stopped drinking too much. >Patient is a vegetarian, he takes supplements such as multivitamins and vitamin C (Cecon); he is able to consume 8 glasses of water per day and drinks juice

every meal. He has good appetite but he complained of experiencing nausea last night. Today the patient had 4 bowel movements and passed out a slightly formed pea sized stool, “mga 25 mg” as stated by the patient. With regards to his urinary elimination, the patient voided 10 times this day with an amount of more than 1L as stated by the patient. Patient has no difficulty in urinating and defecating. >The patient claimed that he does exercise every morning and the usual types of exercises he performs are the non-strenuous ones such as jogging and swimming. During his spare time he keeps himself busy by doing some leisure activities such as going to the beach, playing basketball and gardening (planting vegetables). >With regards to patient’s self care, at present the patient stated that he needs assistance in going to the bathroom and in dressing, however in eating he is able to feed himself. Patient is mobile and ambulatory. >With regards to the patient’s sleep pattern, he said that he has no sleep onset problems though sometimes he sleeps late, at present he usually has early awakenings because of the need to go to the bathroom to urinate. He also stated that he isn’t able to sleep well because he is not that comfortable with his room. V. Family History: >The patient has a family history of hypertension specifically on his paternal side. But he does not have any family history of DM, heart diseases, arthritis, epilepsy, cancer and psychosis. VI. Social Data >The patient is single and currently lives with his parents at V&G subdivision. He works as a high school economics teacher. >In cases of problems, it is his family who helps him a lot and supports him emotionally. He claims that he has many sets of friends and he is able to get along well with others. >Financially, he is able to support himself and able to provide his own needs with his own income. >He is a religious person, and values his spiritual faith a lot. PHYSICAL EXAMINATION: A. General Health: patient is a 33 y.o male adult. He is cooperative, easy to talk with, and frequently smiles. He has a good posture and good body built. B. Vital Signs: BP: 110/80 mm Hg HR: 76 bpm RR: 20 cpm Temp: 36°C C. Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass, absence of nodules. D. Hair: Inspection: Evenly distributed, scalp has no infection or infestation; Palpation: moderately thick, resilient hair E. Nails: Inspection: Convex curvature, capillary bed is pale-light pink in color; Palpation: smooth texture, slight delay in return of capillary refill (about 5 seconds; normal is less than 4 seconds) F. Skin: Inspection: light brown in color, no presence of edema, there is some scars on patient’s feet as a result of the lesions he got from his previous allergic reaction; Palpation: skin is moderately warm to touch, has good skin turgor. G. Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no discharge and no discoloration, and sclera appears white and anicteric, pupils are equally round and reactive to light and accommodation, no visual disturbances; Palpation: light pink conjunctiva, no periorbital edema, no tenderness over lacrimal gland.. H. Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, able to hear with normal voice tones; Palpation: auricles are mobile, firm and not tender I. Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions

J. Mouth: Inspection: uniform pink in color, able to purse lips, good set of teeth, pinkish gums, no dentures, tongue moves freely; Palpation: soft, moist and smooth texture K. Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible; Palpation: no palpable lymph nodes L. Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact, symmetric chest expansion, no use of accessory muscles, no retractions, quiet, effortless respiration; Palpation: no tenderness and no masses, Auscultation: no wheeze or crackles M. Cardiovascular: Inspection: precordium no abnormal pulsations; Palpation: palpable radial pulse; Auscultation: no abnormal heart sound, no murmurs N. Abdomen: Inspection: flat and rounded, no evidence of enlargement of liver; Palpation: soft, slight tenderness O. Musculoskeletal: Inspection: no contractures, no tremors, with slight weakness of muscles of the body; Palpation: no tenderness or swelling, with good handgrip, P. Mental Status: Oriented to time, place and person, alert and responsive, with intact memory REVIEW OF SYSTEMS: A. B. C. D. E. F. G. H. I. J. K. L. General Health: No weight loss, no fever and chills, not diaphoretic, no colds Skin: no pruritus, no itchiness Head: no headache, no dizziness, not nauseated Eyes: no blurring of vision, no visual difficulties Ears: no ringing of ears, no tenderness Nose: no change in sense of smell, no colds, no bleeding Mouth: no bleeding gums, no difficulty in swallowing and chewing of food Respiratory: not dyspneic, not out of breath when moving, no difficulty breathing when supine Cardiovascular: no chest pain, no syncope Gastrointestinal: moderate pain on abdomen, 4 episodes of bowel movement with slightly formed stool in moderate amount Genitourinary: voided 10 times fro more than 1L in amount, no pain and discomfort during urination Musculoskeletal: slight weakness of body, still needs assistance in some of self care activities such as toileting and dressing.

I. PATIENTS PROFILE Name: Menchie Militante Miranda Case No: 51527-2007 Age: 31 years old Sex: Female Civil status: Married Address: Brgy. Cabuynan Tanauan, Leyte Occupation: Housewife Religion: Roman Catholic Nationality: Filipino Birthday: October 22, 1975 Birthplace: Tanauan, Leyte Date of Admission: June 18, 2007 Time: 3:26 AM Father: Mauricio Militante Age: 50+ Occupation: Fisherman Mother: Anacorita Militante Age:50+ Occupation: Dressmaker Husband: Marcello Miranda Age: 35 Occupation: Junior salesman Attending Consultant: Dr. M. Tan and Dr. J. Borrinaga Chief Complaint: “Nalinop ako, nagsirom an ak pangitaan tas diri ak nakahinga.” Admitting diagnosis: Syncope and Vertigo II. History Present Illness Few hours PTA, while the patient was sleeping, she suddenly woke up to read the text message on her cellphone. When she was about to reach her cellphone, she suddenly experienced syncope episodes. This was followed by vertigo and dyspnea. So these symptoms lead the patient to the hospital. According to the patient, the symptoms she felt was just sudden last night. Although she was having headaches for about a week now. The headache occurs only when she is so tired or stressed. She only feels pain in her head, in which according to

her, the intensity is about 7 in a scale of 1-10. The symptoms that she is feeling occur only when she is very tired and when she is reading. Before, when she has headache, she just relax and sometimes drink Biogesic. III. Past History • The patient had experienced measles, chicken pox and mumps during her childhood years. • The patient has complete 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 has been hospitalized many times before, but unable to recall exactly when it happened. Among the reasons for hospitalizations are due to fever, stomachache and when she gives birth. IV. Family History According to the patient, her family has a history of heart disease, diabetes mellitus, hypertension and arthritis. V. Lifestyle • The patient drinks alcohol specifically Tube about 7-8 glasses occasionally. • She eats three meals a day and does not like to take snacks. • She is the one who cooks for her family. • Her typical diet comprises rice, fish and vegetables. She seldom eats meat, or sometimes eats meat only during Sundays or during occasions. • The patient usually sleeps at around 9PM and wakes up at 2AM. She wakes up early because she needs to prepare for her kids. But in the afternoon, she usually takes a nap for an hour. Before, she had insomnia. • She dos not have any exercise regimen and doing the household work is her form of exercise. VI. Social Data • In times of stress, her family is very much supportive of her, not only financially but especially emotionally. • The patient is a college graduate. She is already a licensed teacher but was unable to land on a job. So now, she is a housewife. • Her family lives in Brhy. Cabuynan Tanauan Leyte. They have a one room house made of concrete and wood. Their water source is NAWASA and their electrical source is DORELCO. They have one toilet.

REVIEW OF SYSTEMS General: No weight loss, no fever and chills. Skin: No rashes, no bruising, no itching and no change in skin color. Head: Headache, and dizziness. Eyes: Blurring of vision, changes in visual field, no pain and no discharges. Ears: No discharges, no pain Nose: No sneezing, no allergies, no epistaxis. Throat: No bleeding gums, no lesions Respiratory: No cough, no chest pain, no hemoptysis, dyspnea. Cardiovascular: Dyspnea, no edema or no chest pain. Gastrointestinal: No dysphagia, no heartburn, no ulcer, no indigestion. Genitourinary: No dysuria, no hematuria, no nocturia. Endocrine: Fatigue, no weight change, no polyphagia, polyuria and polydipsia. Musculoskeletal: No stiffness or limitation of movement. PHYSICAL EXAMINATION General: The patient is an adult, 31 years old female. She is not assuming any unsual position. She is also cooperative, pleasant and easy to talk with.

Vital signs: BP: 180/100

RR: 24 cpm

HR: 88bpm

Integument: Inspection: Skin color ranges form light to deep brown; generally uniform skin color except in areas exposed to the sun; no edema, no lesions or abrasions. Palpation: Skin warm to touch, and with good capillary refill. Hair: Inspection: Evenly distributed hair; thin hair; no infection or infestation. Nails: Inspection: Convex curvature, capillary bed is light pink in color, intact epidermis. Palpation: Smooth texture and good capillary refill. Eyes: Inspection: Eyebrows symmetrically aligned with equal movement, eyelids have no discharge and no discoloration, and sclera appears white and anicteric, pupils are equally round and reactive to light and accommodation, no visual disturbances. Palpation: Light pink conjunctiva, no periorbital edema, no tenderness over lacrimal gland. Ears: Inspection: Symmetrical, auricle aligned with outer canthus of the eye, able to hear with normal voice tones. Palpation: Auricles are mobile, firm and not tender Nose: Inspection: No discharge or flaring. Palpation: Not tender, no lesions Mouth: Inspection: Uniform pink in color, able to purse lips, good set of teeth, pinkish gums, no dentures, and tongue moves freely. Palpation: Soft, moist and smooth texture. Neck: Inspection: Able to flex hyperextend and rotate, thyroid gland not visible. Palpation: No palpable lymph nodes Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact, symmetric chest expansion, no use of accessory muscles, no retractions, and quiet, effortless respiration. Palpation: No tenderness and no masses: Auscultation: No wheeze or crackles Cardiovascular: Inspection: Precordium no abnormal pulsations. Palpation: Palpable radial pulse. Auscultation: No abnormal heart sound, no murmurs Abdomen: Inspection: Flat and rounded, no evidence of enlargement of liver. Auscultation: Audible bowel sounds Palpation: No tenderness, relaxed abdomen with smooth consistent tension. Musculoskeletal: Inspection: No contractures, no tremors. Palpation: No tenderness or swelling, with good handgrip, Mental Status: Oriented to time, place and person, alert and responsive, with intact memory

DIAGNOSTIC EXAMS I. Ultrasound Report (June 18, 2007) Findings: Chest x-ray PA view • Lung fields are clear. • Heart shadow is not enlarged. • Trachea is in the midline. • Hemidiaphragms and sulci are intact. • Other structures are unremarkable. Impressions: Essentially unremarkable cardio pulmonary findings. II. Urinalysis (June 18, 2007) Exam Color Transparency pH Specific gravity Albumin Sugar Pus cells Red blood cells Epithelial cells Bacteria A.urates Mucus threads Ketones Result Light yellow Slightly turbid 6.0 1.005 Negative Negative 0-2/hpf 0-2/hpf Occasional Few Rare rare Negative Normal Findings Colorless to dark yellow Clear 4.6-8.0 1.006-1.030 Negative Negative 0-2/hpf 0-2/hpf None Negative Normal Significance Normal Normal Normal Normal Normal Normal Normal Normal

III. Clinical Chemistry (April 26, 2007) Exam Sodium Potassium Cal-D Uric-E Result 139.9mmol/l 4.77mmol/L 2.21mmol/L 0.38mmol/L Normal Values 135-148mmol/L 3.5-5.3mmol/L 2.15-2.57mmol/L 0.17-035mmol/L Significance Normal Normal Normal Increased in gouty arthritis, acute leukemia, lymphomas treated by chemotherapy and toxemia of pregnancy. Decreased in hyperinsulinism, hypothyroidism, late hyperpituitarism, pernicious vomiting, addison’s diseas and extensive hepatic damage. Normal Increased

Gluc-D

3.51mmol/L

3.90-6.40mmol/L

Chol-E Trig-E

4.3mmol/L 2.06mmol/L

3.9-6.7mmol/L 0.46-1.88mmol/L

HDL

1.78mmol/L

0.00-1.68mmol/L

Increased in folic acid deficiency, increased risk for vascular disease and homosystinuria.

LDL

1.5mmol/L

IV. Hematology (April 26, 2007) Exam Hemoglobin Result 113g/L Normal Values Male: 140-175g/L Female: 120-160g/L Male: 0.42-0.50 Female: 0.36-0.46 4.5-11.3x109/L 0.45-0.65 0.02-0.04 Significance Decreased in hemodilution(fluid overload), anemia, recent hemorrhage Decreased in hemodilution, anemia, and acute massive blood loss. Normal Normal Increased in inflammatory disease, tissue necrosis, anemia, allergic reactions. Normal Normal

Hematocrit

0.34

WBC Neutrophils Eosinophils

4.7x109/L 0.54 0.07

Lymphocytes Monocytes

0.35 0.04

0.20-0.35 0.02-0.06

I.

Patients Profile: Name: Alcantara, Consuelo Chua Age: 71 y.o Sex: F Civil Status: Married Religion: Catholic Date of Birth: 12-03-35 Birthplace: Borongan E. Samar Citizenship: Filipino Address: Brgy. Mabini, Laping Northern Samar Date of admission: 06-19-07 Time of admission: 3:39 PM Physician: Del Pilar, Jose Carlo, MD Chief Complaint: Cough Diagnosis: CAP (Community Acquired Pneumonia) History of Present Illness >The condition of the patient started 2 weeks prior to admission where she experienced chest pain and productive cough with thick whitish to yellow sputum, not associated with dyspnea and fever. When patient was asked about what caused the occurrence of her condition, she stated that this condition of hers has been a recurrent one; she even had her previous hospitalization with the same chief complaint. Patient tried to relieve the symptoms by taking an antibiotic; however this measure did not totally alleviate the condition. Morning prior to admission the symptoms persisted thus prompted consult and admission. Past History >The patient had her immunizations during childhood but can’t recall if she had completed them for according to the patient “diri pa man sugad kauso an mga bakuna hadto, diri parehas yana”. With regards to the patient’s previous hospitalizations, she claimed that just last May 2007 she was admitted at EVRMC for the same chief complaint. Other hospitalizations of the patient she can’t recall anymore. The patient did not suffer any

II.

III.

accidental injuries and fractures in the past. Other illnesses that the patient currently has are asthma, arthritis and heart problem (Heart failure), in association with these illnesses she stated that she takes her maintenance medications such as Diclofenac for her arthritis and take this only when her joints become inflamed and painful and Captopril for her heart problem. She has a known history of hypertension but no history of DM, has no known allergies to any food and drugs, and has not had any blood transfusions in the past. According to the patient her asthma is the main cause of her present condition and this was aggravated because of her heart problem. IV. Lifestyle >The patient is a non-smoker and non-alcoholic beverage drinker. She no difficulty in eating and swallowing but she stated that at present she isn’t able to eat as much food as she wants for she has some diet restrictions. According to her she doesn’t eat foods that are “makatol”, those high in fat, and vegetables with seeds. She does not take any supplements. With regards to her fluid intake, she claimed that she drinks a lot of water. In fact she is even able to consume more or less 20 glass of water per day, though at present because of her condition she isn’t able to drink that much because she was told that she must be able to consume at least only about 1L of water a day. Today the patient has no bowel movement, and according to her that this is only normal because her normal BM pattern is every 2 or 3 days interval. With regards to her urinary elimination, at present she voided twice this morning and once this afternoon with no difficulty or discomforts. The patient stated that she don’t usually perform exercise, whenever she has nothing else to do, during her leisure times she just usually sit down, do nothing and sometimes sleeps, though oftentimes she also walks around their house. With regards to her sleep pattern, according to her she has no sleep onset problems, but at present because of her productive cough and difficulty of breathing she isn’t able to sleep well a night. In performing self care activities, she said that she still needs assistance in lying down and getting up from bed, in going to the bathroom and in dressing, however in eating and in standing from sitting position, she is able to do it by herself. Family history >The patient has a family history of hypertension. But she does not have any family history of DM, heart diseases, arthritis, epilepsy, cancer and psychosis. Social Data >The patient is married to Vivencio Alcantara and has 10 children. She is a plain housewife while her husband was a formerly a farmer before but at present he also has no work, he stopped because he said he is already old and weak. She and her husband live with their daughter Eufemia Alcantara together with her own family. Financially, they just ask for help and support from their daughter. In case of stressful situations and problems, she said she usually just prays and ask for a divine intervention, and sometimes talk to her husband and seek support.

V.

VI.

PHYSICAL EXAMINATION: Q. General Health: Patient is a 71 y.o female adult, awake, cooperative, answers to questions and is easy to talk with, but appear fatigued. R. Vital Signs: BP: 100/70 mm Hg HR: 71 bpm RR: 19 cpm Temp: 36.3°C S. Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass, absence of nodules. T. Hair: Inspection: white with some strands of black hair, evenly distributed, scalp has no infection or infestation; Palpation: thick, resilient hair U. Nails: Inspection: Convex curvature, capillary bed is pale-light pink in color; Palpation: smooth texture, delay in return of capillary refill (about 5 seconds; normal= less than 4 seconds) V. Skin: Inspection: light brown in color with visible age spots, is saggy and wrinkled, with slight non-pitting edema on lower extremities (left leg). Palpation: skin is moderately warm to touch, dry, with poor senile skin turgor. W. Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no discharge and no discoloration, and sclera appears white and anicteric, pupils are equally round and reactive to light and accommodation, no visual disturbances; Palpation: light pink conjunctiva, no periorbital edema, no tenderness over lacrimal gland. X. Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, unable to hear effectively with normal voice tones; Palpation: auricles are mobile, firm and not tender Y. Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions

Z.

Mouth: Inspection: uniform light pink in color, able to purse lips, not complete set of teeth on lower teeth with brown to black discoloration of the enamel of the remaining teeth, pinkish gums, no dentures, tongue moves freely; Palpation: soft, moderately dry and smooth texture AA. Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible; Palpation: no palpable lymph nodes BB. Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact, with shallow respiration, use of accessory muscles, no retractions, with some effort in respiration, with productive cough; Palpation: with moderate chest pain and no masses, Auscultation: with crackles CC. Cardiovascular: Inspection: precordium no abnormal pulsations; Palpation: small weak radial pulse DD. Abdomen: Inspection: flabby and rounded. Palpation: soft, no evidence of enlargement of liver EE. Musculoskeletal: Inspection: no contractures, no tremors, with slight weakness of muscles of the body; Palpation: no tenderness or swelling, with good handgrip, FF. Mental Status: Oriented to time, place and person, drowsy but responsive, unable to recall some past memories, fatigued, restless at times, no difficulty in walking, able to balance. REVIEW OF SYSTEMS: M. N. O. P. Q. General Health: No weight loss, no fever and chills, not diaphoretic Skin: no pruritus, no itchiness Head: no headache, no dizziness, not nauseated Eyes: no blurring of vision, no visual difficulties, no use of eyeglasses Ears: no ringing of ears, no tenderness, with some difficulty in hearing but does not use any hearing aid. R. Nose: no change in sense of smell, no colds, no bleeding S. Mouth: no bleeding gums, no difficulty in swallowing and chewing of food T. Respiratory: has productive cough with thick, difficult to expectorate whitish sputum dyspneic, has difficulty in breathing, shortness of breath U. Cardiovascular: with chest pain, no syncope, V. Gastrointestinal: no tenderness, has no bowel movement, with good appetite, not nauseated W. Genitourinary: voided 3 times from morning to afternoon with, no pain and discomfort during urination X. Musculoskeletal: slight weakness of body, still needs assistance in some of self care activities such as toileting and dressing. Y. Neurologic: with feeling of body weakness, no paralysis of any body part, no numbness, no tremors.

LABORATORY EXAMS Date 06-1907 Lab Exam Urinalysis Result Color: yellow Transparency: Slight Turbid pH: 6.0 Specific Gravity: 1.015 Protein: (-) Sugar: (-) Pus cells: 0-2/hpf Red cells: none Epith. Cells: few Mucus threads: rare A. Urates/phosphates: few Bacteria: rare K: 4.99 mmol/L CREA-B: 132.6 umol/L TSH:0.07 Normal Value Pale yellowdeep amber Clear 5.5-6.5 1.002-1.035 Negative Negative 0-2/hpf <3/hpf Rare-few Rare-few Rare-few None 3.50-5.30 53.0-115.0 0.25-5.0 uU/mol 4.0-8.3 pmol/L 9-20 pmol/L Significance >Normal >Increased in concentration of urine >Normal >Normal >Normal >Normal >Normal >Normal >Normal >Normal >Normal >Normal >Normal >Increased in renal failure >Decreased in secondary hypothyroidism; high doses of dopamine >Normal >Normal

06-1907

Special Chemistry

FT3: 6.66 FT4: 19.16 Test: 109.6% 12.5 sec INR: 1.021 Control: 100% 13.7 sec INR: 1.16 Hgb: 106 g/L

06-1907

Prothrombin Time

9.5-12 sec 1.0

>slightly increased by deficiency of factors I, II, V, VII, and X

06-1907

Hematology

F: 120-160

Hct: 0.32 WBC: 5.7 x 10~9/L Differential Ct.: Neutrophils: 0.6 Lymphocytes: 0.28 Monocytes: 0.05 Eosinophils: 0.05 Stabs: 0.02 Result Platelet Count: 245 x 10~9/L Reticulocyte ct: 0.8% GLUC-b: 6.78 mmol/L CHON-E: 5.2 mmol/L TRIG-E: 1.07 mmol/L HDL-BM: 1.79 mmol/L LDL: 3.0mmol/L Test: 4.8%

F: 0.36-0.46 4.5-11.3 0.45-0.65 0.20-0.35 0.02-0.06 0.02-0.04 0.02-0.04 Normal Value 140-440 0.5-1.5% 3.90-6.40 3.9-6.7 0.46-1.88 0.80-1.68 4.5-6.3%

>Decreased in all anemias and excessive fluid intake, but in the case of the patient since she has heart failure, this is a way to compensate to reduce the fluid volume in the body. >Decreased in severe anemias and acute massive blood loss >Normal >Normal >Normal >Normal >Increased in allergy, parasitic disease, and subacute infections >Normal Significance >Normal >Normal >Increased in Diabetes Mellitus and Nephritis >Normal >Normal >Increased >Normal

Date 0620-07

Lab Exam Heamatology

Clinical Lab

Test HbAIC

I.

Test: Gram’s & AFB

Specimen: sputum A. Gram: Few organisms are seen consisting of gram (+) cocci in pairs of gram (-) bacilli. Few leukocytes are present B. AFB: Negative II. Test: Peripheral smear Specimen: Blood Result: The red cell are normocytic and normochromic. There are no abnormal leukocytes, the platelets are adequate.

I. PATIENTS PROFILE Name: Ernesto Abocejo Abarientos Case No: 345123 Age: 45 years old Sex: Male Civil status: Married Address: Brgy. Candaro, Dulag, Leyte Occupation: Businessman Religion: Roman Catholic Nationality: Filipino Birthday: 7/15/1965 Birthplace: Dulag, Leyte Date of Admission: July 2, 2007 Time: 10:30 AM Father: Ernesto Abarientos Sr. Mother: Reynalda Abarientos Wife: Genelyn M. Abarientos Chief Complaint: “Nagsinakit it akon likod, tas naginubo gihap ngan nakurian ak pagginhawa.” Diagnosis: Thyrotoxic Heart Disease; Cardiomegaly; AF; CHF II; CAP moderate risk. II. History Present Illness 3 months PTA, the patient experienced on and off non-productive cough. This was associated with easy fatigability and 2 pillow orthopnea. But there was no consultation done. Instead the patient just took his maintenance medication which is the Propylthiouracil 50mg 1tablet TID PO. 2 weeks PTA, the patient had productive cough with yellowish phlegm. This was associated with fever, dyspnea and 3 pillow orthopnea. Still the patient has not consulted a doctor. Last June 30, the patient started feeling back pain. First, he though it would just subside after some rest. But the back pain became severe, and then was associated with dyspnea. So, he was brought to EVRMC, hence was admitted. III. Past History • According to the patient, he had chicken pox, measles, and mumps when he was young. • The patient is not sure if his immunizations are complete. • He has no allergies with any food, drugs or other things. • Last January 1986, the patient had a car accident. • The patient has been hospitalized many times in different hospital. • Among his maintenance medications are Lanoxin, PTU, Lasix, Propanolol and captopril. IV. Family History According to the patient, his family has history of diabetes and asthma but has no history of heart diseases. V. Lifestyle • The patient is a known smoker. He usually consumes 1-2 packs a day. He is also an occasional alcoholic beverage drinker. He can drink about a grandy of beer and tuba. • He loves to eat meat, vegetables and hard types of foods. • He usually is the one who cooks at home. • The patient usually sleeps at around 7PM and wakes up at around 6 in the morning. Lately, he had difficulty in sleeping due to dyspnea and orthopnea. He also experiences palpitations and back pain. • The patient’s form of exercise is walking and his hobby is just singing. VI. Social Data

• • • •

In times of stress, his family is very much supportive of him, not only financially but especially emotionally. The patient is a college graduate. In fact, he is both a civil and electrical engineer. Before the patient was a contractor, then he became plant maintenance, then authorized representative and now he is a businessman. He has a meat shop in Dulag as well as piggery. The patient and his family lives in Dulag, Leyte. Their house is made of concrete, bamboo and other native material. It is a 3 bedroom house with 2 toilet rooms. Their water source is from the deep well and they also have a supply of electricity. Their house is about 150meter away from the main road and about 50meters distance from their neighbors. Aside from the piggery, they also have dogs and cats in their house.

REVIEW OF SYSTEMS: Z. General Health: Weight loss, no fever and chills, easy fatigability and diaphoresis. AA. Skin: no pruritus, no itchiness BB. Head: no headache, no dizziness, not nauseated CC. Eyes: no blurring of vision, no visual difficulties DD. Ears: no ringing of ears, no tenderness EE.Nose: no change in sense of smell, no colds, no bleeding FF. Mouth: no bleeding gums, no difficulty in swallowing and chewing of food GG. Respiratory: Dyspnea, cough, no hemoptysis and no chest pain. HH. Cardiovascular: Dyspnea. Orthopnea, palpitations, no chest pain and no tightness. II. Gastrointestinal: No ulcer, no constipation, no abdominal pain. JJ. Genitourinary: No dysuria, no nocturia and no incontinence. KK. Musculoskeletal: No limitation of movement, no muscle weakness. LL.Endocrine: Heat and cold intolerance, weight change, fatigue. PHYSICAL EXAMINATION: General Health: Patient is a 45 y.o male adult. He is cooperative, easy to talk with, and frequently smiles. He has a good posture and good body built. Vital Signs: BP: 130/80 mm Hg RR: 19 cpm Head: Inspection: normocephalic and symmetrical. Palpation: No tenderness or mass, absence of nodules. Hair: Inspection: Evenly distributed, scalp has no infection or infestation but with dandruff. Palpation: moderately thick, resilient hair Nails: Inspection: Convex curvature, capillary bed is pale-light pink in color, intact epidermis but with dirty nails. Palpation: smooth texture, slight delay in return of capillary refill (about 5 seconds; normal is less than 4 seconds) Skin: Inspection: Dark brown in color, no presence of edema, has uniform skin color. Palpation: skin is moderately warm to touch at the upper extremities but cold to touch at lower extremities. Eyes: HR: 71 bpm Temp: 37°C

Inspection: hair in the eyebrows evenly distributed, skin intact and symmetrically aligned, eyelashes equally distributed and curled slightly outward, eyelids with yellowish discoloration and closes symmetrically, PERRLA. Palpation: pale conjunctiva, no periorbital edema, no tenderness over lacrimal gland. Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, able to hear with normal voice tones. Palpation: auricles are mobile, firm and not tender Nose: Inspection: no discharge or flaring, nasal septum intact at midline. Palpation: Not tender, no lesions Mouth: Inspection: uniform non-pinkish in color, able to purse lips, dry lips, pale gums and yellowish teeth. Neck: Inspection: able to flex, hyperextend and rotate, anterior neck mass. Palpation: no palpable lymph nodes Chest and Lungs: Inspection: Breast symmetrical and equa in size, no lumps and discharges, rounded thorax. Palpation: Warm to touch Auscultation: Rales and crackles. Heart: Inspection: abnormal pulsations. Palpation: palpable radial pulse. Auscultation: abnormal heart sound. Abdomen: Inspection: flat and rounded, no evidence of enlargement of liver. Palpation: soft, slight tenderness Musculoskeletal: Inspection: no contractures, no tremors, with slight weakness of muscles of the body. Palpation: no tenderness or swelling, with good handgrip, Mental Status: Oriented to time, place and person, alert and responsive, with intact memory. LABORATORY EXAMS: I. Hematology (July 2, 2007) Exam Hemoglobin Hematocrit Neutrophils Leukocytes Result 165g/L 0.49 0.65 17.15x109/L Normal Values Male: 135-170g/L Female: 120-160g/L Male: 0.40-0.54 Female: 0.36-0.47 0.6-0.7 4.5-10.0x109/L Significance Normal Normal Normal Increased in infection, leukemia, tissue necrosis, and acute

Lymphocytes Monocytes Exam Eosinophils Test Control INR

0.31 0.03Result 0.01 seconds 14.6 12.0seconds 1.41 seconds

infectious diseases. 0.200-0.350 Normal 0.020-0.060Values Normal Normal Significance 0.01-0.04 Normal 10-13 seconds Increased 1.5-2.0 seconds Increased 2.0-3.0 seconds Decreased in MI, thrombophlebitis and pulmonary embolism.

II. Radiographic findings (July 2, 2007) Chest PA: Examination of the chest reveals enlargement of the cardiac shadow with mild distension of hilar vessels. Trachea at midline, not unusual. Impression: Cardiomegaly with mild pulmonary congestion. III. Protime (July 4, 2007) IV. Clinical Chemistry (July 4, 2007) Exam Sodium Result 129.6mmol/L Normal Values
135-155mmol/L

Significance
Decreased in vomiting, diarrhea, gastric suction, SIADH, tissue injury, low-Na diet, burns and saltwasting renal disease.

Potassium

3.37mmol/L

3.5-5.5mmol/L

Creatinine

59umol/L

53-106umol/L

Decreased in vomiting, diarrhea, DHN, malnutrition, stress, trauma, injury, gastric suction, metabolic acidosis, burns, and diabetic acidosis. Normal

II.

PATIENTS PROFILE

Name: Severa Pore Obiña Case No: 343283 Age: 66 years old Sex: Female Civil status: Married Address: Brgy. Daro, Jaro, Leyte Occupation: N/A Religion: Roman Catholic Nationality: Filipino Birthday: November 13, 1940 Birthplace: Jaro, Leyte Date of Admission: June 30, 2007 Time: 8:00 AM Father: Julian Pore Mother: Florentina Pore Husband: Sulpicio Obiña Age: 72 Occupation: Coco farmer Attending Consultant: Dr. Egos Chief Complaint: “Nagkukuri man hiya paghinga.” Stated by the significant others. Admitting diagnosis: Acute LV failure, Thyrotoxic Heart Disease II. History Present Illness Five days prior to admission, client was discharged from EVRMC with an improved condition from EVRMC diagnosed from Hyperthyroidism, Intestinal amoebiasis with dehydration. Was ordered to come back on June 29, 2007 for check-up with take home meds enumerated as follows: Metronidazole 500mg 1 ½ tab TID x 7 days, PTU 50mg 4 tab TID, Propanolol 40mg OD and Ranitidine 300mg at HS. Stayed at home at Jaro, Leyte from from June 26 to June 28 with noticeable weakness.

Two days before admission, client according to daughter was continuously vomiting and wretching during the day. Headed to Tacloban and arrived at four o’clock in the afternoon and arrived an hour later still with noticeable weakness. Stayed at her daughter’s house in Paterno still with episodes of vomiting. Poor appetite observed by significant others. Noted activities were sitting and lying on bed. Self-care activities assisted by significant others. Wretches in every change in position. Went to EVRMC the next day at six o’clock in the morning for check-up. Doctor noted improved condition except for low potassium level due to prior existing dehydration. Maintenance medications abated as ordered by doctor. Arrived at house of daughter at Paterno around 10:30 in the morning. Still weakness noted by significant others. Wretches and vomits ingested food and were restless. Given small feedings by significant others. Skin was warm to touch and flushed face noted. At one o’clock in the morning, June 30, 2007, Daughter planned to take client to said hospital as the client was experiencing sleeplessness and fatigability. “Sige iya yakan, hagoy hagoy.” Due to transportation constraints, daughter decided to take mother to hospital in the morning. Thirty minutes before the admission, client verbalized, “Gusto ko na umuli”, referring to home at Jaro, Leyte significant others noted. Weak speech, reddened eyes, capillaries evident (eye), use of accessory respiratory muscles, cyanotic lips and upper extremities, flushed face. Brought to hospital assisted by significant others by way of a tricycle at eight o’clock in the morning, hence, admission. III. Past History • 2002: Hospitalized at Bethany hospital with chief complaint of dyspnea; unable to recall diagnosis. • 2006: Hospitalized at City Hospital with chief complaint of dyspnea, still unable to recall diagnosis. • 2007: June 15, diagnosed with hyperthyroidism, intestinal amoebiasis with dehydration ordered to return for check-up (June 29, 2007) and prescribed with the following home medication: 1. Metronidazole 500mg 1 ½ tab TID x 7 days 2. PTU 50mg 4 tab TID 3. Propanolol 40mg OD 4. Ranitidine 300mg at HS. • Never had any surgical procedures or operations as recalled. • OTC drugs used includes Biogesic for fever, neozep for colds and Medicol for headache; no nutritional supplement taken. • Recalls mother telling her about having had chicken pox (date unknown), no complications and no other childhood diseases. • No immunizations; states “ Waray pa man ion hira hadto.” • No known allergies to foods, medications or any environmental elements. • Can’t recall clients injuries and accidents.

IV. Family History • Mother died from heart disease at the age of 70. • Father died from hypertension at the age of 67. • No other known family-linked health problems. • Negates any family member having had problems similar to throne of those of the client. V. Lifestyle Client is a nonsmoker; occasional alcoholic beverage drinker, 5-8 glasses of tuba. Likes to drink coffee, 3 glasses a day. Typical 24 hour diet includes food guide pyramid groups. Usually eats fish. Sleeps an average of 7 hours a day. Usually sleps at 10PM and wakes up at 6AM. Negates any sleeping difficulties. Able to perform ADL without difficulties prior to June 15 admission. VI. Social Data Lives at Barangay Daro, Jaro, Leyte with husband and with youngest child. House made of concrete with two rooms and one toilet and with modern conveniences of electricity. Secures water from deep well. House is cleaned regularly by the client. Dog stays outside. Neighborhood is usually safe. House is about 15-30 minutes away from the main road per habal-habal. A high school graduate, used to have own business until became a plain housewife.

VII. Psychologic Data Describes family as self-sufficient with children giving additional support financially. Does recognize stress until she became very nervous with SOB, trembling hands. With good family support system. VIII. Patterns of Healthcare Visits hospital when sick. Sees the dentist only when something bothers her, can’t remember last visit. No vision check since can remember.

LABORATORY EXAMINATION CLINICAL CHEMISTRY- July 3, 2007 Exam Sodium Result 118.4mmol/l Normal Values 135-155mmol/L Significance Decreased in vomiting, diarrhea, gastric suction, SIADH, tissue injury, low-Na diet, burns and saltwasting renal disease. Normal

Potassium

3.74mmol/L

3.5-5.5mmol/L

CLINICAL CHEMISTRY- June 30, 2007 Exam Sodium Result 131.4mmol/l Normal Values 135-155mmol/L Significance Decreased in vomiting, diarrhea, gastric suction, SIADH, tissue injury, low-Na diet, burns and saltwasting renal disease. Normal

Potassium

3.88mmol/L

3.5-5.5mmol/L

HEMATOLOGY- June 30, 2007 Exam Hemoglobin Hematocrit WBC Segmenter Result 120g/L 0.40 4.90x109/L 0.50 Normal Values Male: 135-170g/L Female: 120-160g/L Male: 0.40-0.54 Female: 0.36-0.47 4.5-10.0x109/L 0.6-0.7 Significance Normal Normal Normal Decreased in viral diseases, leukemias, agranulocytosis, aplastic and iron deficiency anemias. Normal Increased in allergies, parasitic diseases, cancer and phlebitis.

Lymphocytes Eosinophils

0.38 0.12

0.200-0.350 0.01-0.04

Progress Notes 7/3/07 3-11 3:00PM

 Received lying awake on bed, dyspneic and unresponsive with
an IVF of D5W 500cc- infusing well.

 With O2
inhalation at 3L/min per nasal cannula.

3:30PM PNSS 1 L     Seen and examined by Dr. Ehos with new orders. Replaced to ongoing IVF above and regulated to KVO. NGT inserted by Dr.Egos On blenderized feeding at 1,500 kcal/day in 4 divided feedings.

4:00 PM  V/S taken and recorded: BP=130/90mmhg RR= 35cpm HR= 105 bpm Temp= 38.1°C  TSB instructed and done by significant others. 6:00PM  NGT feeding done after checking its proper placement with aspiration precaution.  For repeat CBC.  For chest xray PA view. 6:10PM  PRN meds given for temp 38.1°C  Health teachings imparted: 1. Frequent turning to sides 2. Continue TSB if febrile 3. Assist to assume position of comfort.

7/4/07 3-11 3:00PM  Received awake lying on bed, dyspneic with an IVF of 0.9 NaCl 1liter at 975cc levelinfusing well.  With O2 inhalation at 3L/min per nasal cannula.  With NGT in placed.  With FBC attached to urobag in placed draining to lightyellow colored urine output.  On blenderized feeding at 1,500 kcal/day in 4 divided feedings.  Seen and examined by Dr. Egos with new orders.  Above IVF regulated to fast drip to consume 100cc then regulated at 20gtts/min.  For CVP line insertion.  V/S monitored every 1 hour. 4:00 PM  V/S taken and recorded: BP=110/70mmhg RR= 34cpm HR= 110 bpm Temp= 38.7°C 4:20PM  Suctioned secretions by clerk on duty PRN. 5:00PM

 PRN meds given for temp 38.7°C
5:10PM  CVP line insertion-hold temporarily- as ordered. 7:00PM  NGT feeding done after checking its proper placement with aspiration precaution.  Health teachings imparted: 1. Frequent turning to sides 2. Continuous TSB if febrile 3. Proper oral hygiene

REVIEW OF SYSTEMS:

Integumentary: Circumscribe patches on the face, no rashes, no lesions, no sores, no bruising. Head: Negates headache, vertigo, syncope. Eyes: Gradual change in vision, no pain, no discharges. Ears: Hears only with loud voice, no pain, no discharges, negates tinnitus. Nose and Sinuses: Negates epistaxis, obstruction, no pain, no discharge, no snoring. Mouth: No bleeding gums, no lesions, no dysphagia, and no altered taste. Neck: No stiffness, non-tender Cardiovascular: Palpitations with cold extremities, no edema, no paresthesia. Endocrine: heat intolerance, thinning hair. Respiratory: Cough, dyspnea, no hemoptysis, no pain, no wheezing. Gastrointestinal: Blenderized feeding per NGT, constipation,, epigastric pain. Urinary: No hematuria, no dysuria. Musculoskeletal: Limited movements, generalized muscle weakness, no joint swelling. Neurologic: No seizures, no paralysis. PHYSICAL EXAMINATION: Date of Examination: July 3, 2007 General Survey: Symmetrical body, no deformities, lying in bed with oxygen inhalation via nasal cannula at 3L/min with IVF of 0.9NaCl 1 L at right arm, with intact NGT, clean, neatly dressed, slurred speech, flat facial expression, restless, sweating. Vital signs: BP= 130/90mmhg HR= 105bpm
Skin: Inspection: No lesions, no ecchymosis, circumscribed irregular brown patch, near right eye, approximately 1-1.5cm, visible age spots on lower and upper extremities especially areas exposed to sun. Palpation: Warm, moist, poor skin turgor. Nails: Inspection: Onycholysis at left index feet, pale nail beds, no clubbing, trimmed fingernails. Palpation: Firm nail base, smooth capillary refill at 6seconds. Head: Inspection: Normocephalic, no lesions, shiny scalp, symmetrical facial features. Palpation: No masses, no depressions, smooth skull contour, non-tender. Hair: Inspection: Equally distributed with visible white hairs. Palpation: Fine, brittle, no infestations. Eyes: Inspection: Symmetrical, pale palpebral conjunctiva, anicteric sclerae, PERRLA, pupil dilatation=3-4mm, no proptosis, no lesions, ptosis.

RR= 35cpm Temperature= 38.1°C

Ears: Inspection: Symmetrical, auricles aligned with outer canthus of the eye, no lesions, no discharges, hears with loud voice. Palpation: Non-tender, auricles recoil when pinched. Nose: Inspection: With NGT attached at right nare, at midline, no discharges. Palpation: Non-tender sinus. Throat and Mouth: Inspection: Dark red lips, moist oral mucosa, pinkish tongue at midline, no lesions with gag reflex, with clear to yellowish sputum, reddened uvula, one lower incisor teeth only, foul breath. Neck: Inspection: Visible neck mass, symmetrical neck muscles, use of sternocleidomastoid muscle for breathing. Palpation: Palpable thyroid gland both at left and right lobe, smooth, soft, slightly enlarged but less than twice the size of a normal thyroid gland, tender non enlarged lymph nodes. Thorax and Lungs: Anterior: Inspection: Symmetrical chest walls, clavicles at same height, with effort breathing on inspiration, rib angle 45°, retracted ICS during inspiration, tachypnea=35cpm Palpation: Non-tender, symmetric chest expansion, no nodules nor mass. Percussion: (resonant) Auscultation: Bronchovesicular breath sounds. Posterior: Inspection: Scapula at same height bilaterally, spine at midline. Palpation: Non tender, no nodules, no mass. Percussion: (resonant) Auscultation: Bronchovesicular breath sounds. Heart: Inspection: Not observable apical pulse. Palpation: No thrilss, no heaves, PMI at 5th ICS MCL Percussion: Dullness over heart. Auscultation: Irregular heart rhythm, murmur at PMI, tachycardia=105bpm Abdomen: Inspection: Symmetrical bilaterally with uniform color and pigmentation. Auscultation: Bowel sounds Percussion: Tymphanic over stomach, dullness over liver. Palpation: Non tender, non palpable spleen and kidney, non enlarged liver. Extremities: Upper • with good sensation • Palpable radical and brachial pulses • With reflexes Lower • With good sensation • Palpable popliteal, posterior tibial, dorsalis pedis pulse. • Negative babinski reflex Muscle strength:

Cardiovascular System: Arterial pulses: Rate: Rhythm: Irregular Amplitude: Scale +4

Neurologic system: Confused, follows command at times, flat facial expression Glasgow Coma Scale: Level of Consciousness Eye opening= 3 Motor response= 4 Verbal response= 4 _______ 11/15 Interpretation: Stuporous Functional level Classification: 3= requires the use of equipment or device and help from other people.

. PATIENTS PROFILE Name: Mrs. O Case No: 343283 Age: 66 years old Sex: Female Civil status: Married Address: Brgy. Daro, Jaro, Leyte Occupation: N/A Religion: Roman Catholic Nationality: Filipino Birthday: November 13, 1940 Birthplace: Jaro, Leyte Date of Admission: June 30, 2007 Time: 8:00 AM Husband: Mr. O Age: 72 Occupation: Coco farmer Attending Consultant: Dr. Egos Chief Complaint: “Nagkukuri man hiya paghinga.” Stated by the significant others. Admitting diagnosis: Acute LV failure, Thyrotoxic Heart Disease II. History Present Illness Five days prior to admission, client was discharged from EVRMC with an improved condition from EVRMC diagnosed from Hyperthyroidism, Intestinal amoebiasis with dehydration. Was ordered to come back on June 29, 2007 for check-up with take home meds enumerated as follows: Metronidazole 500mg 1 ½ tab TID x 7 days, PTU 50mg 4 tab TID, Propanolol 40mg OD and Ranitidine 300mg at HS. Stayed at home at Jaro, Leyte from from June 26 to June 28 with noticeable weakness. Two days before admission, client according to daughter was continuously vomiting and wretching during the day. Headed to Tacloban and arrived at four o’clock in the afternoon and arrived an hour later still with noticeable weakness. Stayed at her daughter’s house in Paterno still with episodes of vomiting. Poor appetite observed by significant others. Noted activities were sitting and lying on bed. Self-care activities assisted by significant others. Wretches in every change in position. Went to EVRMC the next day at six o’clock in the morning for checkup. Doctor noted improved condition except for low potassium level due to prior existing dehydration. Maintenance medications abated as ordered by doctor. Arrived at house of daughter at Paterno around 10:30 in the morning. Still weakness noted by significant others. Wretches and vomits ingested food and were restless. Given small feedings by significant others. Skin was warm to touch and flushed face noted. At one o’clock in the morning, June 30, 2007, Daughter planned to take client to said hospital as the client was experiencing sleeplessness and fatigability. “Sige iya yakan, hagoy hagoy.” Due to transportation constraints, daughter decided to take mother to hospital in the morning. Thirty minutes before the admission, client verbalized, “Gusto ko na umuli”, referring to home at Jaro, Leyte significant others noted. Weak speech, reddened eyes, capillaries evident (eye), use of accessory respiratory muscles, cyanotic lips and upper extremities, flushed face. Brought to hospital assisted by significant others by way of a tricycle at eight o’clock in the morning, hence, admission. III. Past History • 2002: Hospitalized at Bethany hospital with chief complaint of dyspnea; unable to recall diagnosis. • 2006: Hospitalized at City Hospital with chief complaint of dyspnea, still unable to recall diagnosis. • 2007: June 15, diagnosed with hyperthyroidism, intestinal amoebiasis with dehydration ordered to return for check-up (June 29, 2007) and prescribed with the following home medication: 1. Metronidazole 500mg 1 ½ tab TID x 7 days 2. PTU 50mg 4 tab TID 3. Propanolol 40mg OD 4. Ranitidine 300mg at HS. • Never had any surgical procedures or operations as recalled. • OTC drugs used includes Biogesic for fever, neozep for colds and Medicol for headache; no nutritional supplement taken.

• • • •

Recalls mother telling her about having had chicken pox (date unknown), no complications and no other childhood diseases. No immunizations; states “ Waray pa man ion hira hadto.” No known allergies to foods, medications or any environmental elements. Can’t recall client’s injuries and accidents.

IV. Family History • Mother died from heart disease at the age of 70. • Father died from hypertension at the age of 67. • No other known family-linked health problems. • Negates any family member having had problems similar to throne of those of the client. V. Lifestyle Client is a nonsmoker; occasional alcoholic beverage drinker, 5-8 glasses of tuba. Likes to drink coffee, 3 glasses a day. Typical 24 hour diet includes food guide pyramid groups. Usually eats fish. Sleeps an average of 7 hours a day. Usually sleps at 10PM and wakes up at 6AM. Negates any sleeping difficulties. Able to perform ADL without difficulties prior to June 15 admission. VI. Social Data Lives at Barangay Daro, Jaro, Leyte with husband and with youngest child. House made of concrete with two rooms and one toilet and with modern conveniences of electricity. Secures water from deep well. House is cleaned regularly by the client. Dog stays outside. Neighborhood is usually safe. House is about 15-30 minutes away from the main road per habal-habal. A high school graduate, used to have own business until became a plain housewife. VII. Psychologic Data Describes family as self-sufficient with children giving additional support financially. Does recognize stress until she became very nervous with SOB, trembling hands. With good family support system. VIII. Patterns of Healthcare Visits hospital when sick. Sees the dentist only when something bothers her, can’t remember last visit. No vision check since can remember.

LABORATORY EXAMINATION July 7, 2007 URINALYSIS

Exam Color Transparency pH Specific gravity Albumin Sugar Pus cells Red blood cells Epithelial cells Bacteria A.urates Mucus threads

Result yellow Slight turbid 5.0 1.010 POSITIVE Negative 4-6/hpf 18-20/hpf rare Few few Some

Normal Findings Colorless to dark yellow Clear 4.6-8.0 1.006-1.030 Negative Negative 3-5/hpf 2-4/hpf No significance Rare/Few/None No significance No significance

July 5,2007 MICROSCOPY RESULT Specimen: Sputum Exam done: Gram Stain >25 Pus cells Epithelial cells Result: Gram (+) cocci in pairs July 7, 2007 CLINICAL CHEMISTRY

<25 X X

Test Glucose (FBS) BUN

Normal values 4.20-4.4 mmol/l 2.5-6.5mmol/L

Result 4.74 4.30

July 6, 2007 CLINICAL CHEMISTRY

Test Creatinine

Normal values 44-9-80umol/L

Result 57.1

CLINICAL CHEMISTRY

Clinical chemistry: Na K

Normal values 135-155mmol/L 3.5-5.5 mmol/L

7-5-07 128.5 3.74

7-3-07 118.4 3.74

CLINICAL CHEMISTRY- July 3, 2007 Exam Sodium Result 118.4mmol/l Normal Values 135-155mmol/L Significance Decreased in vomiting, diarrhea, gastric suction, SIADH, tissue injury, low-Na diet, burns and saltwasting renal disease. Normal

Potassium

3.74mmol/L

3.5-5.5mmol/L

CLINICAL CHEMISTRY- June 30, 2007 Exam Sodium Result 131.4mmol/l Normal Values 135-155mmol/L Significance Decreased in vomiting, diarrhea, gastric suction, SIADH, tissue injury, low-Na diet, burns and saltwasting renal disease. Normal

Potassium

3.88mmol/L

3.5-5.5mmol/L

HEMATOLOGY- June 30, 2007 Exam Hemoglobin Hematocrit WBC Segmenter Result 120g/L 0.40 4.90x109/L 0.50 Normal Values Male: 135-170g/L Female: 120-160g/L Male: 0.40-0.54 Female: 0.36-0.47 4.5-10.0x109/L 0.6-0.7 Significance Normal Normal Normal Decreased in viral diseases, leukemias, agranulocytosis, aplastic and iron deficiency anemias. Normal Increased in allergies, parasitic diseases, cancer and phlebitis.

Lymphocytes Eosinophils

0.38 0.12

0.200-0.350 0.01-0.04

CHEST X-RAY 6-15-07 Findings: chest film shows hyperlucent lung fields with mild widening of the intercostal spaces and low lying hemidiaphragms with blunted sulci. Heart is narrowed. Calcified aortic arch. Trachea at midline. Visualized soft tissues and osseous structures shows no identifiable abnormalities. Impression: emphysematous changes Atheromatius aorta T3-T4-TSH test T4 TSH Normal values 60-120 nmol/L 0.25-5nIU/L Result 255.10 Less than 0.05

Urinalysis- 6- 15 – 07 Color- yellow Transparency -slightly turbid pH-5 Specific gravity1.025 Pus cells-3-7hpf RBC-0-2hpf Epithelial cellsmoderate Bacteria- some A. urates- some Mucus thread -rare Cast-CGC- 2-4/hpf TGC-1-3/hpf Hyaline cast-02/lpg

Urinalysis- 6- 21 – 07 Color- light yellow Transparency -slightly turbid pH-5 Specific gravity-1.005 Pus cells-0-2 hpf RBC-0-1hpf Epithelial cells- some Bacteria-few A. urates- some Mucus thread -rare

Hematology 6- 21 – 07 Hgb-137 Hct- .31 WBC-7.35 x 10 9/L Segmenter-0.62 Lymphocyte-0.23 Eosinophils-0.15

6-16-07

.33g/L 6.20x10^9/L .86 .12 .02

Clinical chemistry: Na K creatinine

Normal values 135-155mmol/L 3.5-5.5 mmol/L 44-88umol/L

6-15-07 132.4 3.24 93.0

6-19-07 135.2 3.12

Fecalysis 6-15-07 Color- light brown Microscopic: RBC- 12-16/hpf Pus-2-3/hpf Others-(+) for E. histolytica cyst

Consistency –watery Ova: no parasitic ova seen

ECG 6-15-07 Rate : 150cpm =180º
PR interval=0.12sec QRS Complex Remarks : Sinus tachycardia normal axis; no ischemic or hypermorhic pattern

rhythm :sinus
T waves-upright ST segment-is

Progress Notes 7/3/07 3-11

3:00PM

 Received lying awake on bed, dyspneic and unresponsive with
an IVF of D5W 500cc- infusing well.  With O2 inhalation at 3L/min per nasal cannula.

3:30PM PNSS 1 L     Seen and examined by Dr. Ehos with new orders. Replaced to ongoing IVF above and regulated to KVO. NGT inserted by Dr.Egos On blenderized feeding at 1,500 kcal/day in 4 divided feedings.

4:00 PM  V/S taken and recorded: BP=130/90mmhg RR= 35cpm HR= 105 bpm Temp= 38.1°C  TSB instructed and done by significant others. 6:00PM  NGT feeding done after checking its proper placement with aspiration precaution.  For repeat CBC.  For chest xray PA view. 6:10PM  PRN meds given for temp 38.1°C  Health teachings imparted: 1. Frequent turning to sides 2. Continue TSB if febrile 3. Assist to assume position of comfort.

7/4/07 3-11 3:00PM  Received awake lying on bed, dyspneic with an IVF of 0.9 NaCl 1liter at 975cc level-infusing well.  With O2 inhalation at 3L/min per nasal cannula.  With NGT in placed.  With FBC attached to urobag in placed draining to lightyellow colored urine output.  On blenderized feeding at 1,500 kcal/day in 4 divided feedings.  Seen and examined by Dr. Egos with new orders.  Above IVF regulated to fast drip to consume 100cc then regulated at 20gtts/min.  For CVP line insertion.  V/S monitored every 1 hour. 4:00 PM  V/S taken and recorded: BP=110/70mmhg RR= 34cpm HR= 110 bpm Temp= 38.7°C 4:20PM  Suctioned secretions by clerk on duty PRN. 5:00PM

 PRN meds given for temp 38.7°C
5:10PM  CVP line insertion-hold temporarily- as ordered. 7:00PM  NGT feeding done after checking its proper placement with aspiration precaution.  Health teachings imparted: 1. Frequent turning to sides 2. Continuous TSB if febrile 3. Proper oral hygiene

REVIEW OF SYSTEMS Integumentary: Vitiligo all over extremities especially on areas exposed to sun, no rashes, no lesions, no sores, no bruising. Head: Negates headache, vertigo, syncope. Eyes: Gradual change in vision, no pain, no discharges. Ears: Hears only with loud voice, no pain, no discharges, negates tinnitus. Nose and Sinuses: Negates epistaxis, obstruction, no pain, no discharge, no snoring. Mouth: No bleeding gums, no lesions, no dysphagia, and no altered taste. Neck: No stiffness, non-tender Cardiovascular: Palpitations with cold extremities, no edema, no paresthesia. Endocrine: heat intolerance, thinning hair. Respiratory: Nonproductive cough, dyspnea, no hemoptysis, no pain, wheezig, crackles, subcostal and suprasternal retractions, 2-pillow orthopnea. Gastrointestinal: Blenderized feeding per NGT, constipation,, epigastric pain. Urinary: No hematuria, no dysuria. Musculoskeletal: Limited movements, generalized muscle weakness, no joint swelling. Neurologic: No seizures, no paralysis, nervousness and tremors. PHYSICAL EXAMINATION: Date of Examination: July 3, 2007 General Survey: Symmetrical body, no deformities, lying in bed with oxygen inhalation via nasal cannula at 3L/min with IVF of 0.9NaCl 1 L at right arm, with intact NGT, clean, neatly dressed, slurred speech, flat facial expression, restless, sweating, fatigue, generalized weakness. Vital signs: BP= 130/90mmhg HR= 105bpm Skin: RR= 35cpm Temperature= 38.1°C

Inspection: No lesions, no ecchymosis, vitiligo approximately 2cm at right outer canthus of eyes and all over extremities especially areas exposed to the sun. Palpation: Warm, moist, poor skin turgor. Nails: Inspection: Onycholysis at left index feet and left index finger, pale nail beds, no clubbing, trimmed fingernails. Palpation: Firm nail base, smooth capillary refill at 6seconds. Head: Inspection: Normocephalic, no lesions, shiny scalp, symmetrical facial features. Palpation: No masses, no depressions, smooth skull contour, nontender. Hair: Inspection: Equally distributed with visible white hairs. Palpation: Fine, brittle, no infestations. Eyes: Inspection: Symmetrical, pale palpebral conjunctiva, anicteric sclerae, PERRLA, pupil dilatation=3-4mm, no proptosis, no lesions, ptosis. Ears: Inspection: Symmetrical, auricles aligned with outer canthus of the eye, no lesions, no discharges, hears with loud voice. Palpation: Non-tender, auricles recoil when pinched. Nose: Inspection: With NGT attached at right nare, at midline, no discharges. Palpation: Non-tender sinus. Throat and Mouth: Inspection: Dark red lips, moist oral mucosa, pinkish tongue at midline, no lesions with gag reflex, with clear to yellowish sputum, reddened uvula, one lower incisor teeth only, foul breath. Neck: Inspection: Visible neck mass, symmetrical neck muscles, use of sternocleidomastoid muscle for breathing. Palpation: Palpable thyroid gland both at left and right lobe, smooth, soft, slightly enlarged but less than twice the size of a normal thyroid gland, tender non enlarged lymph nodes. Thorax and Lungs: Anterior:

Inspection: Symmetrical chest walls, clavicles at same height, with effort breathing on inspiration, rib angle 45°, retracted ICS during inspiration, subcostal and suprasternal retractions, tachypnea=35cpm Palpation: Non-tender, symmetric chest expansion, no nodules nor mass. Percussion: flat Auscultation: Bilateral crackles in inspiration, and wheezes on expiration.

Posterior: Inspection: Scapula at same height bilaterally, spine at midline. Palpation: Non tender, no nodules, no mass. Percussion: flat Auscultation: Bilateral crackles in inspiration, and wheezes on expiration. Heart: Inspection: Not observable apical pulse. Palpation: No thrills, no heaves, PMI at 5th ICS MCL Percussion: Dullness over heart. Auscultation: Irregular heart rhythm, split S2 sound, tachycardia=105bpm. Abdomen: Inspection: Symmetrical bilaterally with uniform color and pigmentation. Auscultation: Bowel sounds= 1 in every 20 minutes Percussion: Tymphanic over stomach, dullness over liver. Palpation: Non tender, non palpable spleen and kidney, non enlarged liver. Extremities: Arms • Mild weakness • With flexion and extension • With reflexes Legs • Severe weakness • No flexion and no extension • Negative babinski reflex

Muscle strength:

Cardiovascular System: Arterial pulses Rate: 105 bpm Rhythm: Irregular Amplitude: Pulsus alterans Scale +4

Neurologic system: Confused, follows command at times, flat facial expression Glasgow Coma Scale: Level of Consciousness Eye opening= 3 Motor response= 5 Verbal response= 5 _______ 13/15 Interpretation: Lethargic Functional level Classification: 4

\ ANATOMY AND PHYSIOLOGY Anatomy of the Heart The essential function of the heart is to pump blood to various parts of the body. The mammalian heart has four chambers: right and left atria and right and left ventricles. The two atria act as collecting reservoirs for blood returning to the heart while the two ventricles act as pumps to eject the blood to the body. As in any pumping system, the heart comes complete with valves to prevent the back flow of blood. Deoxygenated blood returns to the heart via the major veins (superior and inferior vena cava), enters the right atrium, passes into the right ventricle, and from there is ejected to the pulmonary artery on the way to the lungs. Oxygenated blood returning from the lungs enters the left atrium via the pulmonary veins, passes into the left ventricle, and is then ejected to the aorta.

The inner edge of the tricuspid and the mitral valves end in filamentous connective tissue (chordae tendineae). These are attached to small columns of muscle (papillary muscles) arising out of the inner surface of the ventricles. As the pressure builds in the ventricles, the valves snap shut, and the papillary muscles prevent the valves from blowing into the atrium and opening.

Pumping Action of the Heart The pumping action starts with the simultaneous contraction of the two atria. This contraction serves to give an added push to get the blood into the ventricles at the end of the slow-filling portion of the pumping cycle called "diastole." Shortly after that, the ventricles contract, marking the beginning of "systole." The aortic and pulmonary valves open and blood is forcibly ejected from the ventricles, while the mitral and tricuspid valves close to prevent backflow. At the same time, the atria start to fill with blood again. After a while, the ventricles relax, the aortic and pulmonary valves close, and the mitral and tricuspid valves open and the ventricles start to fill with blood again, marking the

end of systole and the beginning of diastole. It should be noted that even though equal volumes are ejected from the right and the left heart, the left ventricle generates a much higher pressure than does the right ventricle.

Electrical Activity of the Heart When vertebrate muscles are excited, an electrical signal (called an "action potential") is produced and spreads to the rest of the muscle cell, causing an increase in the level of calcium ions inside the cell. The calcium ions bind and interact with molecules associated with the cell's contractile machinery, the end result being a mechanical contraction. Even though the heart is a specialized muscle, this fundamental principle still applies.

One thing that distinguishes the heart from other muscles is that the heart muscle is a "syncytium," meaning a meshwork of muscle cells interconnected by contiguous cytoplasmic bridges. Thus, an electrical excitation occurring in one cell can spread to neighboring cells. Another defining characteristic is the presence of pacemaker cells. These are specialized muscle cells that can generate action potentials rhythmically.

Under normal circumstances, a wave of electrical excitation originates in the pacemaker cells in the sinoatrial (S-A) node, located on top of the right atrium. Specialized muscle fibers transmit this excitation throughout the atria and initiate a coordinated contraction of the atrial walls. Meanwhile, some of these fibers excite a group of cells located at the border of the left atrium and ventricle known as the atrioventricular (A-V) node. The A-V node is responsible for spreading the excitation throughout the two ventricles and causing a coordinated ventricular contraction.

How Your Thyroid Works Your thyroid gland is a small gland, normally weighing less than one ounce, located in the front of the neck. It is made up of two halves, called lobes, that lie along the windpipe (trachea) and are joined together by a narrow band of thyroid tissue, known as the isthmus. The thyroid is situated just below your "Adams apple" or larynx. During development (inside the womb) the thyroid gland originates in the back of

the tongue, but it normally migrates to the front of the neck before birth. Sometimes it fails to migrate properly and is located high in the neck or even in the back of the tongue (lingual thyroid) This is very rare. At other times it may migrate too far and ends up in the chest (this is also rare). The function of the thyroid gland is to take iodine, found in many foods, and convert it into thyroid hormones: thyroxine (T4) and triiodothyronine (T3). Thyroid cells are the only cells in the body which can absorb iodine. These cells combine iodine and the amino acid tyrosine to make T3 and T4. T3 and T4 are then released into the blood stream and are transported throughout the body where they control metabolism (conversion of oxygen and calories to energy). Every cell in the body depends upon thyroid hormones for regulation of their metabolism. The normal thyroid gland produces about 80% T4 and about 20% T3, however, T3 possesses about four times the hormone "strength" as T4. The thyroid gland is under the control of the pituitary gland, a small gland the size of a peanut at the base of the brain (shown here in orange). When the level of thyroid hormones (T3 & T4) drops too low, the pituitary gland produces Thyroid Stimulating Hormone (TSH) which stimulates the thyroid gland to produce more hormones. Under the influence of TSH, the thyroid will manufacture and secrete T3 and T4 thereby raising their blood levels. The pituitary senses this and responds by decreasing its TSH production. One can imagine the thyroid gland as a furnace and the pituitary gland as the thermostat. Thyroid hormones are like heat. When the heat gets back to the thermostat, it turns the thermostat off. As the room cools (the thyroid hormone levels drop), the thermostat turns back on (TSH increases) and the furnace produces more heat (thyroid hormones). The pituitary gland itself is regulated by another gland, known as the hypothalamus (shown in our picture in light blue). The hypothalamus is part of the brain and produces TSH Releasing Hormone (TRH) which tells the pituitary gland to stimulate the thyroid gland (release TSH). One might imagine the hypothalamus as the person who regulates the thermostat since it tells the pituitary gland at what level the thyroid should be set. Normal anatomy • • • Two lateral lobes are connected by a thin isthmus Thyroid gland is anterior and lateral to upper trachea and Parathyroid glands and recurrent laryngeal nerve are just

esophagus, just below level of cricoid cartilage behind thyroid gland

Develops from evagination of pharyngeal epithelium at

foramen caecum (base of tongue), descends as a component of the thyroglossal duct from anterior neck in midline; fully developed by week 14 of gestation • • • duct • • Normal weight in adults is 15-25g Divided into lobules of 20-40 follicles, each with a single Lateral thyroid develops from ultimobranchial body that May be lingual/subhyoid (too high) or substernal (too low) Pyramidal lobe, present in 40%, is vestige of thyroglossal gives rise to C cells, is considered a fifth branchial pouch

layer of cuboidal to low columnar epithelium, filled with thyroglobulin that is secreted by follicular cells as colloid • • Colloid is scalloped and pale in follicles with active secretory Intrafollicular stroma contains C cells, formerly called activity; densely eosinophilic if inactive parafollicular cells, derived from neural crest; they secrete calcitonin, which lowers serum calcium by promoting bone absorption of calcium and inhibiting bone resorption by osteoclasts Sanderson’s polsters: collections of small follicles projecting into the lumen of large actively secreting follicles Oncocytes (Hürthle cells, oxyphilic cells, Askanazy cells) have abundant granular cytoplasm and numerous mitochondria • Thyroid gland blood supply is superior and inferior thyroidal arteries, regulated by cervical sympathetic ganglia. Positive stains: follicular cells and colloid thyroglobulin, T3

(triiodothyronine), T4 (thyroxine) • Follicles also stain with low molecular weight keratin, EMA, vimentin, estrogen beta (not alpha) and progesterone receptors

• C cells stain for calcitonin, low molecular weight keratin, chromogranin A and B, synaptophysin, CEA; but NOT for thyroglobulin • Colloid contains birefringent calcium oxalate crystals, particularly in nodular goiter Normal physiology Hypothalamus releases thyroid releasing factor (TRF) into hypothalamic-pituitary portal blood circulation, which travels to pituitary, which releases thyroid stimulating hormone (TSH) into blood. Follicular cells normally synthesize thyroglobulin and secrete it into the follicular lumen, where it is stored as colloid. In response to TSH, follicular cells pinocytize colloid and convert thyroglobulin to T4 (thyroxine) and T3, which are secreted into bloodstream. residues. Most T4/T3 is reversibly bound to thyroid binding globulin, which maintains levels within narrow limits. Free T4/T3 enters cells, binds to nuclear receptors, increases carbohydrate and fat catabolism and protein synthesis (basal metabolic rate). Decreased T3/T4 stimulates release of TRF and TSH via negative feedback regulation; elevated levels have opposite effect. Chronically stimulated (hyperplastic) follicular cells are tall and columnar, may be papillary. Goitrogens: suppress T3/T4 synthesis causing an increased TSH which causes goiter and (enlargement iodides in of large thyroid doses, gland); which examples inhibit include propylthiouracil, which inhibits oxidation of iodide and blocks T3/T4 production, proteolysis. The Thyroid Gland The thyroid gland synthesizes and secretes: •thyroxine (T4) and •calcitonin T4 and T3 thyroglobulin Conversion to T4/T3 occurs via thyroid peroxidase, which catalyzes tyrosine iodination and coupling of iodotyrosyl

(T4 ) is a derivative of the amino acid tyrosine with four atoms of iodine. In target cells (e.g. liver cells), one atom of iodine is removed from T4 converting it into triiodothyronine (T3). T3 is the active hormone. It has many effects. Among the most prominent of these are: •an increase in metabolic rate (seen by a rise in the uptake of oxygen); •an increase in the rate and strength of the heart beat. The thyroid cells responsible for the synthesis of T4 take up circulating iodine from the blood. This action, as well as the synthesis of the hormones, is stimulated by the binding of TSH to transmembrane receptors at the cell surface.

PROGNOSIS
Hyperthyroidism is a condition due to excessive production of the thyroid gland hormone, thyroxine. It is characterized by increased synthesis & secretion of T3 & T4, lending to an increase metabolic rate. There are 3 major complications of hyperthyroidism; the exophthalmus, heart disease & thyroid storm. In our patient, his complication is the heart disease which leads him to have left ventricular heart failure & thyrotoxic heart disease. Management of thyrotoxic heart disease usually takes place in a hospital setting, with care managed by the physician, nurse & pharmacists. Proper management through correcting or increasing cardiac output, effective gas exchange & tissue perfusion, tolerance in activity, and stabling the vital signs could mean a higher chance of recovery. However, if untreated, left ventricular heart failure could lead to complications in the lungs, kidneys & liver which can also causes death. In the case of our patient, prognosis is good, considering the fact that thyrotoxic heart disease is being managed properly by giving medication & monitoring the patient’s condition. The client also shows signs of improvement.

CONCLUSION This is a case of Mrs. O, 66 years old, female from Barangay Daro, Jaro, Leyte. She was admitted at EVRMC last June 30, 2007 with the chief complaint of dyspnea and diagnosed with Acute left ventricular heart failure and thyrotoxic heart disease. The risk factors included in our nursing care plan are Impaired gas exchange, ineffective airway clearance, Hyperthermia, Risk for impaired skin integrity, Activity Intolerance, Imbalanced nutrition, Impaired physical mobility, Ineffective peripheral tissue perfusion and decreased cardiac output. Hyperthyroidism is a condition in which an overactive thyroid gland is producing an excessive amount of thyroid hormones that circulate in the blood. ("Hyper" means "over" in Greek). Thyrotoxicosis is a toxic condition that is caused by an excess of thyroid hormones from any cause. Thyrotoxicosis can be caused by an excessive intake of thyroid hormone or by overproduction of thyroid hormones by the thyroid gland. Since the patient is undergoing treatment, it is therefore concluded that patient will be able to go through the disease process with proper understanding of it, its manifestations, treatment and when to seek medical assistance.

RECOMMENDATION In view of all circumstances, the following are thereby recommended: • Prompt diagnosis and treatment of hyperthyroidism to reduce and possibly eliminate associated cardiovascular symptoms. • Careful and thorough assessment of gerontologic clients to avoid overlooking of manifestations. • Early initiation of adjunctive therapy of hyperthyroidism to prevent occurrence of thyrotoxic storm. • Attention to health teachings be emphasized on medication compliance and the need for follow-up appointments with physician.

OBJECTIVES

1. 2. 3.

To present a reliable patient’s profile and history of the patient To state the results and significance of diagnostic and laboratory examination of the patient. To illustrate and explain briefly the CNS.

4.

To site the pharmacology of the medication of the patient.

PATIENTS PROFILE Name: Mrs.HN Age: 67 Sex: Female Marital status: married Address: Brgy. Batang Hernani, Eastern Samar Religion: Roman Catholic Nationality: Filipino Birthday: July 13, 1939 Birthplace: Hernani,Samar Date of Admission: June 19, 2007 Time: 8:03 AM Husband: Mr. HN AGE:65 Occupation: columnist Chief Complaint: Loss of consciousness Diagnosis: CVA- hemorrhagic

HISTORY OF PRESENT ILLNESS A case of Mrs. HN 67 yrs.old, female, Filipino, residing at Brgy. Batang, Hernani Eatern Samar, was admitted for the first time at Bethany Hospital last June 19, 2007 at 8:30 am referred from Banawa Hospital Llorente, Eastern Samar with chief complaint of “loss of consciousness”. Patient condition started June 12, 2007 about twelve noon, when patient experienced sudden vertigo, headache, blurring of vision’ numbness of upper extremities then followed by loss of consciousness. The patient was noted by husband with a loud cry, rolling eyeballs upward, stiffening of lower and upper extremities, with head extended with a preferential gaze to the right which lasted for approximately 4 minutes. Vomiting was noted. The patient was immediately brought to the nearest hospital via tricycle which was 6 kilometers away. During transportation while patient is still in the state of unconsciousness, seizure attacks recurred for 3 more times with same characteristics as previously with an interval of approximately 5-8 minutes. Before onset of manifestation patient was noted to be angry and irritable because she was prohibited to eat the foods she likes. A spoon was inserted on top of the tongue as a seizure precaution by the husband. The patient was then admitted at Baconawa Hospital, Llorente, Eastern Samar, with an admitting impression of cerebrovascular disease. Upon admission had BP of 180/100, the patient was noted to have facial asymmetry to the left, protrusion of tongue to the left, a Glascow Coma Scale of 9, and a Bp of 120/100 mmHg, oxygen inhalation was administered at 4-5 L/min and was maintained on NPO for one day. The patient was prescribed with the following medications: Mannitol 20% to infuse 100 cc q 6˚, Ranitidine 50 mg I amp IVTT, Furosemide20 mg I amp IVTT, Diazepam 10 mg I amp IVTT, Captopril 25 mg I tab 3 x a day SL. Three day after admission, the patient was noted to have a non-productive cough and was instructed to drink plenty of water. The patient was then prescribed Cefuroxime 750 mg IVTT q 8˚ and Salbutamol nebulization I neb OD and was advised to undergo CTscan and X-ray, hence discharged on June 15, 2007 in fair condition and was referred to a tertiary hospital of choice. However, due to financial constraints, the patient was not immediately admitted and stayed for3 more days at her daughter’s house in Marasbaras, Tacloban City with no seizure attacks noted. On June 19, 2007 at 8:03 am when patient was conscious and ambulatory, decided to comply with the referral from Baconawa Hospital, hence subsequently admitted.

PAST MEDICAL HISTORY Patient had chickenpox and measles when she was in grade school. No known allergy to foods and drugs. No major accidents nor injuries that cause medical attention. Patient had three previous hospitalizations. Last 2006, was her first admission in Manila and was diagnosed of CVA, and was found out to be hypertensive. No paralysis noted. The patient was given take home prescriptions but fail to comply due to financial constraints. Husband fails to recall take home prescriptions. Patient’s second hospitalization was last December 2006 in Manila, still diagnosed with CVA, with paralysis noted hemiplegia (left), but recovered immediately without consultation to a physical therapist. With take home medications, yet fails to comply again. Patient’s third hospitalization was last January 2007, still diagnosed with CVA, paralysis noted hemiplegia (left), but recovered immediately with seizures noted 2 times during hospital stay and was advised to undergo CT-Scan yet fails to comply with this diagnostics exam. Patient has been suffering from ulcer since she was 25 years old up to the present, with consultation but no medications taken.

FAMILY HEALTH HISTORY Both parents had hypertension and a relative died from liver disease. Patient negates any other heredo-familial diseases LIFESTYLE HISTORY Patient is a non-smoker, occasional beverage drinker, usually drinks Red horse along with friends. Abstain from drinking since diagnosed of CVA. Loves to eat fatty foods especially fried chickens and loves sauces especially toyo with calamansi. Patient always feel thirsty and could consume up to 2-3 liters a day. Patient can sleep well in the presence of her favorite pillow. Usually sleeps 6-8 hours a day. Patient’s daily routine activity are watching TV and doing household chores, like washing the dishes, and sweeping the floor, easy fatigability noted by husband. PSYCHOSOCIAL HISTORY Patient is currently living with her son in Batang, Eastern Samar. Household occupants include 8 people and usually divide household chores. Highest educational attainment was grade 5 and had worked 40 years ago in a private nursery school. HOUSING CONDITION Patient is living in a semi concrete house along the highway with electricity and potable water supply.

DIAGNOSTIC EXAM Blood Chemistry 6/19/07 Exam Normal Values Results Significance

Sodium

135-148mmol/L

136.8 mmol/L

normal

Potassium

3.5-5.3 mmol/L

3.55 mmol/L

normal

Crea-B

53-115 mmol/L

74.0 mmol/L

Normal

Hematology 6/19/07 Exam Normal Values Results Significance

Hemoglobin Hematocrit WBC

120-160 g/dL 0.36-0.46 4.5-11.3 x10 9/L

106 g/dL 0.32 2.2x10 9/L

Anemia Anemia Bone arrow depression

Neutrophils Lymphocytes

0.45-0.65 0.20-0.35

0.60 0.36

Normal Chronic bacterial infection

Monocytes Stabs

0.02-0.06 0.02-0.04

0.02 0.02

Normal Normal

Urinalysis 6/19/07

Exam

Normal Values

Results

Significance

Color

Pale yellow-deep amber

Yellow

Normal

Transparency

Clear

Slightly turbid

Normal

pH Specific Gravity

4.5-8.0 1.002-1.035

6.5 1.005

Normal Normal

Protein S Sugar Pus Cells Red Blood Cells

Negative Negative 0-2/hpf 0-2/hpf

(-) (-) 0-1/hpf None

Normal Normal Normal Normal

Epithelial Cells Mucus Threads

Rare Rare

Rare None

Normal Normal

Amorphous Urates

Rare

Moderate

Normal

Bacteria

None - few

rare

Normal

Chest PA (x-ray) 6/19/07 Chest PA View: The lung fields are clear. Heart shadow is not enlarged. Trachea is in the midline. Hemidiaphragms and sulci are intact. Other chest structures are unremarkable. Impression: Essentially unremarkable cardio pulmonary findings. CT Scan 6/20/07 Report: Plain and contrast scan of the brain using fused 5.0 and 10.0mm axial slice was done. There is a hypodensity noted on the right temporo-parietal lobe. No enhancement noted after contrast examination. The midline structures are in placed. The cisterns, sulci and ventricles are prominent. The mastoids are well aerated. No fracture of the cranial vault noted. Impression: Cerebral infarction, right temporo-paraital lobe, likely chronic; Cerebral atrophy.

PROSENCEPHALON Function: • Chewing • Directs Sense Impulses Throughout the Body • Equilibrium • Eye Movement, Vision • Facial Sensation • Hearing, Phonation • Intelligence • Memory, Personality • Respiration • Salivation, Swallowing

• Smell, Taste Location: • The prosencephalon is the most anterior portion of the brain. It is also called the forebrain. Structures: • The prosencephalon consists of the telencephalon, striatum, diencephalon, lateral ventricle and third ventricle.
MESENCEPHALON Function: • Controls Responses to Sight • Eye Movement • Pupil Dilation • Body Movement • Hearing Location: • The mesencephalon is the most rostral portion of the brainstem. It is located between the forebrain and brainstem. Structures: • The mesencephalon consists of the tectum and tegmentum.

RHOMBENCEPHALON Function: • Attention and Sleep • Autonomic Functions • Complex Muscle Movement • Conduction Pathway for Nerve Tracts • Reflex Movement • Simple Learning Location: • The rhombencephalon is the inferior portion of the brainstem. Structures: • The rhombencephalon is comprised of the metencephalon, the myelencephalon, and the reticular formation.

BASAL GANGLIA Function: • Controls Cognition • Movement Coordination • Voluntary Movement Location: • The basal ganglia is located deep within the cerebral hemispheres in the telencephalon region of the brain. It consists of the corpus stratium, subthalamic nucleus and the substantia nigra.

BROCA'S AREA Function: • Controls Facial Neurons • Controls Speech Production • Understanding Language Location: • Broca's area is located in the left frontal lobe, around the opercular and triangular sections of the inferior frontal gyrus.

CENTRAL SULCUS (FISSURE OF ROLANDO) Function: • The central sulcus is the large deep groove or indentation that separates the parietal and frontal lobes.

CEREBELLUM Function: • Controls Fine Movement Coordination • Balance and Equilibrium • Muscle Tone Location: • The cerebellum is located just above the brainstem, beneath the occipital lobes at the base of the skull.

CEREBRAL CORTEX Function: • Determines Intelligence • Determines Personality • Interpretation of Sensory Impulses • Motor Function • Planning and Organization • Touch Sensation Location: • The cerebral cortex is the outer portion (1.5mm to 5mm) of the cerebrum. It is divided into lobes: frontal, parietal, temporal and occipital. The insula is also found in this region of the brain.

FRONTAL LOBES Function: • Motor Functions • Higher Order Functions • Planning • Reasoning • Judgement • Impulse Control • Memory OCCIPITAL LOBES Function: • Controls Vision • Color Recognition Location: • The occipital lobes are the most caudal portion of the cerebral cortex. PARIETAL LOBES Function: • Cognition • Information Processing • Pain and Touch Sensation • Spatial Orientation • Speech • Visual Perception Location: • The parietal lobes are superior to the occipital lobes and posterior to the central sulcus (fissure) and frontal lobes

TEMPORAL LOBES Function: • Emotional Responses • Hearing

Memory Speech Location: • The temporal lobes are anterior to the occipital lobes and lateral to the Fissure of Sylvius. INSULA Function: • Associated With Visceral Functions • Integrates Autonomic Information Location: • The insula is located within the cerebral cortex, beneath the frontal, parietal and temporal opercula. DIENCEPHALON Function: • Chewing • Directs Sense Impulses Throughout the Body • Equilibrium • Eye Movement, Vision • Facial Sensation • Hearing • Phonation • Respiration • Salivation, Swallowing • Smell, Taste Location: • The diencephalon is located between the cerebral hemispheres and above the midbrain. Structures: • Structures of the diencephalon include the thalamus, hypothalamus, the optic tracts, optic chiasma, infundibulum, Ventricle III, mammillary bodies, posterior pituitary gland and the pineal gland. TELENCEPHALON Function: • Determines Intelligence • Determines Personality • Interpretation of Sensory Impulses • Motor function • Planning and Organization • Sense of Smell • Touch Sensation Location: • The telencephalon is the anterior portion of the brain, rostral to the midbrain. Structures: • The telencephalon consists of the cerebral cortex, basal ganglia, corpus striatum and olfactory bulb. THE BRAIN Most brains exhibit a substantial distinction between the gray matter and white matter. Gray matter consists primarily of the cell bodies of the neurons, while white matter is comprised mostly of the fibers (axons) which connect neurons. The axons are surrounded by a fatty insulating sheath called myelin (oligodendroglia cells), giving the white matter its distinctive color. The outer layer of the brain is gray matter called cerebral cortex. Deep in the brain, compartments of white matter (fasciculi, fiber tracts), gray matter (nuclei) and spaces filled with cerebrospinal fluid (ventricles) are found. The brain innervates the head through cranial nerves, and it communicates with the spinal cord, which innervates the body through spinal nerves. Nervous fibers transmitting signals from the brain are called efferent fibers. The fibers transmitting signals to the brain are called afferent (or sensory) fibers. Nerves can be afferent, efferent or mixed (i.e., containing both types of fibers). The brain is the site of reason and intelligence, which include such components as cognition, perception, attention, memory and emotion. The brain is also responsible for control of posture and movements. It makes possible cognitive, motor and other forms of learning. The brain can perform a variety of functions automatically, without the need for conscious awareness, such as coordination of sensory systems (eg. sensory gating and multisensory integration), walking, and homeostatic body functions such as heart rate, blood pressure, fluid balance, and body temperature. Many functions are controlled by coordinated activity of the brain and spinal cord. Moreover, some behaviors such as simple reflexes and basic locomotion, can be executed under spinal cord control alone. The brain undergoes transitions from wakefulness to sleep (and subtypes of these states). These state transitions are crucially important for proper brain functioning. (For example, it is believed that sleep is important for knowledge consolidation, as the neurons appear to organize the day's stimuli during deep sleep by randomly firing off the most recently used neuron pathways; additionally, without sleep, normal subjects are observed to develop symptoms resembling mental illness, even auditory hallucinations). Every brain state is associated with characteristic brain waves. Neurons are electrically active brain cells that process information, whereas Glial cells perform supporting function. In addition to being electrically active, neurons constantly synthesize neurotransmitters. Neurons modify their properties (guided by gene expression) under the influence of their input signals. This plasticity underlies learning and adaptation. It is notable that some unused neuron pathways (constructions which have become physically isolated from other cells) may continue to exist long after the memory is absent from consciousness, possibly developing the subconscious. The study of the brain is known as neuroscience, a field of biology aimed at understanding the functions of the brain at every level, from the molecular up to the psychological. There is also a branch of psychology that deals with the anatomy and physiology of the brain, known as biological psychology. This field of study focuses on each individual part of the brain and how it affects behavior.

• •

REVIEW OF SYSTEMS General: Weight gain; no fever, no chills, no night sweats. Skin: No rashes, no pruritus, no bruising, no changes in color. Head: Headache, no injury, no tenderness. Eyes: Blurring of vision, with eyeglasses, pupils equally round and reactive to light, cannot read newsprint. Ears: Change in hearing, no tinnitus, no pain, no discharges, and no dizziness. Nose: Clear nasal discharges, sneezing, no epistaxis, no loss of sense of smell. Throat and Mouth: 5 missing teeth, dental caries in the molars, no mouth sores,no difficulty of swallowing, no ulcerations, and no lesions. Respiratory: non productive cough, no chest pain, no dyspnea, no hemoptysis. Cardiovascular: No chest pain, no palpitations, no shortness of breath. Gastrointestinal: with ulcer, constipation, no indigestion, no food intolerances, no diarrhea, and no abdominal pain. Genitourinary: Nocturia present with incontinence, no dysuria, no hematuria. Endocrine: Thyroid gland palpable on the left. Musculoskeletal: Limitation of movement at the left upper arm, weakness, no stiffness, no joint swelling, with easy fatigability and restlessness. PHYSICAL EXAMINATION Vital Signs Pulse Rate: 74 bpm Respiratory rate: 22 breaths/min Temperature: 37°C Blood Pressure: 130/80 mm Hg General Survey: Fairly groomed with visible fat deposits in abdomen and extremities, conscious, lying in bed, with adult diaper, with an IVF of .9 NaCl1L @ 10 gtts/min @ left hand. Integument: Inspection: Brown in complexion, uniform in color through out body, brown “age spots” on exposed body areas, dry and pallor, scar @ lower extremities Palpation: Fair skin turgor, warm to touch Nails: Inspection: Untrimmed, dirty fingernails, smooth, nail plate-convex curvature Palpation: Thick, capillary refill = 5 seconds. Head: Inspection: Normocephalic skull, grayish evenly distributed hai, no infestation Palpation: Smooth skull contour, dry brittle hair Eyes: Inspection: Symmetrical, glossy white circle around the periphery of the cornea, pale palpebral conjunctiva, pupils equally round and reactive to light; pupils dilatation: 3-4mm, cannot read newsprint.

Ears: Inspection: Symmetrical, auricles aligned with the outer canthus of the eye, cannot hear normal voice tone. Palpation: No discharge, non tender. Nose: Inspection: Symmetrical at midline with clear discharges and frequent sneezing. Palpation: Non tender sinus, patent nasal passages. Throat and Mouth: Inspection: Moist oral mucosa, smooth yellow tooth enamel, 5 missing teeth, dental caries on molars, able to purse lips, whitish tongue, moves freely, reddened uvula, non-inflamed tonsils, no dysphagia. Neck: Inspection: Coordinated movements with no discomforts, thyroid gland not visible. Palpation: Non-enlarged lymph nodes, palpable thyroid gland Chest & Lungs: Anterior: Inspection: Symmetrical chest, irregular respiratory rhythm, tachypnea (RR=22cpm) Palpation: Non-tender, symmetric chest expansion, no nodules nor mass. Percussion: Resonance Auscultation: Clear breath sounds Posterior: Inspection: Humpback on spine; spine on midline. Palpation: Non-tender, no nodules nor mass. Percussion: Resonance Auscultation: Clear breath sounds

Heart: Inspection: Not observable apical pulse Palpation: No thrills, PMI at 5th ICS Midclavicular Percussion: Dullness over heart Auscultation: Regular heart rhythm, good S1 and S2. Abdomen: Inspection: Uniform color, round in shape. Auscultation: Regular bowel sound (7 per min.) Percussion: Dullness over liver, tymphany over stomach. Palpation: No tenderness, non-palpable spleen and kidneys. Extremities:

Upper: • With good sensation • With reflexes on the right • Palpable peripheral pulses • No resistance at left upper arm. Lower: • With good sensation • With reflexes • Palpable peripheral pulses • With less resistance on left extremities. Neurologic System: Not oriented to place and time, oriented to person, gradual memory loss, affect appropriate to situation, irritable at times and confusion, poor judgment, slow movement and decrease in speed walking. Level of Consciousness: Glasgow Coma scale Eye opening= 4 Motor response= 6 Verbal response= 4 ______ 14/15 Functional level classification: 1; requires use of equipment or device. Cranial Nerve Assessment: I: Can identify objects through smell II: Cannot see far objects; cannot read newsprint. III: With extraocular eye movement, pupils equally round and reactive to light, pupil dilation= 3-4mm. IV: Can move eyeballs downward and upward. V: Can chew food, with sensation on face, and with positive blink reflex. VI: Moves eyeballs laterally. VII: Different kinds of facial expression. VIII: Negative balance, cannot hear normal voice tone. IX: with gag reflex. X: No hoarseness of speech can swallow. XI: Can move head with resistance XII: Move tongue and can draw tongue out. CEREBROVASCULAR ACCIDENT A cerebrovascular accident is also called a CVA, brain attack, or stroke. It occurs when blood flow to a part of the brain is suddenly stopped and oxygen cannot get to that part. This lack of oxygen may damage or kill the brain cells. Death of a part of the brain may lead to loss of certain body functions controlled by that affected part.

CAUSES: • A piece of fatty plaque (debris) that is formed in a blood vessel breaks away and flows through the bloodstream going to the brain. The plaque blocks an artery which causes a stroke. This is called an embolic stroke. • A thrombus (blood clot) formed in an artery (blood vessel) and blocked blood flow to the brain. This is called a thrombotic stroke. • A torn artery in the brain, causing blood to spill out. This is called a cerebral hemorrhage or hemorrhagic stroke. It often results from high blood pressure. • Blockage of certain small blood vessels inside the brain.

RISK FACTORS: • Cigarette smoking, cocaine use, or drinking too much alcohol. • Diabetes (high blood sugar). • You or a close family member has had a stroke. • Atherosclerosis (hardening of the arteries) or fatty cholesterol deposits on artery walls. • Heart disease, such as coronary artery disease. • High blood cholesterol (fat). • High blood pressure. SIGNS AND SYMTPOMS: • numbness (no feeling) • tingling, • weakness • paralysis (cannot move) on one side of the body • trouble walking, swallowing, talking, or understanding • vision (sight) may be blurred or doubled • severe headache • feel dizzy • confused or pass out. A stroke occurs when the blood supply to the brain is disturbed in some way. As a result, brain cells are starved of oxygen causing some cells to die and leaving other cells damaged. Types of stroke Most strokes occur when a blood clot blocks one of the arteries (blood vessels) that carries blood to the brain. This type of stroke is called an ischaemic stroke. Transient ischaemic attack (TIA) is a short-term stroke that lasts for less than 24 hours. The oxygen supply to the brain is restored quickly, and symptoms of the stroke disappear completely. A transient stroke needs prompt medical attention as it is a warning of serious risk of a major stroke. Cerebral thrombosis occurs when a blood clot (thrombus) forms in an artery (blood vessel) supplying blood to the brain. Furred-up blood vessels with fatty patches of atheroma (arteriosclerosis) may make a thrombosis more likely. The clot interrupts the blood supply and brain cells are starved of oxygen. Cerebral embolism is a blood clot that forms somewhere in the body before travelling through the blood vessels and lodging in the brain. This causes the brain cells to become starved of oxygen. An irregular heartbeat or recent heart attack may make you prone to forming emboli. Cerebral haemorrhage occurs when a blood vessel bursts inside the brain and bleeds (haemorrhages). With a haemorrhage, extra damage is done to the brain tissue by the blood that seeps into it.

PROGRESS NOTES 3/20/07 3-11

3:00PM    

    

Received conscious, lying on bed with on going IVF of 0.9NaCl I liter at 10gtts/min at 900cc level infusing well at left hand. On low salt, low fat diet- instructed. Afebrile with temperature of 36.8°C. Vital signs taken and recorded: BP: 13/80 Temp: 36.5°C RR: 17cpm PR: 68bpm Neuro vital signs taken and recorded. Still for CBC in the morning. Bedside care done. Due meds given by NOD. Health teachings imparted with emphasis on the following: o Compliance to medications. o Safety precautions. o Foods low in salt and fats.

CONCLUSION This is a case of Mrs. HN, 67 years old, female from Barangay Batang Hernani, Eastern Samar. She was admitted at Bethany Hospital last June 19, 2007 with the chief complaint of loss of consciousness and was later diagnosed as cerebrovascular accident. The risk factors included in our nursing care plan are Ineffective cerebral tissue perfusion, disturbed thought process, impaired physical mobility, risk for injury and incontinence. Cerebrovascular accident is also called a CVA, brain attack, or stroke. It occurs when blood flow to a part of the brain is suddenly stopped and oxygen cannot get to that part. This lack of oxygen may damage or kill the brain cells. Death of a part of the brain may lead to loss of certain body functions controlled by that affected part. Treatments recommended for the patients are anticoagulants and antithrombotics with goals t achieve maximum benefit with fewest side effects. Good nursing care is fundamental in maintaining skin care, feeding, hydration, positioning, and monitoring vital signs such as temperature, pulse and blood pressure. Since the patient is undergoing treatment, it is therefore concluded that patient will be able to go through the disease process with proper understanding of CVA, its manifestations, treatment and when to seek medical assistance. RECOMMENDATION • • • • • • • Stress the importance of compliance to medications. Encourage SO to notify physicians if symptoms of complications occur. Encourage SO and the patient’s family to provide holistic emotional, psychosocial support and care to the patient. Encourage patient and SO to comply with health teachings, treatment and regimen. Encourage SO to promote safety within home vicinity and observe proper sanitation. Encourage patient to eat foods low in salt and fat. Encourage the use of supportive measure thru stroke rehabilitation.

PROGNOSIS A cerebrovascular accident prognosis will tell a patient what to expect after a stroke. It is a medical doctor’s professional opinion about the course and likelihood of recovery after a stroke (also known as a CVA). The prognosis can include information about the expected recovery time, the risk of complications, the probable outcomes, and likelihood of survival after a stroke. CVA are the third leading cause of death in developed countries. Of those people who survive a CVA, only about ten percent will recover most or total functioning. The CVA prognosis for half of all stroke survivors will leave them with some degree of long-term disability. Forty percent of all stoke survivors will require long term nursing care after a cerebrovascular accident. A patients’ cerebrovascular accident prognosis will depend on a number of factors such as the type of stroke suffered, the extent of resulting brain damage, the presence of related medical problems, the risk of complications, and the likelihood of suffering additional strokes. Early treatment for a stroke can greatly improve a patient’s cerebrovascular accident prognosis. Prompt treatment can mitigate the extent of brain damage that a patient suffers. The type of treatment required to improve a patient’s cerebrovascular accident prognosis will depend on the type of stroke that they suffered. An ischemic stroke involves a blockage in blood flow in or to the brain.The prognosis for an ischemic stroke can be more favorable in cases where a patient has received prompt medical attention to restore blood flow in and to the brain. It will also depend on the likelihood and occurrence of complications. Complications that can compromise a CVA prognosis can include: paralysis, cognitive deficits, speech problems, emotional difficulties, daily living problems, and pain. This complications will typically develop soon after a stroke though recurring strokes and other related health problems can also cause these complications. Disability affects 75% of stroke survivors enough to decrease their employability. Stroke can affect patients physically, mentally, emotionally, or a combination of the three. The results of stroke vary widely depending on size and location of the lesion. Dysfunctions correspond to areas in the brain that have been damaged. Some of the physical disabilities that can result from stroke include paralysis, numbness, pressure sores, pneumonia, incontinence, apraxia (inability to perform learned movements), difficulties carrying out daily activities, appetite loss, vision loss, and pain. If the stroke is severe enough, coma or death can result. Emotional problems resulting from stroke can result from direct damage to emotional centers in the brain or from frustration and difficulty adapting to new limitations. Post-stroke emotional difficulties include anxiety, panic attacks, flat affect (failure to express emotions), mania, apathy, and psychosis.

30 to 50% of stroke survivors suffer post stroke depression (Post stroke depression), which is characterized by lethargy, irritability, sleep disturbances, lowered self esteem, and withdrawal.[23] Depression can reduce motivation and worsen outcome, but can be treated with antidepressants. Cognitive deficits resulting from stroke include perceptual disorders, speech problems, dementia, and problems with attention and memory. A stroke sufferer may be unaware of his or her own disabilities, a condition called anosognosia. In a condition called hemispatial neglect, a patient is unable to attend to anything on the side of space opposite to the damaged hemisphere. Up to 10% of all stroke patients develop seizures, most commonly in the week subsequent to the event; the severity of the stroke increases the likelihood of a seizure. Lower Glasgow coma scores are associated with poorer prognosis and higher mortality. A larger volume of blood is associated with a poorer prognosis. The presence of blood in the ventricles is associated with a higher mortality rate. The patient’s CT Scan result revealed cerebral infarction which affected the right temporo-parietal lobe and resulted to cerebral atrophy. The patient also developed complications of CVA such as pain and cognitive deficit leading to a poor prognosis for Mrs. HN. PATHOPHYSIOLOGY RISK FACTORS • Advancing age (67 Y/O) • Hypertensive • Prior stroke (3 times) • • Poor compliance to medications • Fatty food preferences Family history of hypertension

Related/ Continuous injury to normal artery (Right middle cerebral artery) Changes in smooth muscle cells cells Production of collagen, grounded substances and elastin Matrix of the fibrofatty plaque formation Loss of thromboresistance in endothelial Local thrombin formation Fibrofatty plaque formation

Trapping of lipid within the plaque Neointima formation Further platelet fibrin microthrombi formation Atherosclerotic plaque increases in size Arterial stenosis Lack of O2 supply to the ischaemic neurons ATP depletion Membrane ion transport system stops functioning Depolarization of neurons Efflux of Potassium and water Excitotoxicity Further depolarization of cell Further calcium influx Triggering of inflammatory response Cerebral infarction in right temporo-paraital lobe • • • • • • • • • Dizziness Blurring of vision Numbness of upper extremities Loss of consciousness Loss of balance Cannot hear normal voice tone Not oriented to time and place Gradual memory loss Seizure attacks CLINICAL MANIFESTATIONS: • Rolling of eyeballs upward • Stiffening of lower and upper extremities • Head extended with preferential gaze to the right • Glasgow coma scale of 9 • Facial asymmetry to the left • Protrusion of tongue to the left Influx of Calcium, sodium, chloride

PATIENTS PROFILE Name: Lolita Obero Javines Case No: 325528 Age: 45 years old Sex: Female Civil status: Married Address: Barangay Culasian Capoocan Leyte Occupation: Housewife Religion: Roman Catholic Nationality: Filipino Birthday: July 20, 1962 Birthplace: Capoocan, Leyte Date of Admission: 8/27/07 Time: 1:30 PM Father: Deceased Mother: Encarnacion Cabiltes Husband: Dino Javines Age: 43 years old Occupation: farmer Attending Consultant:: Dr. Henry Salubon Chief Complaint:: Removal of Implant (ROI) History Present Illness Last April 23, 2007, the patient was involved in an accident. Around 6 in the evening that day, she was walking towards their house at the side of the streets, when suddenly a motorcycle driver hit her. The driver was under the influence of alcohol. Immediately after the accident, the patient lost her consciousness and was brought to the hospital. She regained her consciousness the following day in St. Paul’s hospital where her son brought him. When she woke up, her right arm has a cast and her leg had a bandaged. She stayed in the hospital for 5 days. During which she was operated In her right leg. Her cast was removed after three weeks and she went on a regular check-up. Then last August 27, 2007, she was admitted in this institution for the removal of her implant. Past History According to the patient, the only childhood illness she can remember that she had was measles. Her immunizations was complete. She has no allergies to any food, drug, animal, plant or others. She was hospitalized first in St. Pauls Hospital last April 23, 2007 because of the accident.. She was confined there for 5 days only and was operated on her right leg and had a cast on her right arm. Family History According to the patient, her family has a history of hypertension but no asthma, diabetes, heart diseases or others. Psychosocial history: The patient is a plain and devoted housewife. She takes care of her family. Her usual activities of daily living are cooking, cleaning the house, washing their clothes and utensils, and others. Household chores is her form of exercise. She does not smoke but admitted she drinks tuba before, but now is afraid to drink because of the accident. Sometimes the patient has difficulty in sleeping because of the setting in the hospital. Social Data The patient has 6 children. Some of her children has their own family and lives separately. Her highest educational attainment was Grade 6. Before, she was working in a restaurant as a cook. The patient’s house has 2 bedrooms, 1 toilet, has no electricity, only lampara, and their source of water is from the faucet in the barangay. Their house is made of cement and wood and is about 150 meters away from the main road. REVIEW OF SYSTEMS: General: No weight loss, no fever and chills. Skin: No rashes, pruritus, bruising, change in color, lumps, sores, itching, nor dryness Head: No headaches, injury, tenderness nor dizziness Eyes: no change in visual field, glasses, contact lenses, diplopia, pain, excessive discharge nor dry eyes. Ears: No Change in hearing, tinnitus, pain, discharge nor dizziness Nose: no allergies, sinus problem, obstruction, polyps, loss of sense of smell, sneezing nor epistaxis. Throat: no toothaches, loose teeth, bleeding gums, mouth sores, hoarseness, dysphagia, ulcerations nor lesions Respiratory: no chest pain, dyspnea, cough nor hemoptysis Cardiovascular: no Chest pain, pressure/ tightness, palpitations, orthopnea, SOB, nor edema. GIT: no dysphagia, heartburn, ulcer, indigestion, diarrhea, constipation, abdominal pain, food intolerance nor hemorrhoids. GUT: no urgency, frequency, nocturia, dysuria, hematuria, UTI nor incontinence Endocrine: no Heat/cold intolerance, weight change, fatigue, polydipsia, polyuria, polyphagia nor change in hair distribution Musculoskeletal: limitation in movement, slight weakness, pain in her right leg.

PHYSICAL EXAMINATION Vital Signs Pulse Rate: 90 bpm Respiratory rate: 20 breaths/min Temperature: 37°C Blood Pressure: 140/90mm Hg General Survey: Fairly groomed, conscious, sitting on bed with no IVF. Integument: Inspection: Brown in complexion, scar at right extremity. Palpation: Fair skin turgor, warm to touch Nails: Inspection: trimmed, clean fingernails, smooth, nail plate-convex curvature Palpation: Thick, capillary refill = 3 seconds. Head: Inspection: Normocephalic skull, blackish evenly distributed hair, no infestation Palpation: Smooth skull contour Eyes: Inspection: Symmetrical, PERLLA, can read newsprint, pinkish palpebral conjunctiva Ears: Inspection: Symmetrical, auricles aligned with the outer canthus of the eye, can hear normal voice tone. Palpation: No discharge, non tender. Nose: Inspection: Symmetrical at midline with no discharges and no frequent sneezing. Palpation: Non tender sinus, patent nasal passages. Throat and Mouth: Inspection: Moist oral mucosa, able to purse lips, pinkish tongue, moves freely, reddened uvula, non-inflamed tonsils, no dysphagia. Neck: Inspection: Coordinated movements with no discomforts, thyroid gland not visible. Palpation: Non-enlarged lymph nodes, palpable thyroid gland Chest & Lungs: Anterior: Inspection: Symmetrical chest, regular respiratory rhythm, eupnea (RR=20cpm) Palpation: Non-tender, symmetric chest expansion, no nodules nor mass. Percussion: Resonance Auscultation: Clear breath sounds Posterior: Inspection: spine on midline. Palpation: Non-tender, no nodules nor mass. Percussion: Resonance Auscultation: Clear breath sounds Heart: Inspection: Not observable apical pulse Palpation: No thrills, PMI at 5th ICS Midclavicular Percussion: Dullness over heart Auscultation: Regular heart rhythm, good S1 and S2. Abdomen: Inspection: Uniform color, round in shape. Auscultation: Regular bowel sound (7 per min.) Percussion: Dullness over liver, tymphany over stomach. Palpation: No tenderness, non-palpable spleen and kidneys.

LABORATORY EXAMINATION

I. Date: August 20, 2007 X RAY Impression: No significant chest findings II. Date: August 20, 2007 Hematology Exam Result Hemoglobin 137g/L Hematocrit WBC Segmenter Lymphocytes Monocytes Clotting time 0.40 5.9x109/L 0.65 0.30% 0.05% 4mins and 6seconds Normal Values Male: 135-170g/L Female: 120-160g/L Male: 0.40-0.54 Female: 0.36-0.47 4.5-10.0x109/L 0.6-0.7 0.200-0.350% 0.20-0.060% 7-120 seconds Significance Normal Normal Normal Normal Normal Normal Increased in severe coagulation problems and therapeutic administration of heparin. Decreased

Bleeding time

1minute and 38 seconds

3-8 mins

III. Date: August 20, 2007 Urinalysis Exam Result Color Yellow Transparency pH Specific gravity Albumin Sugar WBC Red blood cells Epithelial cells Bacteria A.urates Mucus threads Reaction Slight Turbid 5.0 1.025 Positive Negative 8-12/hpf 1-2/hpf Some Few Few Moderate Acidic

Normal Findings Colorless to dark yellow Clear 4.6-8.0 1.006-1.030 Negative Negative 3-4/hpf 2-4/hpf No significance None No significance No significance Acidic

Significance Normal Normal Normal Normal Proteinuria, severe stress, acute infectious disease Normal UTI, fever, strenuous exercise, renal disease Normal Normal Normal Normal Normal Normal

IV. Date: August 21, 2007 Clinical Chemistry Exam Result FBS 5.19mmol/L Cholesterol 3.62 mmol/L Creatinine 51 umol/L BUA 445 umol/L HDL 1.78 mmol/L

Normal Findings 3.89-5.84mmol/L Up to 5.7mmol/L 50-100umol/L 135-357umol/L More than 1.68mmol/L Less than 3.9mmol/L 0.46-1.60mmol/L 135-148mmol/L 3.5-5.3mmo/L

LDL Triglycerrides NA K

1.63mmol/L 0.46mmol/L 141mmol/L 3.89mmol/L

Significance Normal Normal Normal Increased Increased hypolilolproteinemia, acute MI, DM, Diet high in saturated fats Normal Normal Normal Normal

PATIENTS PROFILE Name: Jojo Sarmiento Lagrimas Case No: 346529 Age: 28 years old Sex: Male Civil status: Married Address: Barangay Macatingog Calbayog City Occupation: Motorcycle driver Religion: Roman Catholic Nationality: Filipino Birthday: December 26, 1978 Birthplace: Calbayog City Date of Admission: 7/23/07 Time: 11 PM

Father: Bienvenido Lagrimas Sarmiento Wife: Alhpy Lagrimas Attending Consultant:: Dr. Jude Macasil Chief Complaint:: Vehicular accident

Mother: Age: 23 years old

Flora

History Present Illness Last July 2007, the patient was involved in a vehicular accident in Calbayog City. While he was driving his motorcycle, a truck driver was out of the line and hit his motorcycle. The truck driver was under the influence of alcohol. After he was hit, he became unconsciousness, and when he woke up he was already in the hospital in Calbayog city. He had many wounds, fracture on his extremities especially the left femur. Aside from the fracture, the patient now has fever. Whenever he changes his position, he feels the pain in his leg. This is relieved by meds and rest. Past History According to the patient, he had measles, chicken pox and mumps when he was a child. His immunizations are complete. According to his mother, he has allergy to a certain type of fish but was unable to recall that certain fish. His first hospitalizations was in Calbayog city after the accident. Family History According to the patient, her family has a history of asthma but no HPN, diabetes, heart diseases or others. Psychosocial history: The patient is a motorcycle driver in Calbayog city. So because of that, his usual ADL is driving. He doest not exercise regularly and doest not drink alcoholic beverages and does not smoke. He has no problems with his sleeping patterns. Social Data The patient has two children. His highest educational attainment is 1st year high school. Their house has 1 bedroom, no toilet and their source of water is the faucet in the barangay. They have electricity and their house is made of wood. REVIEW OF SYSTEMS: General: weight loss, fever and no chills. Skin: Bruising, change in color, scars, drying, wounds Head: No headaches, injury, tenderness nor dizziness Eyes: no change in visual field, glasses, contact lenses, diplopia, pain, excessive discharge nor dry eyes. Ears: No Change in hearing, tinnitus, pain, discharge nor dizziness Nose: no allergies, sinus problem, obstruction, polyps, loss of sense of smell, sneezing nor epistaxis. Throat: no toothaches, loose teeth, bleeding gums, mouth sores, hoarseness, dysphagia, ulcerations nor lesions Respiratory: no chest pain, dyspnea, cough nor hemoptysis Cardiovascular: no Chest pain, pressure/ tightness, palpitations, orthopnea, SOB, nor edema. GIT: no dysphagia, heartburn, ulcer, indigestion, diarrhea, constipation, abdominal pain, food intolerance nor hemorrhoids. GUT: no urgency, frequency, nocturia, dysuria, hematuria, UTI nor incontinence Endocrine: no Heat/cold intolerance, weight change, fatigue, polydipsia, polyuria, polyphagia nor change in hair distribution Musculoskeletal: limitation in movement, stiffness, redness, weakness. PHYSICAL EXAMINATION Vital Signs Pulse Rate: 102 bpm Respiratory rate: 22 breaths/min Temperature: 38.4°C Blood Pressure: 120/70mm Hg General Survey: Fairly groomed, conscious, lying on bed, with scars on his extremities, fracture and bandages on his extremities also and ongoing IVF of D5LR. Integument: Inspection: Brown in complexion, scars at extremities and shoulder and forehead, not uniform in color throughout the body. Palpation: Fair skin turgor, warm to touch Nails: Inspection: Untrimmed, dirty fingernails, smooth, nail plate-convex curvature Palpation: Thick, capillary refill = 4 seconds.

Head: Inspection: Normocephalic skull, blackish evenly distributed hair, no infestation Palpation: Smooth skull contour Eyes: Inspection: Symmetrical, PERLLA, can read newsprint, pale palpebral conjunctiva Ears: Inspection: Symmetrical, auricles aligned with the outer canthus of the eye, can hear normal voice tone. Palpation: No discharge, non tender. Nose: Inspection: Symmetrical at midline with no discharges and no frequent sneezing. Palpation: Non tender sinus, patent nasal passages. Throat and Mouth: Inspection: Moist oral mucosa, able to purse lips, pale tongue, moves freely, reddened uvula, non-inflamed tonsils, no dysphagia. Neck: Inspection: Coordinated movements with no discomforts, thyroid gland not visible. Palpation: Non-enlarged lymph nodes, palpable thyroid gland Chest & Lungs: Anterior: Inspection: Symmetrical chest, regular respiratory rhythm, eupnea (RR=22cpm) Palpation: Non-tender, symmetric chest expansion, no nodules nor mass. Percussion: Resonance Auscultation: Clear breath sounds Posterior: Inspection: spine on midline. Palpation: Non-tender, no nodules nor mass. Percussion: Resonance Auscultation: Clear breath sounds Heart: Inspection: Not observable apical pulse Palpation: No thrills, PMI at 5th ICS Midclavicular Percussion: Dullness over heart Auscultation: Regular heart rhythm, good S1 and S2. Abdomen: Inspection: Uniform color, round in shape. Auscultation: Regular bowel sound Percussion: Dullness over liver, tymphany over stomach. Palpation: No tenderness, non-palpable spleen and kidneys. LABORATORY EXAMINATION I. Date: July 20, 2007 Hematology Exam Clotting time Result 2 minutes 40 seconds 1 minute and 10 seconds Normal Values 7-120 seconds Significance Increased in severe coagulation problems and therapeutic administration of heparin. Decreased

Bleeding time

3-8 minutes

II. Date: July 30, 2007 Hematology Exam Hemoglobin Result 56g/L Normal Values Male: 135-170g/L Female: 120-160g/L Male: 0.40-0.54 Female: 0.36-0.47 Male:4.6-6.2x1012/L Significance Decreased in hemodilution(fluid overload), anemia, recent hemorrhage Decreased in hemodilution, anemia, and acute massive blood loss. Decreased in anemia, fluid

Hematocrit Erythrocytes

0.17 1.81x1012/L

Female:4.2-5.4x1012/L Leukocytes Granulocytes Lymphocytes 5.60x109/L 0.52% 0.38% 4.5-10.0x109/L 0.500-0.750% 0.200-0.350%

Monocytes MCV MCH MCHC

0.10% 93 fl 31pg 333

0.20-0.060% 80-96 fl 27-31 pg 320-360

overload, recent hemorrhage, leukemia. Normal Normal Increased in infectious mononucleosis, chronic bacterial infections, tuberculosis, pertussis, lymphocytic leukemia. Decreased in aplastic anemia and lymphocytic anemia Normal Normal Normal

III. Date: July 31, 2007 Hematology Exam Hemoglobin Result 118g/L Normal Values Male: 140-180g/L Female: 120-160g/L Significance Decreased in all anemias and excessive fluid intake, but in the case of the patient since she has heart failure, this is a way to compensate to reduce the fluid volume in the body. Decreased in severe anemias and acute massive blood loss

Hematocrit

0.35

Male: 0.42-0.47 Female: 0.37-0.42

I. PATIENTS PROFILE Name:VALENZONA MERALUNA MAZO Age:8 years old Sex: Female Civil status: elementary pupil Address: Brgy. Magauhan Baybay, Leyte Occupation: N/A Religion: Roman Catholic Nationality: Filipino Birthday: July 11, 1999 Birthplace: Baybay, Leyte Date of Admission:August 28, 2007 Time: 4:15 PM Father: Mario Valenzona Mother: Alona Mazo Occupation: farmer Occupation: housewife Chief Complaint: “Nabari an iya kamot kay nagslide hiya”, as verbalized by the father. Post-op Diagnosis: Supracondylar fracture. Open Type II, Left humerus Operation Performed: “E” ORIF, Crosspinning, Debridement II. History Present Illness Last August 8,2007 at around 5pm while on her way home from school, patient passed on a slope area where she accidentally slide and fractured her left arm. She was sent home by a friend crying for pain then they took her to a known “hilot” in the barrio. The “hilot” immobilized the arm affected by putting a sling. Two days after, her father noticed that the fractured site was swelling so they decided to bring her in brgy, health center near their place but still offers no relief. They decided to bring her to EVRMC for further evaluation and care but they still had to ask for monetary assistance from their Brgy. Captain and Mayor. It took them 18 days more to finally gather enough money for hospitalization, thus on Aug. 28, 2007; the patient was brought to the institution and was admitted the same day and she had her operation last September 1, 2007. III. Past History o No known allergies to foods, medications or any environmental elements. o Never had any surgical procedures or operations. o OTC drugs used includes Biogesic for fever, neozep for colds and no supplement taken. o She completed her immunizations, according to father. o No previous serious injuries and accidents. IV. Childhood Illness o Patient haven’t experienced measles and chicken pox. o She had mumps when she was 6 years old. o According to her father, patient has asthma since she was a younger. V. Family History o Her grandfather on father’s side has hypertension. o Her mother has asthma. o On her father side there is also a history of diabetes meliitus.

nutritional

VI. Lifestyle Patient is a 4th child among six children. She is a grade II pupil in an elementary school near their barangay. She just walks in going to school with her brother. According to her father, patient loves to play with her brothers and sisters after doing their assignment in the evening. But since the accident happen, she stopped going to school and rarely plays with her siblings anymore due to the fracture on her left arm. VII. Social Data Patient lives at Brgy. Magauhan Baybay, Leyte with her parents and four siblings. Their house is made of light materials and conveniences of electricity. Secures water from “tubod” near the house. Dog, pigs and chickens stays outside. Neighborhood is usually safe. VIII. Patterns of Healthcare Visits Brgy. Health Center (also called "sentro” by the father) when sick usually with fever or asthma. She had never visited a dentist.

LABORATORY EXAMINATION HEMATOLOGY- August 28, 2007 Exam Hemoglobin Result 112g/L Normal Values Male: 135-170g/L Female: 120-160g/L 4.5-10.0x109/L 0.6-0.7 Significance Normal;

WBC Segmenter

8.90x109/L 0.53

Normal; Decreased in viral diseases, leukemias, agranulocytosis, aplastic and iron deficiency anemias. Normal; Increased in allergies, parasitic diseases, cancer and phlebitis.

Lymphocytes Eosinophils

0.34 0.13

0.200-0.350 0.01-0.04

MISCELLANEOUS- August 28, 2007 Exam Color: yellow Transparency pH Specific Gravity Albumin Sugar Pus cells Red cells Epith. Cells Mucus threads A. Urates/ phosphates Result yellow clear 6.0 1.010 negative negative 3-5/hpf 0-2/hpf few rare few Normal Values Yellow clear 5.5-6.5 1.002-1.035 Negative Negative 0-2/hpf >3/hpf Rare-few Rare-few Rare-few Significance Normal Normal Normal Normal Normal Normal Increased in infection Normal Normal Normal Normal

Bacteria:

some

none

Increased in infection

REVIEW OF SYSTEMS: Integumentary: no rashes, no lesions, no sores, no bruising. Head: Negates headache, vertigo, syncope. Eyes: no pain, no discharges. Ears: no pain, no discharges, negates tinnitus. Nose and Sinuses: with colds, negates epistaxis, no obstruction, no pain Mouth: No bleeding gums, no lesions, no dysphagia, and no altered taste, no toothache Neck: No stiffness, non-tender Cardiovascular: no edema, no palpitations Endocrine: no excessive sweating Respiratory: no cough, no dyspnea, no hemoptysis, no wheezing. Gastrointestinal: on DAT, no constipation,, no epigastric pain. Urinary: No hematuria, no dysuria. Musculoskeletal: with fracture on left arm, limited movements, with pain when moving affected arm Neurologic: No seizures, no paralysis.

PHYSICAL EXAMINATION: Date of Examination: September 2, 2007 General Survey: Symmetrical body, with fractured left arm, lying in bed with IVF of D50.3%NaCl 500cc at right arm, neatly dressed, sad facial expression, restless and febrile. Vital signs: RR= 28cpm HR= 103bpm Skin: Inspection: No lesions, no ecchymosis, with presence of scars on extremities Palpation: Warm, moist, good skin turgor. Nails: Inspection: pinkish nail beds, no clubbing, dirty fingernails. Palpation: Firm nail base, smooth capillary refill at 2seconds. Head: Inspection: Normocephalic, no lesions, shiny scalp, symmetrical facial features. Palpation: No masses, no depressions, smooth skull contour, non-tender. Hair: Inspection: Equally distributed, there is no presence of lice Palpation: Fine, brittle, no infestations. Eyes: Inspection: Symmetrical, pinkish palpebral conjunctiva, anicteric sclerae, no lesions, no ptosis. Ears: Inspection: Symmetrical, auricles aligned with outer canthus of the eye, no lesions, no discharges Palpation: Non-tender, auricles recoil when pinched. Nose: Inspection: With colds, at midline Palpation: Non-tender sinus. Throat and Mouth: Inspection: with red lips, moist oral mucosa, pinkish tongue at midline, no lesions with gag reflex, with clear to yellowish sputum, reddened uvula, with cavities Neck: Inspection: no neck mass, symmetrical neck muscles Palpation: non-tender, non enlarged lymph nodes. Thorax and Lungs: Anterior: Inspection: Symmetrical chest walls, clavicles at same height, with no effort on breathing Palpation: Non-tender, symmetric chest expansion, no nodules nor mass. Auscultation: bronchovesicular breath sounds. Posterior: Inspection: Scapula at same height bilaterally, spine at midline. Palpation: Non tender, no nodules, no mass. Auscultation: bronchovesicular breath sounds. Heart: Inspection: Not observable apical pulse. Palpation: No thrills, no heaves Auscultation: with regular heart rhythm, no murmur, HR=103bpm Abdomen: Inspection: Symmetrical bilaterally with uniform color. Auscultation: Bowel sounds Palpation: Non tender, non palpable spleen and kidney, non enlarged liver. Extremities: Upper • • With fractured left arm, pain on movement Palpable radical and brachial pulses(right arm)

Temperature= 37.7°C

Lower • With good sensation • Palpable popliteal, posterior tibial, dorsalis pedis pulse. Cardiovascular System:

Heart Rate: 103bpm Rhythm: regular Neurologic: Patient is oriented to person, place and time. No headache.

I. PATIENTS PROFILE Name:ESTOLERO, SELVESTRE BAGALAN Age:27 years old Sex: Male Civil status: single Address: Brgy.san Antonio, Basey,Samar Occupation: None Religion: Roman Catholic Nationality: Filipino Birthday: January 15, 1980 Birthplace: Basey, Samar Date of Admission: June 28, 2007 Time: 2:30 PM Father: -desceasedMother: Anna Estolero Chief Complaint: “Nagcrash ako ha motor asya tak pagnginanhi” as verbalized by the pt. II. History Present Illness Last June 24, 2007 at around 9pm, driving a motorcycle alone on his way home, patient was drunk and he was from a beach with his friends where they had drinking session. He felt asleep while driving that’s why all of the sudden he barely noticed that he had already an accident. According to the patient he doesn’t have any other injury aside from a fractured knee. After the accident, he didn’t loss his consciousness. He was then brought directly to EVRMC by his brother-in-law for management and care. III. Past History o He has known allergies to foods, such as noodles and canned foods. No known allergies to medications or any environmental elements. o He was hospitalized 5yrs ago for dengue and had surgical operations due to stab wound on his right shoulder.. o OTC drugs used includes Biogesic for fever, neozep for colds and no nutritional supplement taken. o He completed his immunizations. o He has no known medical illness. IV. Childhood Illness • Recalls mother telling him about having had chicken pox (date unknown) and mumps, no complications and no other childhood diseases. V. Adult Illness o Patient has no HPN, DM, TB, or asthma. IV. Family History o The patient has a family history of hypertension specifically on his paternal side. But he does not have any family history of DM, heart diseases, arthritis, epilepsy, cancer and psychosis.

VII. Lifestyle

• •

The patient is a known alcoholic and states that he can’t estimate how many liters he drinks every session. He claims that he drinks any alcoholic beverage which ever is available 2-4 times a week. According to him he never tries to smoke. He loves to eat meat, fish, vegetables and hard types of foods. He usually is the one who cooks at home. The patient’s form of exercise is walking and his hobby is just singing.

V. Social Data o

o

The patient is single and currently lives with his parents at Basey, Samar.. He has no works and refer himself as “tambay”. In cases of problems, it is his family who helps him a lot and supports him emotionally. He claims that he has many sets of friends and he is able to get along well with others. Financially, he can’t support himself and can’t provide his own needs for he has no work.

VIII. Patterns of Healthcare Visits hospital when sick. Sees the dentist only when something bothers him, can’t remember last visit. No vision check since can remember. LABORATORY EXAMINATION HEMATOLOGY- June 27, 2007 Exam Clotting time Result 2 mins 55 sec Normal Values 7-120sec Significance Prolonged in severe coagulation problems and therapeutic administration of heparin Prolonged in thrombocytopenia, defective platelet function and aspirin therapy Decrease; various anemias, severe or prolonged hemorrhage and with excessive fluid intake Decrease; severe anemias, acute massive blood loss

Bleeding time

0 mins and 30 sec

1-9 min

Hemoglobin

104g/L

Male: 135-170g/L Female: 120-160g/L

Hematocrit

0.29

Male:0.40-0.54 Female: 0.36-0.47

RBC WBC Segmenter

3.65x10^12/L 11.30x109/L 0.53

Male: 4.6-6.2 Female: 4.2-5.4 4.5-10.0x109/L 0.6-0.7

Decrease; all anemias, after hemorrhage and when blood volume has been restored increase; acute infectious disease Decreased in viral diseases, leukemias, agranulocytosis, aplastic and iron deficiency anemias. Normal; Increased in allergies, parasitic diseases, cancer and phlebitis. Normal Normal Normal

Lymphocytes Monocytes

0.26 0.05

0.200-0.350 0.01-0.04

MCV MCH MCHC

81.00fl 28.59pg 354

80-96 27-31 320-360

Radiologic Exam- June 25,2007 Exam: left thigh to include left knee joint APL Impression: Fracture left femur Left thigh/knee APL Complete displaced fracture involving the distal half of the left femur. No knee dislocation noted. REVIEW OF SYSTEMS:

Integumentary: no rashes, no lesions, no sores, no bruising, swelling on left thigh Head: Negates headache, vertigo, syncope. Eyes: no pain, no discharges. Ears: no pain, no discharges, negates tinnitus. Nose and Sinuses: with colds, negates epistaxis, no obstruction, no pain Mouth: No bleeding gums, no lesions, no dysphagia, and no altered taste, no toothache Neck: No stiffness, non-tender Cardiovascular: no edema, no palpitations Endocrine: no excessive sweating Respiratory: no cough, no dyspnea, no hemoptysis, no wheezing. Gastrointestinal: on DAT, no constipation, no epigastric pain. Urinary: No hematuria, no dysuria. Musculoskeletal: with fracture on left arm, limited movements, with pain when moving affected arm Neurologic: No seizures, no paralysis. PHYSICAL EXAMINATION: Date of Examination: September 2, 2007 General Survey: Symmetrical body, with fractured left arm, sitting on bed without IVF, patient wearing no shirt Vital signs: RR= 21cpm PR= 63bpm Temperature= 36.8°C BP: 110/70mmHg Skin: Inspection: No lesions, no ecchymosis, with presence of scars on extremities and on left shoulder area from stab wound Palpation: Warm, moist, good skin turgor. Nails: Inspection: pale nail beds, no clubbing, dirty fingernails and hands Palpation: Firm nail base, smooth capillary refill at 2seconds. Head: Inspection: Normocephalic, no lesions, shiny scalp, symmetrical facial features. Palpation: No masses, no depressions, smooth skull contour, non-tender.

Hair: Inspection: Equally distributed, there is no presence of lice Palpation: Fine, brittle, no infestations. Eyes: Inspection: Symmetrical, pinkish palpebral conjunctiva, anicteric sclerae, no lesions, no ptosis. Ears: Inspection: Symmetrical, auricles aligned with outer canthus of the eye, no lesions, no discharges Palpation: Non-tender, auricles recoil when pinched. Nose: Inspection: With colds, at midline Palpation: Non-tender sinus.

Throat and Mouth: Inspection: with red lips, moist oral mucosa, pinkish tongue at midline, no lesions with gag reflex, with clear to yellowish sputum, reddened uvula, with cavities Neck: Inspection: no neck mass, symmetrical neck muscles Palpation: non-tender, non enlarged lymph nodes. Thorax and Lungs: Anterior: Inspection: Symmetrical chest walls, clavicles at same height, with no effort on breathing Palpation: Non-tender, symmetric chest expansion, no nodules nor mass. Auscultation: bronchovesicular breath sounds. Posterior: Inspection: Scapula at same height bilaterally, spine at midline. Palpation: Non tender, no nodules, no mass. Auscultation: bronchovesicular breath sounds. Heart: Inspection: Not observable apical pulse. Palpation: No thrills, no heaves Auscultation: with regular heart rhythm, no murmur, PR=63bpm

Abdomen: Inspection: Symmetrical bilaterally with uniform color. Auscultation: Bowel sounds Palpation: Non tender, non palpable spleen and kidney, non enlarged liver. Extremities: Upper • • Palpable radical and brachial pulses With good sensation

Lower • With fractured left thigh, with slight pain on movement • Palpable popliteal, posterior tibial, dorsalis pedis pulse(right leg) Cardiovascular System: Pulse Rate: 63bpm Rhythm: regular Neurologic: Patient is oriented to person, place and time. No headache.

PATIENTS PROFILE Name: Jojo Sarmiento Lagrimas Case No: 346529 Age: 28 years old Sex: Male Civil status: Married Address: Barangay Macatingog Calbayog City Occupation: Motorcycle driver Religion: Roman Catholic Nationality: Filipino Birthday: December 26, 1978 Birthplace: Calbayog City Date of Admission: 7/23/07 Time: 11 PM Father: Bienvenido Lagrimas Mother: Flora Sarmiento Wife: Alhpy Lagrimas Age: 23 years old Attending Consultant:: Dr. Jude Macasil Chief Complaint:: Vehicular accident History Present Illness Last July 2007, the patient was involved in a vehicular accident in Calbayog City. While he was driving his motorcycle, a truck driver was out of the line and hit his motorcycle. The truck driver was under the influence of alcohol. After he was hit, he became unconsciousness, and when he woke up he was already in the hospital in Calbayog city. He had many wounds, fracture on his extremities especially the left femur. Aside from the fracture, the patient now has fever. Whenever he changes his position, he feels the pain in his leg. This is relieved by meds and rest. Past History According to the patient, he had measles, chicken pox and mumps when he was a child. His immunizations are complete. According to his mother, he has allergy to a certain type of fish but was unable to recall that certain fish. His first hospitalizations was in Calbayog city after the accident. Family History According to the patient, her family has a history of asthma but no HPN, diabetes, heart diseases or others. Psychosocial history: The patient is a motorcycle driver in Calbayog city. So because of that, his usual ADL is driving. He doest not exercise regularly and doest not drink alcoholic beverages and does not smoke. He has no problems with his sleeping patterns. Social Data The patient has two children. His highest educational attainment is 1st year high school. Their house has 1 bedroom, no toilet and their source of water is the faucet in the barangay. They have electricity and their house is made of wood. REVIEW OF SYSTEMS:

General: weight loss, fever and no chills. Skin: Bruising, change in color, scars, drying, wounds Head: No headaches, injury, tenderness nor dizziness Eyes: no change in visual field, glasses, contact lenses, diplopia, pain, excessive discharge nor dry eyes. Ears: No Change in hearing, tinnitus, pain, discharge nor dizziness Nose: no allergies, sinus problem, obstruction, polyps, loss of sense of smell, sneezing nor epistaxis. Throat: no toothaches, loose teeth, bleeding gums, mouth sores, hoarseness, dysphagia, ulcerations nor lesions Respiratory: no chest pain, dyspnea, cough nor hemoptysis Cardiovascular: no Chest pain, pressure/ tightness, palpitations, orthopnea, SOB, nor edema. GIT: no dysphagia, heartburn, ulcer, indigestion, diarrhea, constipation, abdominal pain, food intolerance nor hemorrhoids. GUT: no urgency, frequency, nocturia, dysuria, hematuria, UTI nor incontinence Endocrine: no Heat/cold intolerance, weight change, fatigue, polydipsia, polyuria, polyphagia nor change in hair distribution Musculoskeletal: limitation in movement, stiffness, redness, weakness. PHYSICAL EXAMINATION Vital Signs Pulse Rate: 102 bpm Respiratory rate: 22 breaths/min Temperature: 38.4°C Blood Pressure: 120/70mm Hg General Survey: Fairly groomed, conscious, lying on bed, with scars on his extremities, fracture and bandages on his extremities also and ongoing IVF of D5LR. Integument: Inspection: Brown in complexion, scars at extremities and shoulder and forehead, not uniform in color throughout the body. Palpation: Fair skin turgor, warm to touch Nails: Inspection: Untrimmed, dirty fingernails, smooth, nail plate-convex curvature Palpation: Thick, capillary refill = 4 seconds. Head: Inspection: Normocephalic skull, blackish evenly distributed hair, no infestation Palpation: Smooth skull contour Eyes: Inspection: Symmetrical, PERLLA, can read newsprint, pale palpebral conjunctiva Ears: Inspection: Symmetrical, auricles aligned with the outer canthus of the eye, can hear normal voice tone. Palpation: No discharge, non tender. Nose: Inspection: Symmetrical at midline with no discharges and no frequent sneezing. Palpation: Non tender sinus, patent nasal passages. Throat and Mouth: Inspection: Moist oral mucosa, able to purse lips, pale tongue, moves freely, reddened uvula, non-inflamed tonsils, no dysphagia. Neck: Inspection: Coordinated movements with no discomforts, thyroid gland not visible. Palpation: Non-enlarged lymph nodes, palpable thyroid gland Chest & Lungs: Anterior: Inspection: Symmetrical chest, regular respiratory rhythm, eupnea (RR=22cpm) Palpation: Non-tender, symmetric chest expansion, no nodules nor mass. Percussion: Resonance Auscultation: Clear breath sounds Posterior: Inspection: spine on midline. Palpation: Non-tender, no nodules nor mass. Percussion: Resonance Auscultation: Clear breath sounds

Heart: Inspection: Not observable apical pulse Palpation: No thrills, PMI at 5th ICS Midclavicular Percussion: Dullness over heart Auscultation: Regular heart rhythm, good S1 and S2. Abdomen: Inspection: Uniform color, round in shape. Auscultation: Regular bowel sound Percussion: Dullness over liver, tymphany over stomach. Palpation: No tenderness, non-palpable spleen and kidneys. LABORATORY EXAMINATION I. Date: July 20, 2007 Hematology Exam Clotting time Result 2 minutes 40 seconds 1 minute and 10 seconds Normal Values 7-120 seconds Significance Increased in severe coagulation problems and therapeutic administration of heparin. Decreased

Bleeding time

3-8 minutes

II. Date: July 30, 2007 Hematology Exam Hemoglobin Result 56g/L Normal Values Male: 135-170g/L Female: 120-160g/L Male: 0.40-0.54 Female: 0.36-0.47 Male:4.6-6.2x1012/L Female:4.2-5.4x1012/L 4.5-10.0x109/L 0.500-0.750% 0.200-0.350% Significance Decreased in hemodilution(fluid overload), anemia, recent hemorrhage Decreased in hemodilution, anemia, and acute massive blood loss. Decreased in anemia, fluid overload, recent hemorrhage, leukemia. Normal Normal Increased in infectious mononucleosis, chronic bacterial infections, tuberculosis, pertussis, lymphocytic leukemia. Decreased in aplastic anemia and lymphocytic anemia Normal Normal Normal

Hematocrit Erythrocytes Leukocytes Granulocytes Lymphocytes

0.17 1.81x1012/L 5.60x109/L 0.52% 0.38%

Monocytes MCV MCH MCHC

0.10% 93 fl 31pg 333

0.20-0.060% 80-96 fl 27-31 pg 320-360

III. Date: July 31, 2007 Hematology Exam Hemoglobin Result 118g/L Normal Values Male: 140-180g/L Female: 120-160g/L Significance Decreased in all anemias and excessive fluid intake, but in the case of the patient since she has heart failure, this is a way to compensate to reduce the fluid volume in the body. Decreased in severe anemias and acute massive blood loss

Hematocrit

0.35

Male: 0.42-0.47 Female: 0.37-0.42

PATIENTS PROFILE

Name: Lolita Obero Javines Case No: 325528 Age: 45 years old Sex: Female Civil status: Married Address: Barangay Culasian Capoocan Leyte Occupation: Housewife Religion: Roman Catholic Nationality: Filipino Birthday: July 20, 1962 Birthplace: Capoocan, Leyte Date of Admission: 8/27/07 Time: 1:30 PM Father: Deceased Mother: Encarnacion Cabiltes Husband: Dino Javines Age: 43 years old Occupation: farmer Attending Consultant:: Dr. Henry Salubon Chief Complaint:: Removal of Implant (ROI) History Present Illness Last April 23, 2007, the patient was involved in an accident. Around 6 in the evening that day, she was walking towards their house at the side of the streets, when suddenly a motorcycle driver hit her. The driver was under the influence of alcohol. Immediately after the accident, the patient lost her consciousness and was brought to the hospital. She regained her consciousness the following day in St. Paul’s hospital where her son brought him. When she woke up, her right arm has a cast and her leg had a bandaged. She stayed in the hospital for 5 days. During which she was operated In her right leg. Her cast was removed after three weeks and she went on a regular check-up. Then last August 27, 2007, she was admitted in this institution for the removal of her implant. Past History According to the patient, the only childhood illness she can remember that she had was measles. Her immunizations was complete. She has no allergies to any food, drug, animal, plant or others. She was hospitalized first in St. Pauls Hospital last April 23, 2007 because of the accident.. She was confined there for 5 days only and was operated on her right leg and had a cast on her right arm. Family History According to the patient, her family has a history of hypertension but no asthma, diabetes, heart diseases or others. Psychosocial history: The patient is a plain and devoted housewife. She takes care of her family. Her usual activities of daily living are cooking, cleaning the house, washing their clothes and utensils, and others. Household chores is her form of exercise. She does not smoke but admitted she drinks tuba before, but now is afraid to drink because of the accident. Sometimes the patient has difficulty in sleeping because of the setting in the hospital. Social Data The patient has 6 children. Some of her children has their own family and lives separately. Her highest educational attainment was Grade 6. Before, she was working in a restaurant as a cook. The patient’s house has 2 bedrooms, 1 toilet, has no electricity, only lampara, and their source of water is from the faucet in the barangay. Their house is made of cement and wood and is about 150 meters away from the main road. REVIEW OF SYSTEMS: General: No weight loss, no fever and chills. Skin: No rashes, pruritus, bruising, change in color, lumps, sores, itching, nor dryness Head: No headaches, injury, tenderness nor dizziness Eyes: no change in visual field, glasses, contact lenses, diplopia, pain, excessive discharge nor dry eyes. Ears: No Change in hearing, tinnitus, pain, discharge nor dizziness Nose: no allergies, sinus problem, obstruction, polyps, loss of sense of smell, sneezing nor epistaxis. Throat: no toothaches, loose teeth, bleeding gums, mouth sores, hoarseness, dysphagia, ulcerations nor lesions Respiratory: no chest pain, dyspnea, cough nor hemoptysis Cardiovascular: no Chest pain, pressure/ tightness, palpitations, orthopnea, SOB, nor edema. GIT: no dysphagia, heartburn, ulcer, indigestion, diarrhea, constipation, abdominal pain, food intolerance nor hemorrhoids. GUT: no urgency, frequency, nocturia, dysuria, hematuria, UTI nor incontinence Endocrine: no Heat/cold intolerance, weight change, fatigue, polydipsia, polyuria, polyphagia nor change in hair distribution Musculoskeletal: limitation in movement, slight weakness, pain in her right leg.

PHYSICAL EXAMINATION Vital Signs Pulse Rate: 90 bpm Respiratory rate: 20 breaths/min Temperature: 37°C Blood Pressure: 140/90mm Hg General Survey: Fairly groomed, conscious, sitting on bed with no IVF. Integument: Inspection: Brown in complexion, scar at right extremity. Palpation: Fair skin turgor, warm to touch Nails: Inspection: trimmed, clean fingernails, smooth, nail plate-convex curvature Palpation: Thick, capillary refill = 3 seconds. Head: Inspection: Normocephalic skull, blackish evenly distributed hair, no infestation Palpation: Smooth skull contour Eyes: Inspection: Symmetrical, PERLLA, can read newsprint, pinkish palpebral conjunctiva Ears: Inspection: Symmetrical, auricles aligned with the outer canthus of the eye, can hear normal voice tone. Palpation: No discharge, non tender. Nose: Inspection: Symmetrical at midline with no discharges and no frequent sneezing. Palpation: Non tender sinus, patent nasal passages. Throat and Mouth: Inspection: Moist oral mucosa, able to purse lips, pinkish tongue, moves freely, reddened uvula, non-inflamed tonsils, no dysphagia. Neck: Inspection: Coordinated movements with no discomforts, thyroid gland not visible. Palpation: Non-enlarged lymph nodes, palpable thyroid gland Chest & Lungs: Anterior: Inspection: Symmetrical chest, regular respiratory rhythm, eupnea (RR=20cpm) Palpation: Non-tender, symmetric chest expansion, no nodules nor mass. Percussion: Resonance Auscultation: Clear breath sounds Posterior: Inspection: spine on midline. Palpation: Non-tender, no nodules nor mass. Percussion: Resonance Auscultation: Clear breath sounds Heart: Inspection: Not observable apical pulse Palpation: No thrills, PMI at 5th ICS Midclavicular Percussion: Dullness over heart Auscultation: Regular heart rhythm, good S1 and S2. Abdomen: Inspection: Uniform color, round in shape. Auscultation: Regular bowel sound (7 per min.) Percussion: Dullness over liver, tymphany over stomach. Palpation: No tenderness, non-palpable spleen and kidneys.

LABORATORY EXAMINATION I. Date: August 20, 2007 X RAY Impression: No significant chest findings

II. Date: August 20, 2007 Hematology Exam Result Hemoglobin 137g/L Hematocrit WBC Segmenter Lymphocytes Monocytes Clotting time 0.40 5.9x109/L 0.65 0.30% 0.05% 4mins and 6seconds

Normal Values Male: 135-170g/L Female: 120-160g/L Male: 0.40-0.54 Female: 0.36-0.47 4.5-10.0x109/L 0.6-0.7 0.200-0.350% 0.20-0.060% 7-120 seconds

Significance Normal Normal Normal Normal Normal Normal Increased in severe coagulation problems and therapeutic administration of heparin. Decreased

Bleeding time

1minute and 38 seconds

3-8 mins

III. Date: August 20, 2007 Urinalysis Exam Result Color Yellow Transparency pH Specific gravity Albumin Sugar WBC Red blood cells Epithelial cells Bacteria A.urates Mucus threads Reaction Slight Turbid 5.0 1.025 Positive Negative 8-12/hpf 1-2/hpf Some Few Few Moderate Acidic

Normal Findings Colorless to dark yellow Clear 4.6-8.0 1.006-1.030 Negative Negative 3-4/hpf 2-4/hpf No significance None No significance No significance Acidic

Significance Normal Normal Normal Normal Proteinuria, severe stress, acute infectious disease Normal UTI, fever, strenuous exercise, renal disease Normal Normal Normal Normal Normal Normal

IV. Date: August 21, 2007 Clinical Chemistry Exam Result FBS 5.19mmol/L Cholesterol 3.62 mmol/L Creatinine 51 umol/L BUA 445 umol/L HDL 1.78 mmol/L

Normal Findings 3.89-5.84mmol/L Up to 5.7mmol/L 50-100umol/L 135-357umol/L More than 1.68mmol/L Less than 3.9mmol/L 0.46-1.60mmol/L 135-148mmol/L 3.5-5.3mmo/L

LDL Triglycerrides NA K

1.63mmol/L 0.46mmol/L 141mmol/L 3.89mmol/L

Significance Normal Normal Normal Increased Increased hypolilolproteinemia, acute MI, DM, Diet high in saturated fats Normal Normal Normal Normal

I. PATIENTS PROFILE Name: Stanley Josydre Castroverde Busante Case No: 029599 Age: 5 years old Sex: Male Civil status: Single Address: Brgy. 63 Mangga Sagkahan Tacloban City Religion: Roman Catholic Nationality: Filipino Birthday: November 13, 2001 Birthplace: Tacloban City Date of Admission: September 8, 2007 Time: 2:00PM Father: Marlon Tan Mother: Rhaila Czarina Busante Attending Consultant: Dr. Troyo/ Dr. Añover

Chief Complaint: Fall Diagnosis: Fracture closed proximal 3rd right thigh II. History Present Illness Few hours PTA, patient was riding a bicycle together with his neighbors. Suddenly, they had an accident, and the patient landed on his right side, injuring his right thigh. Immediately, the patient felt severe and unbearable pain. There was also swelling and redness. So, his parents immediately decided to bring him to RTR hospital without moving his right thigh, hence admission. III. Past History • This is the second time the patient was hospitalized. First was in St. Paul’s hospital last 2003 due to pneumonia. • The patient had measles when he was one year old and mumps when he was 4 years old. • He has complete immunizations but except for chicken pox. • The patient has no allergies to food, drugs and animals. • The patient takes Ascorbic Acid as his supplement. IV. Family History The patient’s family has a history of both hypertension and asthma. Hypertension is from the maternal side and asthma on the paternal side. V. Lifestyle • As a child, the patient loves to play with his playmates. • He has no problems with regards to his sleeping pattern. • He usually wakes up at around 6AM because he has to go to school. • He sleeps in the afternoon after school, then wakes up at 5 PM then sleeps at around 10PM. Review of Systems: General: Patient is conscious, coherent, and responsive and oriented to time, place and person. Patient is afebrile. Skin: There are no complaints of rashes, itching, and dryness of skin. Heent: Head: Patient has no headache or dizziness. Eyes: Patient does not wear glasses or contact lenses; negates having blurred vision, double vision excessive tearing, redness and pain. Ears: Negates having hearing problems, vertigo, ear ache, tinnitus and abnormal ear discharges. Nose: Patient has no episodes of epistaxis, no colds and no nasal discharges. Neck: Negates having nuchal pain and stiffness. Respiratory: Negates having dry cough and difficulty of breathing. Cardiovascular: Negates being hypertensive, there’s no complaints of chest pain and discomfort, no palpitations, orthopnea, or heartburn. Gastrointestinal:

Negates having problems swallowing, nausea, lose of appetite, and heartburn. There is no abdominal pain, food intolerance and excessive belching. Musculoskeletal: Complaints of pain on right thigh especially upon movement. Physical Examination General Survey: Conscious, coherent and respomsive V/S: Skin: Inspection: uniformly distribute skin color on the unaffected side, no areas of increased vascularities, ecchymosis or bleeding with dry and intact dressing on right thigh, pale skin color on right thigh. Palpation: warm, good skin turgor but cold clammy skin on right thigh Nails: Inspection: pale nail beds distal to affected area (right thigh) Palpation: firm nail base, smooth Head: Inspection: normocephalic, symmetrical, with intact shiny scalp, evenly distributed hair. Palpation: Smooth skull contours, non tender, without masses or depressions. Eyes: Inspection: symmetrical, pinkish palpebral conjunctiva, PERRLA, no discharges; no lesions. Ears: Inspection: symmetrical, auricles aligned with outer canthus of eye, no lesions, no discharges Palpation: non tender auricles, recoil when pinched. Nose: Inspection: symmetrically in midline of face, without swelling, discharges, lesions Palaption: non tender, non swelling sinus, patent nostrils Throat and mouth: Inspection: moist mucus membrane, no evidence of lesions, or inflammation, with gag reflex. Neck: Inspection: symmetric muscles, without masses or spasms. Palpation: no enlargement of thyroid gland, no masses, or tenderness, no enlarged lymph nodes Auscultation: no presence of bruits observed. RR:22 cpm HR:88 bpm T: 36°C

Thorax and Lungs: Inspection: symmetric chest walls, shoulders at same height, scapula at same height bilaterally, no retractions, or bulging ICS, with regular rhythmic breathing. Palpation: no tender symmetric chest expansion, no nodules or masses Percussion: resonant overall lung fields Auscultation: bronchovesicular lung sounds

Heart: Inspection: not observable apical pulse Palpation: no thrills, nor heaves, Percussion: dullness over heart Auscultation: no murmurs, S1,S2 sounds Abdomen: Inspection: with uniform color and pigmentation, symmetrical bilateral Percussion: tympany over stomach, dullness over liver Palpation: no tenderness, no palpable spleen and kidney non enlarged liver The musculo-skeletal system • Pain, pale skin color, capillary refill of 6, cold clammy skin on affected area. • With limitation of movement • Weakness

PATIENTS PROFILE Name: Christopher Panistan Maballo Age: 2 years old Address: Brgy. Rizal, La Paz Leyte Religion: N/A Birthday: March 24, 2005 Date of Admission: September 16, 2007 Father: Eduardo Maballo Mother: Nilda Maballo Attending Consultant: Dr. Arcano/ Verano/ Dadizon Chief Complaint: Abscess left gluteal area Case No: 353692 Sex: Male Nationality: Filipino Birthplace: La paz, Leyte Time: 3:50PM Occupation: Farmer Occupation: Housewife

II. History Present Illness Five days prior to admission, patient was playing outside their house when suddenly he fell on his left side. The following days, he had an abscess on his left gluteal area. It gradually becomes bigger everyday. Patient complains of severe pain through crying. Symptoms associated with the chief complaint are fever, cough and colds. When patient is sitting or lying on his left side, the pain becomes very severe. Hence parents decided to bring the patient to this center. III. Past History This is the first time the patient was hospitalized. He had not yet experienced chicken pox, measles, mumps or any other childhood disease but according to his parents, he had complete immunizations. He has no allergies to any food or drug. The patient takes multivitamins everyday. IV. Family History According to the significant others, patient’s family has no history of asthma, DM, hypertension, nor heart disease. V. Psychosocial History Patient as a child loves to play with his siblings and to watch programs on television. In the past few days, due to his abscess, he had sleeping difficulties. According to his mother, patient cannot sleep well at night due to severe pain. VI. Social Data Patient’s family lives in Barangay La Paz Leyte. They live in a one bedroom house along side the main road. They have one toilet. Their electricity is from DORELCO and their water source is from the “bomba”. LABORATORY EXAMS: I. X-ray report ( 9/16/07) Chest Xray PA view

Impression: Normal radiographic chest findings. II. Laboratory Report (9/17/07) Specimen: discharge Result: Gram (+) cocci in pairs, short chain and small clusters. Pus cells: 10-19/hpf III. Hematology (9/16/07) Exam Hemoglobin Hematocrit WBC Segmenter Lymphocytes Result 53g/L 0.15 14.1x109/L 0.86 0.14 Normal Values Male: 135-170g/L Female: 120-160g/L Male: 0.40-0.54 Female: 0.36-0.47 5-10.0x109/L 0.5-0.7 0.25-0.40 Significance Decreased in hemodilution(fluid overload), anemia, recent hemorrhage Decreased in hemodilution, anemia, and acute massive blood loss. increase;acute infectious disease Increased acute infections, inflammatory disease, tissue damage. Decreased in leukemia, aplastic anemia, agranulocytosis, renal failure.

REVIEW OF SYSTEMS General: With fever and chills. Skin: Bruising, change in color on left gluteal area. Head: No headaches, injury, tenderness nor dizziness Eyes: no change in visual field, glasses, contact lenses, diplopia, pain, excessive discharge nor dry eyes. Ears: No Change in hearing, tinnitus, pain, discharge nor dizziness Nose: no allergies, sinus problem, obstruction, polyps, loss of sense of smell, sneezing nor epistaxis. Throat: no toothaches, bleeding gums, mouth sores, hoarseness, dysphagia, ulcerations nor lesions Respiratory: no chest pain, dyspnea, nor hemoptysis but with non productive cough. Cardiovascular: no Chest pain, pressure/ tightness, palpitations, orthopnea, SOB, nor edema. GIT: no dysphagia, heartburn, ulcer, indigestion, diarrhea, constipation, abdominal pain, food intolerance nor hemorrhoids. GUT: no urgency, frequency, nocturia, dysuria, hematuria, UTI nor incontinence Endocrine: no Heat/cold intolerance, weight change, fatigue, polydipsia, polyuria, polyphagia nor change in hair distribution Musculoskeletal: limitation in movement, weakness and pain on left gluteal area. Physical Examination General Survey: Conscious, coherent and respomsive V/S: Skin: Inspection: Uniform skin color on some areas, with scars on upper extremities, no bleeding, ecchymosis but with bruising skin color on left gluteal area. Palpation: good skin turgor, warm to touch Nails: Inspection: pale nail beds trimmed, clean fingernails, smooth, nail plate-convex curvature Palpation: firm nail base, smooth Head: Inspection: normocephalic, symmetrical, with intact shiny scalp, evenly distributed hair. Palpation: Smooth skull contours, non tender, without masses or depressions. Eyes: Inspection: symmetrical, pinkish palpebral conjunctiva, PERRLA, no discharges; no lesions. Ears: Inspection: symmetrical, auricles aligned with outer canthus of eye, no lesions, and no discharges Palpation: non tender auricles, recoil when pinched. RR:31 cpm HR:132 bpm T: 37.5°C

Nose: Inspection: symmetrically in midline of face, without swelling, discharges, lesions Palpation: non tender, non swelling sinus, patent nostrils Throat and mouth: Inspection: moist mucus membrane, no evidence of lesions, or inflammation, with gag reflex. Neck: Inspection: symmetric muscles, without masses or spasms. Palpation: no enlargement of thyroid gland, no masses, or tenderness, no enlarged lymph nodes Thorax and Lungs: Inspection: symmetric chest walls, shoulders at same height, scapula at same height bilaterally, no retractions, or bulging ICS, with regular rhythmic breathing. Palpation: no tender symmetric chest expansion, no nodules or masses Percussion: resonant overall lung fields Auscultation: bronchovesicular lung sounds Heart: Inspection: not observable apical pulse Palpation: no thrills, nor heaves, Percussion: dullness over heart Auscultation: no murmurs, S1,S2 sounds Abdomen: Inspection: with uniform color and pigmentation, symmetrical bilateral Percussion: tympany over stomach, dullness over liver Palpation: no tenderness, no palpable spleen and kidney non enlarged liver The musculo-skeletal system • Pain and pale skin color on left gluteal area • Limited movements • Weakness

VII.

Patient’s Profile Name: Ramos, Marissa Ada Age: 36 Sex: Female Address: Naga-naga, Palo Leyte Religion: Catholic Occupation: Fish vendor Date of birth: 10-27-70 Birthplace: Borongan Mother: Delia Ada Father: Bonifacio Baydin Date Admission: 9-05-07 Time of Admission: 9:30 AM Diagnosis: Ductal Breast Carcinoma, Right inflammatory, Cardiomegaly with Pulmonary Congestion, Bibasal Pneumonia History This is a case Ramos, Marissa 36 y.o, female residing at Naga-naga, Palo Leyte was admitted for the first time at EVRMC as a referral from Schistosomiasis Center and Research Hospital for further evaluation and management of the client’s condition. According to the client the development of her disease condition started a year ago when her breast was accidentally strongly hit by the head of her child while she was bathing him. Pain was noted right after the incident but no other manifestations were seen, after one month the patient noticed a small mass about the size of a mongo bean was growing in her right breast, however no consultation was done. After 3 months her right breast became painful and the masses grew bigger, this prompted her to seek consultation to a “tambalan”. She was given virgin coconut oil to be taken everyday. There was a slight decrease in size of the breast mass noted but not totally. Since there was no full abatement of the condition of the patient, she tried to seek consult to another “tambalan”, medication was given to her but could not remember the name, after which she noticed that the mass just grew bigger. Everyday it grew, got bigger, and increased in number. This now prompted her to seek consult at their rural health unit and there she was given Cefalexin. However, the mass still remained to grow in size. 5 months prior to current admission, the patient sought consult at EVRMC and had a biopsy of her breast mass done. The result revealed cellular features consistent with intraductal carcinoma, Right breast. The patient was advised to undergo surgery but due to financial constraints, she wasn’t able to comply. The mass continued to grow in size until it became ulcerated and necrotic. 3 months prior to current admission the patient sought medical consultation at Schistosomiasis Center and Research Hospital and subsequently followed up at the OPD. She was then referred to EVRMC to further evaluate and manage her condition. The patient prompted consult and was then admitted. Past History: The patient had no other previous hospitalization due to serious medical illness before, but she recalled that when she was still a child she experienced a minor vehicular accident which gave her a scar on her left toe, however the accident that she experienced was not that serious enough to cause her fractures and hospitalization. She also stated that she did not experience having previous history of hypertension, diabetes mellitus, asthma, past operation, and transfusion. She has also no known allergy to food, drugs, and animals.

VIII.

IX.

With regards to her childhood illness, she recalled having chickenpox when she was little, but not mumps and measles. The client cannot recall if she received complete doses of her immunizations when she was still a child.

X.

Lifestyle: The patient was a former smoker, and started at the age of 22, she usually is able to consume more or less 1 pack per day, three times a week; however she stopped when she started having manifestations of her present disease condition. She is also an occasional alcoholic beverage drinker prior to illness. With regards to her daily food intake, she said that previously she usually eats anything that is served. She has no diet restrictions and has good appetite. At present, because of her disease condition she said that she is not able to eat very well, she usually has no good appetite for eating. When asked about her fluid intake, she stated that she is able to consume about 6 glasses of water as day. She has no vitamins and supplements being taken. Regarding her elimination pattern, she said that previously and even until present she moves her bowel every morning of everyday to a formed and brown stool, with no difficulty. She also stated that she voids more or less 6 times a day to a yellow colored urine about 1 full glass in amount for every time she voids. The patient has does not perform any exercise regimen in the past. With regards to her sleeping pattern, she said that she usually sleeps at 7 PM and wakes up at 6AM, but at present she stated that she is not able to sleep well at night due to the pain of her breast. Family History: a. Both of the patient’s mother and father are apparently well but are separated a long time ago. When asked about her family history of diseases. She said that both her grandmother and grandfather had hypertension and arthritis; however other diseases such as heart disease, cancer, diabetes, asthma, and bleeding disorders are not present in their family. i. Social Data The patient has a husband; however they are not yet legally married. They also have 2 children both are boys but are not already living with them. The patient is a high school graduate. She formerly works as a fish vendor.

XI.

XII.

PHYSICAL EXAMINATION: GG. General Health: patient is cooperative, easy to talk with, responds when asked but with poor eye contact. Patient appears weak and distressed HH. Vital Signs: BP: 120/80 mm Hg HR: 85 bpm RR: 36 cpm Temp: 37.5°C II. Head: Inspection: normocephalic and symmetrical Palpation: No tenderness or mass, absence of nodules. JJ. Hair: Inspection: short, black, unwashed hair, evenly distributed, scalp has no infection or infestation; Palpation: thin, resilient hair KK. Nails: Inspection: Convex curvature, capillary bed is pale in color Palpation: smooth texture, delay in return of capillary refill (about 4 seconds; normal is less than 3 seconds) LL. Skin: Inspection: light brown in color, with presence of edema on right arm on metacarpal area, is painful and reddened; pallor is noted Palpation: skin is warm to touch, dry, with good skin turgor MM.Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no discharges and no discoloration, and sclera appears white and clear, pupils are equally round and reactive to light and accommodation Palpation: pale palpebral conjunctiva, no periorbital edema, no tenderness over lacrimal gland. NN. Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, has no difficulty in hearing normal voice tones Palpation: auricles are mobile, firm and not tender OO. Nose: Inspection: no discharges, with nasal flaring noted Palpation: Not tender, no lesions PP. Mouth: Inspection: lips pink in color, moist and pinkish buccal membrane, no dentures, tongue moves freely, with good set of teeth, no presence of mouth sores Palpation: soft mucus membrane and smooth texture QQ. Neck: Inspection: able to flex, hyperextend and rotate head, thyroid gland not visible, no neck vein distention, no visible pulsations Palpation: no palpable lymph nodes (no cervical lymphadenopathy) RR. Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact, symmetric chest expansion, use of accessory muscles, no marked retractions, difficulty in breathing, rapid shallow respiration noted, productive cough noted with whitish sputum, with pulmonary congestion Palpation: no tenderness and no masses, Auscultation: with crackles

SS. Breast: Inspection: grossly enlarged right breast, with areas of ulceration and presence of yellowish purulent discharges, skin dimpling and nipple retraction noted, breast looks like an orange peel Palpation: tenderness with great severity of right breast, palpable hard mass TT. Cardiovascular: Inspection: with no abnormal pulsations Palpation: not easily palpable radial pulse Auscultation: no abnormal heart sound, no murmurs, heartbeat is regular and synchronous UU. Abdomen: Inspection: flat and rounded, no evidence of enlargement of liver Palpation: soft, no tenderness Auscultation: 14 bowel sounds/min VV. Musculoskeletal: Inspection: no contractures, no tremors, limited ROM, with poor left leg muscle strength and tone Palpation: tenderness of left groin area, joint pain, normal skin temperature WW. Extremities: Inspection: fat and flabby, unable to raise left leg, no active lesions noted Palpation: no tenderness, with full and equal pulses XX. Mental Status: Oriented to time, place and person, responsive, with no discrepancies with past memory. REVIEW OF SYSTEMS: MM.General Health: patient is restless, appears frail, acutely ill. Distress noted through facial expression of pain and guarding behavior. Patient verbalized of not being able to perform self-care activities due to pain. NN. Skin: pain and edema on right arm at metacarpal area OO. Head: verbalization of nausea, no headache PP. Face: facial grimacing due to pain QQ. Eyes: no blurring of vision, no visual disturbances, no pain around the eyes RR. Ears: no tinnitus and vertigo of ears, no tenderness SS. Nose: no change in sense of smell, no colds, no bleeding, difficulty of breathing TT. Mouth: no hoarseness and sore throat, no bleeding gums, no difficulty in swallowing and chewing of food, poor appetite UU. Respiratory: with orthopnea, dyspnea, and shortness of breath VV. Cardiovascular: no complaints of chest pain, no syncope, no abnormal palpitations WW. Breast: throbbing pain on right breast with the scale of 8 XX. Gastrointestinal: no pain on the stomach YY. Genitourinary: voided more than 6 times during the whole shift with no pain and discomfort during urination ZZ. Musculoskeletal: easy fatigability, decreased muscle strength, limited ROM of extremities (especially the right leg), unable to move about, with difficulty in changing position like turning and sitting and still needs assistance in performing self-care activities

LABORATORY EXAMS Date 09-1407 08-2107 08-1307 Hematology Lab Exam Clinical Chemistry Result Na: 140.3 K: 4.63 Cl: 95.5 Glucose: 4.1 mmol/L Creatinine: 62.3 umol/L Hct: 0.40 WBC: 6.55x 10~9/L Differential count: Segmenter: 0.54 Eosiniphil: 0.09 Lymphocyte: 0.29 Monocyte: 0.08 Clotting time: 3 mins 15 sec Bleeding time: 1 min RBC: 4.04 x 10~12/L WBC: 7.30 x 10~9/L Granulocytes: 0.63 Lymphocyte: 0.33 Monocyte: 0.04 MCV: 86.00 fl MCH: 35.10 pg MCHC: 408 08-1307 Urinalysis Color: Light yellow Transparency: Slt. Turbid Sp. Gr: 1.010 Albumin & Sugar: (-) Epith. Cells: many Pus cells: 0-1/hpf pH: 6 Normal Value 135-148 mmol/L 3.5-5.3 mmol/L 98-107 mmol/L 4.2-6.4 53-97 0.36-0.47 4.5-10.0 0.55-0.60 0.01-0.04 0.200-0.350 0.020-0.060 7 sec-2 min 1-9 min F: 4.2-5.4 4.5-10.0 0.500-0.750 0.200-0.350 0.020-0.060 80-96 27-31 320-360 Yellow Clear 1.002-1.035 Negative Rare-few 0-3/hpf 4.5-8.0 Significance >Normal >Normal >Decreased in pneumonia >Low but not that significant >Normal >Normal >Normal >slightly decreased but not that significant >Increased with neoplasms and skin diseases >Normal >Decreased with infection >Increased in coagulation problems >Normal >Normal >Normal >Normal >Normal >Normal >Normal >Increased which indicates macrocytic cells >Increased which indicated oversized cells >Normal >Due to increased epithelial cells >Normal >Normal >Normal >Normal

07-2707

I. II.

ECG- 09-15-07 b. Result: Incomplete Right Bungle branch block Chest X-ray A. 09-13-07  Result: Radiographic exam of the chest shows homogenous opacity in the right lower lung obscuring the right cardiac border and right diaphragm, intact left hemidiaphragm, trachea at midline. Thoracic cage and soft tissues are unremarkable.  Impression: Pleural Effusion Right B.  Result: Radiographic exam shows enlarged heart and shadow with perivascular blurring of hilar vascular markings as well as presence of kerly B lines at the periphery of both lower lobes suggestive of intestinal edema. There is bibasal haziness. Superior mediastinum is not widened. Thracheal air column is seen at midline intact diaphragmatic leaflets and sulci. Other chest structures are not unusual. Impression: Cardiomegaly with pulmonary congestion coexisting bibasal pneumonia

 III.

Gross and Microscopic Description:  Gross: The mass is firm, approximately 6.0 cm located at the upper aspect of right breast. Skin retraction and nipple ulceration are also noted.  Microscopic: The smears show clusters of ductal cells having increased N:C ration, fine to coarse chromatin, and some having prominent nucleoli. Many isolated tumor cells show marked anisonucleosis. The background is bloody.

VII.

Patients Profile: Name: Alcantara, Consuelo Chua Religion: Catholic Birthplace: Borongan E. Samar Address: Brgy. Mabini, Laping Northern

Age: 71 y.o Sex: F Civil Status: Married Date of Birth: 12-03-35 Citizenship: Filipino Samar

Date of admission: 06-19-07 Time of admission: 3:39 PM Physician: Del Pilar, Jose Carlo, MD Chief Complaint: Cough Diagnosis: CAP (Community Acquired Pneumonia) VIII. History of Present Illness >The condition of the patient started 2 weeks prior to admission where she experienced chest pain and productive cough with thick whitish to yellow sputum, not associated with dyspnea and fever. When patient was asked about what caused the occurrence of her condition, she stated that this condition of hers has been a recurrent one; she even had her previous hospitalization with the same chief complaint. Patient tried to relieve the symptoms by taking an antibiotic; however this measure did not totally alleviate the condition. Morning prior to admission the symptoms persisted thus prompted consult and admission. Past History >The patient had her immunizations during childhood but can’t recall if she had completed them for according to the patient “diri pa man sugad kauso an mga bakuna hadto, diri parehas yana”. With regards to the patient’s previous hospitalizations, she claimed that just last May 2007 she was admitted at EVRMC for the same chief complaint. Other hospitalizations of the patient she can’t recall anymore. The patient did not suffer any accidental injuries and fractures in the past. Other illnesses that the patient currently has are asthma, arthritis and heart problem (Heart failure), in association with these illnesses she stated that she takes her maintenance medications such as Diclofenac for her arthritis and take this only when her joints become inflamed and painful and Captopril for her heart problem. She has a known history of hypertension but no history of DM, has no known allergies to any food and drugs, and has not had any blood transfusions in the past. According to the patient her asthma is the main cause of her present condition and this was aggravated because of her heart problem. Lifestyle >The patient is a non-smoker and non-alcoholic beverage drinker. She no difficulty in eating and swallowing but she stated that at present she isn’t able to eat as much food as she wants for she has some diet restrictions. According to her she doesn’t eat foods that are “makatol”, those high in fat, and vegetables with seeds. She does not take any supplements. With regards to her fluid intake, she claimed that she drinks a lot of water. In fact she is even able to consume more or less 20 glass of water per day, though at present because of her condition she isn’t able to drink that much because she was told that she must be able to consume at least only about 1L of water a day. Today the patient has no bowel movement, and according to her that this is only normal because her normal BM pattern is every 2 or 3 days interval. With regards to her urinary elimination, at present she voided twice this morning and once this afternoon with no difficulty or discomforts. The patient stated that she don’t usually perform exercise, whenever she has nothing else to do, during her leisure times she just usually sit down, do nothing and sometimes sleeps, though oftentimes she also walks around their house. With regards to her sleep pattern, according to her she has no sleep onset problems, but at present because of her productive cough and difficulty of breathing she isn’t able to sleep well a night. In performing self care activities, she said that she still needs assistance in lying down and getting up from bed, in going to the bathroom and in dressing, however in eating and in standing from sitting position, she is able to do it by herself. Family history >The patient has a family history of hypertension. But she does not have any family history of DM, heart diseases, arthritis, epilepsy, cancer and psychosis. Social Data >The patient is married to Vivencio Alcantara and has 10 children. She is a plain housewife while her husband was a formerly a farmer before but at present he also has no work, he stopped because he said he is already old and weak. She and her husband live with their daughter Eufemia Alcantara together with her own family. Financially, they just ask for help and support from their daughter. In case of stressful situations and problems, she said she usually just prays and ask for a divine intervention, and sometimes talk to her husband and seek support.

IX.

X.

XI.

XII.

PHYSICAL EXAMINATION:

YY. General Health: Patient is a 71 y.o female adult, awake, cooperative, answers to questions and is easy to talk with, but appear fatigued. ZZ. Vital Signs: BP: 100/70 mm Hg HR: 71 bpm RR: 19 cpm Temp: 36.3°C AAA. Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass, absence of nodules. BBB. Hair: Inspection: white with some strands of black hair, evenly distributed, scalp has no infection or infestation; Palpation: thick, resilient hair CCC. Nails: Inspection: Convex curvature, capillary bed is pale-light pink in color; Palpation: smooth texture, delay in return of capillary refill (about 5 seconds; normal= less than 4 seconds) DDD. Skin: Inspection: light brown in color with visible age spots, is saggy and wrinkled, with slight non-pitting edema on lower extremities (left leg). Palpation: skin is moderately warm to touch, dry, with poor senile skin turgor. EEE. Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no discharge and no discoloration, and sclera appears white and anicteric, pupils are equally round and reactive to light and accommodation, no visual disturbances; Palpation: light pink conjunctiva, no periorbital edema, no tenderness over lacrimal gland. FFF. Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, unable to hear effectively with normal voice tones; Palpation: auricles are mobile, firm and not tender GGG. Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions HHH. Mouth: Inspection: uniform light pink in color, able to purse lips, not complete set of teeth on lower teeth with brown to black discoloration of the enamel of the remaining teeth, pinkish gums, no dentures, tongue moves freely; Palpation: soft, moderately dry and smooth texture III. Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible; Palpation: no palpable lymph nodes JJJ. Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact, with shallow respiration, use of accessory muscles, no retractions, with some effort in respiration, with productive cough; Palpation: with moderate chest pain and no masses, Auscultation: with crackles KKK. Cardiovascular: Inspection: precordium no abnormal pulsations; Palpation: small weak radial pulse LLL.Abdomen: Inspection: flabby and rounded. Palpation: soft, no evidence of enlargement of liver MMM. Musculoskeletal: Inspection: no contractures, no tremors, with slight weakness of muscles of the body; Palpation: no tenderness or swelling, with good handgrip, NNN. Mental Status: Oriented to time, place and person, drowsy but responsive, unable to recall some past memories, fatigued, restless at times, no difficulty in walking, able to balance. REVIEW OF SYSTEMS: AAA. General Health: No weight loss, no fever and chills, not diaphoretic BBB. Skin: no pruritus, no itchiness CCC. Head: no headache, no dizziness, not nauseated DDD. Eyes: no blurring of vision, no visual difficulties, no use of eyeglasses EEE. Ears: no ringing of ears, no tenderness, with some difficulty in hearing but does not use any hearing aid. FFF. Nose: no change in sense of smell, no colds, no bleeding GGG. Mouth: no bleeding gums, no difficulty in swallowing and chewing of food HHH. Respiratory: has productive cough with thick, difficult to expectorate whitish sputum dyspneic, has difficulty in breathing, shortness of breath III. Cardiovascular: with chest pain, no syncope, JJJ. Gastrointestinal: no tenderness, has no bowel movement, with good appetite, not nauseated KKK. Genitourinary: voided 3 times from morning to afternoon with, no pain and discomfort during urination LLL.Musculoskeletal: slight weakness of body, still needs assistance in some of self care activities such as toileting and dressing. MMM. Neurologic: with feeling of body weakness, no paralysis of any body part, no numbness, no tremors.

LABORATORY EXAMS Date 06-1907 Lab Exam Urinalysis Result Color: yellow Transparency: Slight Turbid pH: 6.0 Specific Gravity: 1.015 Protein: (-) Sugar: (-) Pus cells: 0-2/hpf Red cells: none Epith. Cells: few Mucus threads: rare A. Urates/phosphates: few Bacteria: rare K: 4.99 mmol/L CREA-B: 132.6 umol/L TSH:0.07 Normal Value Pale yellowdeep amber Clear 5.5-6.5 1.002-1.035 Negative Negative 0-2/hpf <3/hpf Rare-few Rare-few Rare-few None 3.50-5.30 53.0-115.0 0.25-5.0 uU/mol 4.0-8.3 pmol/L 9-20 pmol/L Significance >Normal >Increased in concentration of urine >Normal >Normal >Normal >Normal >Normal >Normal >Normal >Normal >Normal >Normal >Normal >Increased in renal failure >Decreased in secondary hypothyroidism; high doses of dopamine >Normal >Normal

06-1907

Special Chemistry

FT3: 6.66 FT4: 19.16 Test: 109.6% 12.5 sec INR: 1.021 Control: 100% 13.7 sec INR: 1.16 Hgb: 106 g/L

06-1907

Prothrombin Time

9.5-12 sec 1.0

>slightly increased by deficiency of factors I, II, V, VII, and X

06-1907

Hematology

F: 120-160

Hct: 0.32 WBC: 5.7 x 10~9/L Differential Ct.: Neutrophils: 0.6 Lymphocytes: 0.28 Monocytes: 0.05 Eosinophils: 0.05 Stabs: 0.02 Result Platelet Count: 245 x 10~9/L Reticulocyte ct: 0.8% GLUC-b: 6.78 mmol/L CHON-E: 5.2 mmol/L TRIG-E: 1.07 mmol/L HDL-BM: 1.79 mmol/L LDL: 3.0mmol/L Test: 4.8%

F: 0.36-0.46 4.5-11.3 0.45-0.65 0.20-0.35 0.02-0.06 0.02-0.04 0.02-0.04 Normal Value 140-440 0.5-1.5% 3.90-6.40 3.9-6.7 0.46-1.88 0.80-1.68 4.5-6.3%

>Decreased in all anemias and excessive fluid intake, but in the case of the patient since she has heart failure, this is a way to compensate to reduce the fluid volume in the body. >Decreased in severe anemias and acute massive blood loss >Normal >Normal >Normal >Normal >Increased in allergy, parasitic disease, and subacute infections >Normal Significance >Normal >Normal >Increased in Diabetes Mellitus and Nephritis >Normal >Normal >Increased >Normal

Date 0620-07

Lab Exam Heamatology

Clinical Lab

Test HbAIC

III.

Test: Gram’s & AFB

Specimen: sputum

A.
B. IV.

Gram: Few organisms are seen consisting of gram (+) cocci in pairs of gram (-) bacilli. Few leukocytes are present AFB: Negative

Test: Peripheral smear Specimen: Blood Result: The red cell are normocytic and normochromic. There are no abnormal leukocytes, the platelets are adequate.

XIII.

Patient’s Profile Name: Llanza, Jay Cuňa Age: Address: Hiagsam, Jaro Leyte Religion: Roman Catholic Mother: Natividad Cuňa Date Admission: 7/01/07 Chief complaint: Fever Physician: Dr. Jaime R. Borrinaga

17 y.o

Sex: Male

Occupation: Student Father: Buenaventura Llanza Time of Admission: 7:05 AM

XIV.

History a. This is a case of Llanza Jay, 17 y.o. a resident of Jaro , Leyte who was admitted for the first time with a chief complaint of fever and body weakness. The condition of the patient started last June 27, Wednesday morning, 4 days prior to admission as onset of low grade fever after he has done washing his clothes. On Thursday morning the patient claimed that he vomited to about a half full glass in quantity, yellowish in color, and watery in consistency. The patient decided to self medicate with paracetamol 500 mg three times a day, and this provided him temporary relief of fever but recurred after a few hours. Morning of Friday, June 29, 1 day prior to admission the symptom still persisted and this time it was accompanied with epistaxis two times that day. The patient tried relieving the epistaxis by placing an ice pack on his forehead and this somehow stopped the bleeding. On June 30, Saturday afternoon, the patient still had fever and generalized body weakness so he decided to seek consult at the EVRMC ER. His platelet and CBC was taken and was found out to be decreased, so he was advised for admission. Past History: i. The patient has had complete immunizations when he was still a child. He has not had chicken pox, mumps, and measles during his childhood. ii. This is the patient’s first hospitalization.

XV.

iii.
iv.

v. vi.

Patient experienced a minor injury when he was still a child. He claimed that he fell from their balcony and broke his left arm but did not sought consult to a doctor instead his parents brought him to a “hilot” . Patient has had an allergy to sunlight. He claimed that whenever he would stay long under the sun he would develop rashes and itching all over his arms. He said he had this when he was 12 years old and disappeared when he aged 14. Patient has no known allergy to any drugs, animals, and food. Patient has no history of serious illness or infection in the past. He did not have any blood transfusions in the past.

XVI.

Lifestyle: i. The patient is a non-smoker and a non alcoholic beverage drinker. ii. Patient eats anything and usually has a good appetite, but when was hospitalized he said that he had difficulty in swallowing. When he was 3 years old until 11 years old he used to take vitamins as supplement. With regards to his fluid intake, he said he is able to consume 6 glasses of water a day. He also drinks milk during morning three times a week. The patient usually has his bowel movement every other day, and at present he has no BM yet. With regards to his urinary elimination, the patient voided 4 times this day. Patient has no difficulty in urinating and defecating. iii. The patient claimed that he does exercise every morning and the usual types of exercises he performs are jogging and karate. During his spare time he keeps himself busy and fit by playing basketball with his friends. iv. With regards to patient’s self care, at present he is able to go to the toilet by himself. He also able to feed and dress all by himself without any assistance. v. With regards to the patient’s sleep pattern, he said that he has no sleep onset problems. His usual sleeping time is 11 PM and his waking time is 3:30 AM. Family History:

XVII.

i.

The patient has no family history of hypertension, Diabetes, heart disease, cancer and tuberculosis. His mother has arthritis and his youngest sister had asthma when she was in her school-age years.

XVIII. Social Data

i.
ii. iii. iv. v. vi.

The patient is a 1st year college student taking up criminology at LC and is currently boarding here in Tacloban city but he usually go home to Jaro every weekends to his family. His father works as a farmer while his mother is a plain housewife. In cases of problems, it is his family who helps and supports him emotionally. He claims that he has many sets of friends and he is able to get along well with them. Financially, he still depends on his parents and his half sister who is currently working in a company in Manila, for his schooling and his other needs. He is a Roman Catholic and gives value and importance to his faith. With regards to the patient’s environmental condition, he claimed that at their boarding house where he is currently residing at there is a nearby swamp. In his hometown in Jaro, their source of water is from the“burabod”. Here in Tacloban they get their water from the faucet, he said that sometimes he boil the water before drinking if he has time.

vii.

PHYSICAL EXAMINATION: OOO. General Health: patient is a 33 y.o male adult. He is cooperative, easy to talk with, but restless at times. He has a good posture and good body built. PPP. Vital Signs: BP: 110/80 mm Hg HR: 76 bpm RR: 20 cpm Temp: 36°C QQQ. Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass, absence of nodules. RRR. Hair: Inspection: Evenly distributed, scalp has no infection or infestation; Palpation: moderately thick, resilient hair SSS. Nails: Inspection: Convex curvature, capillary bed is pale-light pink in color; Palpation: smooth texture, slight delay in return of capillary refill (about 5 seconds; normal is less than 4 seconds) TTT. Skin: Inspection: light brown in color, no presence of edema, there is some scars on patient’s feet as a result of the lesions he got from his previous allergic reaction; Palpation: skin is moderately warm to touch, has good skin turgor. UUU. Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no discharge and no discoloration, and sclera appears white and anicteric, pupils are equally round and reactive to light and accommodation, no visual disturbances; Palpation: light pink conjunctiva, no periorbital edema, no tenderness over lacrimal gland.. VVV. Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, able to hear with normal voice tones; Palpation: auricles are mobile, firm and not tender WWW. Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions XXX. Mouth: Inspection: uniform light pink in color, able to purse lips, good set of teeth, pinkish gums, no dentures, tongue moves freely; Palpation: soft, moderately dry and smooth texture YYY. Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible; Palpation: no palpable lymph nodes ZZZ. Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact, symmetric chest expansion, no use of accessory muscles, no retractions, quiet, effortless respiration; Palpation: no tenderness and no masses, Auscultation: no wheeze or crackles AAAA. Cardiovascular: Inspection: precordium no abnormal pulsations; Palpation: palpable radial pulse; Auscultation: no abnormal heart sound, no murmurs BBBB. Abdomen: Inspection: flat and rounded, no evidence of enlargement of liver; abdominal guarding. Palpation: soft, slight tenderness CCCC. Musculoskeletal: Inspection: no contractures, no tremors, with slight weakness of muscles of the body; Palpation: no tenderness or swelling, with good handgrip, DDDD. Mental Status: Oriented to time, place and person, alert and responsive, with intact memory, restlessness at times REVIEW OF SYSTEMS: NNN. General Health: No weight loss, no fever and chills, not diaphoretic, no colds OOO. Skin: no pruritus, no itchiness PPP. Head: no headache, no dizziness, not nauseated QQQ. Eyes: no blurring of vision, no visual difficulties RRR. Ears: no ringing of ears, no tenderness

SSS. Nose: no change in sense of smell, no colds, no bleeding TTT. Mouth: no bleeding gums, no difficulty in swallowing and chewing of food UUU. Respiratory: not dyspneic, not out of breath when moving, no difficulty breathing when supine VVV. Cardiovascular: no chest pain, no syncope WWW. Gastrointestinal: moderate pain on abdomen, 5 episodes of bowel movement with slightly formed semisolid stool in moderate amount XXX. Genitourinary: voided 10 times fro more than 1L in amount, no pain and discomfort during urination YYY. Musculoskeletal: slight weakness of body, still needs assistance in some of self care activities such as toileting and dressing.

XIX.

Patient’s Profile Name: Del Socorro, Andrew Olang Age: 17 y.o Sex: Male Address: Cabulihan, Ormoc city Birthdate: 11-1-89 Birthplace: Ormoc city Religion: Roman Catholic Occupation: Student Mother: Elizabeth Olang Father: Alejandro Del Socorro Date Admission: 6/30/07 Time of Admission: 3:40 PM Chief complaint: Fever Physician: Dr. Jaime R. Borrinaga History

XX.

This is a case of Del Socorro, Andrew, 17 y.o., a resident of Ormoc city who was admitted for the first time as a referral from Palompon District Hospital for further evaluation and management as dengue suspect. The condition of the patient started June 24, Sunday 1 week prior to admission as onset of moderate fever by touch. It was associated with abdominal pain on epigastric area. There were no other symptoms noted and no consultation was done. Monday, June 25, 5 days prior to admission the patient’s condition persisted and claimed to have had high grade fever at about 38-39˚C and abdominal pain, because of this they decided to bring the patient at Palompon District Hospital and was admitted. During his stay at the hospital, the patient claimed that he experienced loose, watery stools, non-mucoid and non-bloody, several bowls in quantity with associated vomiting noted, 5 times more than three glasses and watery in consistency, but the symptoms was relieved the following night. He was given medications during his stay at Palompon Hospital such as Ranitidine, Ceftriaxone, and Paracetamol. Evening of June 29, a night prior to admission, the patient experienced flashing with petechiae all over the body. The platelet ct of the patient was taken and was found out to drop to 50 x 10~9/L. because of this, the hospital decided to refer the patient at EVRMC, hence patient was admitted. XXI. Past History: i. The patient had complete immunizations when he was still a child. He had chicken pox but has not yet experienced having mumps and measles during his childhood. He experienced having diarrhea when he was 12 years old but was not admitted to the hospital instead he was only given oral hydration which relieved the symptoms. ii. This is the patient’s first hospitalization. iii. Patient did not experience any injury or accidents in the past. iv. Patient has no known allergy to any food, animals, and drugs. v. Patient has no history of serious illness or infection in the past. vi. He did not have any blood transfusions in the past.

a.

XXII.

Lifestyle: i. The patient is a non-smoker but an occasional alcoholic beverage drinker. ii. Currently the patient is on full heme free diet. Normally, patient has adequate food intake, has no difficulty in swallowing and has no diet restrictions. Patient takes vitamins as his daily supplement. With regards to his fluid intake, he said he is able to consume 2-3 glasses of water a day. The patient usually has his bowel movement every other day with normal in consistency. However, at present he has not eliminated yet. With regards to his urinary elimination, the patient voided three times this day to yellowish colored urine. Patient has no difficulty in urinating and defecating. iii. The patient claimed that he is not used in exercising every morning, however the patient stated that he usually spends his leisure time playing basketball with his friends and this keeps him fit and active. iv. With regards to the patient’s self care, at present he still needs a company in going to the toilet, and in dressing. He urinates on a basin at bedside.

v.

With regards to the patient’s sleep pattern, he said that he has no difficulty in going to sleep. His usual sleeping time is 9-10 PM and his waking time is 6-7 AM.

XXIII. Family History: i. The patient has no family history of hypertension, Diabetes, heart disease, cancer, asthma, arthritis and tuberculosis. He lives with his parents and he has one younger sister who is studying in high school at Ormoc. XXIV. Social Data

i.
ii. iii. iv. v. vi.

The patient is a 1st year college student taking up Marine Engineering at Palompon and is staying in a boarding house near their school. His father works as a farmer while his mother is a plain housewife. In cases of problems, it is his family who helps and supports him emotionally. He said that he has many sets of friends and he is able to get along well with them. Financially, he depends on his parent’s support for his other needs but at the same time he also works a part time job in a fast food chain. He is a Roman Catholic and gives value and importance to his faith. With regards to the patient’s environmental condition, he claimed that at their boarding house where he resides there is nearby seawater which usually rises during rainy days.

PHYSICAL EXAMINATION: EEEE. General Health: patient is a 33 y.o male adult. He is cooperative, easy to talk with, but restless at times. He has a good posture and good body built. FFFF. Vital Signs: BP: 110/80 mm Hg HR: 76 bpm RR: 20 cpm Temp: 36°C GGGG. Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass, absence of nodules. HHHH. Hair: Inspection: Evenly distributed, scalp has no infection or infestation; Palpation: moderately thick, resilient hair IIII. Nails: Inspection: Convex curvature, capillary bed is pale-light pink in color; Palpation: smooth texture, slight delay in return of capillary refill (about 5 seconds; normal is less than 4 seconds) JJJJ. Skin: Inspection: light brown in color, no presence of edema, there is some scars on patient’s feet as a result of the lesions he got from his previous allergic reaction; Palpation: skin is moderately warm to touch, has good skin turgor. KKKK. Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no discharge and no discoloration, and sclera appears white and anicteric, pupils are equally round and reactive to light and accommodation, no visual disturbances; Palpation: light pink conjunctiva, no periorbital edema, no tenderness over lacrimal gland.. LLLL. Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, able to hear with normal voice tones; Palpation: auricles are mobile, firm and not tender MMMM. Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions NNNN. Mouth: Inspection: uniform light pink in color, able to purse lips, good set of teeth, pinkish gums, no dentures, tongue moves freely; Palpation: soft, moderately dry and smooth texture OOOO. Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible; Palpation: no palpable lymph nodes PPPP. Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact, symmetric chest expansion, no use of accessory muscles, no retractions, quiet, effortless respiration; Palpation: no tenderness and no masses, Auscultation: no wheeze or crackles QQQQ. Cardiovascular: Inspection: precordium no abnormal pulsations; Palpation: palpable radial pulse; Auscultation: no abnormal heart sound, no murmurs RRRR. Abdomen: Inspection: flat and rounded, no evidence of enlargement of liver; abdominal guarding. Palpation: soft, slight tenderness SSSS. Musculoskeletal: Inspection: no contractures, no tremors, with slight weakness of muscles of the body; Palpation: no tenderness or swelling, with good handgrip, TTTT. Mental Status: Oriented to time, place and person, alert and responsive, with intact memory, restlessness at times REVIEW OF SYSTEMS: ZZZ. AAAA. BBBB. CCCC. General Health: No weight loss, no fever and chills, not diaphoretic, no colds Skin: no pruritus, no itchiness Head: no headache, no dizziness, not nauseated Eyes: no blurring of vision, no visual difficulties

DDDD. Ears: no ringing of ears, no tenderness EEEE. Nose: no change in sense of smell, no colds, no bleeding FFFF. Mouth: no bleeding gums, no difficulty in swallowing and chewing of food GGGG. Respiratory: not dyspneic, not out of breath when moving, no difficulty breathing when supine HHHH. Cardiovascular: no chest pain, no syncope IIII. Gastrointestinal: moderate pain on abdomen, 5 episodes of bowel movement with slightly formed semisolid stool in moderate amount JJJJ. Genitourinary: voided 10 times fro more than 1L in amount, no pain and discomfort during urination KKKK. Musculoskeletal: slight weakness of body, still needs assistance in some of self care activities such as toileting and dressing.

Name: Llanza, Jay Cuňa

DIAGNOSTIC EXAMS:

Date of Admission: 07/01/01 Age: 17 y.o.

Time of Admission: 7:05 AM Sex: Male

Physician: Jaime R. Borrinaga, FPCP Chief Complaint: Fever Diagnosis: DHF II

Date 6-30-07

Lab Exam Hematology

Result Hct= 0.41 Plt=130 WBC= 7.9 Hgb=148 Hct=0.44 Plt= 180 Segmenters=0.54 Lymphocyte=0.46 Hct=0.43 Plt=132 Hct=0.40

Normal Values M: 0.42-0.47 150-450 x 10~9/L 5-10 x 10~10/L M:140-180 g/L M: 0.42-0.47 150-450 x 10~9/L
0.45-0.65 0.20-0.35

Significance >slightly decreased >Decreased >Normal >Normal >Normal >Normal >Normal >Increased >Normal >Decreased >Decreased >Decreased >Normal >Decreased >Normal >Normal >Normal

7-01-07

Hematology 6 AM:

M: 0.42-0.47 150-450 x 10~9/L M: 0.42-0.47 150-450 x 10~9/L M: 0.42-0.47 150-450 x 10~9/L
Pale yellowdeep amber

12 NN: Plt=52 Hct=0.44 6 PM: Plt=88 Urinalysis Macroscopic: Color=yellow Transparency=clear Spc. Gr.= 1.015 pH=6.0 Glucose, Albumin, Blood= (-) Microscopic: Pus=0-2 RBC=0-1 Epith. Cell=occasional Bacteria=some

Clear Negative

7-02-07

Hematology

M. threads=some Hct=0.43 Plt=80 Hct=0.48

M: 0.42-0.47 150-450 x 10~9/L M: 0.42-0.47 150-450 x 10~9/L M: 0.42-0.47 150-450 x 10~9/L

>Normal >Decreased >slightly increased >Decreased >Normal >Decreased

12 MN: Plt=72 7-03-07 Hematology Hct=0.45 Plt=100

DIAGNOSTIC EXAMS Name: Del Socorro, Andrew Olang

Date of Admission: 06/30/07 Age: 17 y.o.

Time of Admission: 3:40 PM Sex: Male

Physician: Jaime R. Borrinaga, FPCP Chief Complaint: Fever Diagnosis: DHF II

Date 6-30-07

Lab Exam Hematology Miscellaneous: Specimen-Plasma Exam DesiredPROTIME

Result APTT=53.3 sec Control=35.4 sec

Normal Values 31.2-39.8 sec

Significance >Normal

Test= >120 sec

Hematology 12 MN:

Control= 12.0 sec Hct= 0.44 Plt= 34 Hgb=146 g/L Hct=0.44 WBC=5.60 x 10~9/L Differential Ct: Segmenter=0.19 Lymphocyte=0.77 Monocyte=0.03 Eosinophil=0.01 Basophil=0.01 Plt=50 x 10~9/L

M: 0.420.47 150-450 x 10~9/L
Male: 140-175

>Normal >Decreased >Normal >Normal >Normal >Decreased >Increased >Normal

M: 0.420.47
4.5-11.3 0.45-0.65 0.20-0.35 0.02-0.06

150-450 x 10~9/L M: 0.420.47 150-450 x 10~9/L M: 0.420.47 150-450 x 10~9/L M: 0.420.47 150-450 x 10~9/L M: 0.420.47 150-450 x 10~9/L >Normal >Decreased >Normal >Decreased >Normal >Decreased >Decreased >Decreased

7-01-07

Hematology 6 AM:

Bld type- O; RH(+) Hct=0.43 Plt=44 Hct=0.43

6 PM Plt=70 7-02-07 Hematology Hct=0.42 Plt=72 7-03-07 Hct=0.38 Plt=108

XXV.

Patient’s Profile Name: Purog, Ramil Apurillo Age: 33 y.o Sex: Male Address: Blk 9, Lot 31, Ilang-ilang St. V&G Tac. City Religion: Catholic Occupation: Teacher Date of birth: 04-18-74 Birthplace: Cebu city Mother: Fe April Purog Father: Jose Purog Date Admission: 06-16-07 Time of Admission: 10:59 PM Chief coplaint: LBM Physician: Dr. C. Baligod

XXVI. History >Morning prior to admission, the patient experienced severe abdominal pain on the umbilical and hypogastric region, he had more than 3 episodes of LBM and passed out watery, pus bloody and non-mucoid stool, scanty in amount associated with scarring abdominal pain. Other symptoms he experienced were numbness, cold clammy, and diaphoresis. No vomiting was noted. When asked about what may have caused the illness, patient stated that he ate food which he bought and mixed it with some vegetables which probably precipitated his condition. Medications taken during the onset of the disease were metronidazole, ofloxacin, hydrite and vitamins, however these medications did not relieved the condition of the patient. His LBM persisted for about 9 episodes which prompted consult and admission. XXVII. Past History: >The patient has had complete immunizations when he was still a child. >Patients had many hospitalizations a few of them which he can still remember are back when he was in high school when he was bitten by a dog, another was when he was operated because of abscess on his lower head, and the most recent was last September 6, 2006 because of amoebiasis.

>Patient did not experienced any serious accidents that lead to fractures and major injuries, though he claimed that he had a very minor accident when he was playing with his bicycle and accidentally fell. >Patient has allergies in foods with MSG, especially junk foods and “dagmay”. He said whenever he eats these foods he would develop a lesion which heals poorly. >Patient claimed that he had a history of asthma when he was a child, and a pulmonary infection when he aged 23 and the patient said that the cause probably was because of chalk dust that irritated his lungs. >He did not have any blood transfusions in the past.

XXVIII.

Lifestyle: >The patient experienced smoking back when he was in his high school years but claimed that he only tried few times only because of peer pressure but did not continue on this vice because he knew that it would be bad for his health. The patient at present is an occasional alcoholic beverage drinker but he revealed that when he was in his 4th year high school he drank alcohol almost weekly with his friends and it was only during 1st yr college that he stopped drinking too much. >Patient is a vegetarian, he takes supplements such as multivitamins and vitamin C (Cecon); he is able to consume 8 glasses of water per day and drinks juice every meal. He has good appetite but he complained of experiencing nausea last night. Today the patient had 5 bowel movements and passed out a slightly watery semisolid stool. With regards to his urinary elimination, the patient voided 10 times this day with an amount of more than 1L as stated by the patient. Patient has no difficulty in urinating and defecating. >The patient claimed that he does exercise every morning and the usual types of exercises he performs are the non-strenuous ones such as jogging and swimming. During his spare time he keeps himself busy by doing some leisure activities such as going to the beach, playing basketball and gardening (planting vegetables). >With regards to patient’s self care, at present the patient stated that he needs assistance in going to the bathroom and in dressing, however in eating he is able to feed himself. Patient is mobile and ambulatory. >With regards to the patient’s sleep pattern, he said that he has no sleep onset problems though sometimes he sleeps late, at present he usually has early awakenings because of the need to go to the bathroom to urinate. He also stated that he isn’t able to sleep well because he is not that comfortable with his room. XXIX. Family History: >The patient has a family history of hypertension specifically on his paternal side. But he does not have any family history of DM, heart diseases, arthritis, epilepsy, cancer and psychosis.

XXX.

Social Data >The patient is single and currently lives with his parents at V&G subdivision. He works as a high school economics teacher. >In cases of problems, it is his family who helps him a lot and supports him emotionally. He claims that he has many sets of friends and he is able to get along well with others. >Financially, he is able to support himself and able to provide his own needs with his own income. >He is a religious person, and values his spiritual faith a lot. PHYSICAL EXAMINATION: UUUU. General Health: patient is a 33 y.o male adult. He is cooperative, easy to talk with, but restless at times. He has a good posture and good body built. VVVV. Vital Signs: BP: 110/80 mm Hg HR: 76 bpm RR: 20 cpm Temp: 36°C WWWW. Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass, absence of nodules. XXXX. Hair: Inspection: Evenly distributed, scalp has no infection or infestation; Palpation: moderately thick, resilient hair YYYY. Nails: Inspection: Convex curvature, capillary bed is pale-light pink in color; Palpation: smooth texture, slight delay in return of capillary refill (about 5 seconds; normal is less than 4 seconds) ZZZZ. Skin: Inspection: light brown in color, no presence of edema, there is some scars on patient’s feet as a result of the lesions he got from his previous allergic reaction; Palpation: skin is moderately warm to touch, has good skin turgor.

AAAAA. Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no discharge and no discoloration, and sclera appears white and anicteric, pupils are equally round and reactive to light and accommodation, no visual disturbances; Palpation: light pink conjunctiva, no periorbital edema, no tenderness over lacrimal gland.. BBBBB. Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, able to hear with normal voice tones; Palpation: auricles are mobile, firm and not tender CCCCC. Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions DDDDD. Mouth: Inspection: uniform light pink in color, able to purse lips, good set of teeth, pinkish gums, no dentures, tongue moves freely; Palpation: soft, moderately dry and smooth texture EEEEE. Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible; Palpation: no palpable lymph nodes FFFFF. Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact, symmetric chest expansion, no use of accessory muscles, no retractions, quiet, effortless respiration; Palpation: no tenderness and no masses, Auscultation: no wheeze or crackles GGGGG. Cardiovascular: Inspection: precordium no abnormal pulsations; Palpation: palpable radial pulse; Auscultation: no abnormal heart sound, no murmurs HHHHH. Abdomen: Inspection: flat and rounded, no evidence of enlargement of liver; abdominal guarding. Palpation: soft, slight tenderness IIIII. Musculoskeletal: Inspection: no contractures, no tremors, with slight weakness of muscles of the body; Palpation: no tenderness or swelling, with good handgrip, JJJJJ. Mental Status: Oriented to time, place and person, alert and responsive, with intact memory, restlessness at times REVIEW OF SYSTEMS: LLLL. General Health: No weight loss, no fever and chills, not diaphoretic, no colds MMMM. Skin: no pruritus, no itchiness NNNN. Head: no headache, no dizziness, not nauseated OOOO. Eyes: no blurring of vision, no visual difficulties PPPP. Ears: no ringing of ears, no tenderness QQQQ. Nose: no change in sense of smell, no colds, no bleeding RRRR. Mouth: no bleeding gums, no difficulty in swallowing and chewing of food SSSS. Respiratory: not dyspneic, not out of breath when moving, no difficulty breathing when supine TTTT. Cardiovascular: no chest pain, no syncope UUUU. Gastrointestinal: moderate pain on abdomen, 5 episodes of bowel movement with slightly formed semisolid stool in moderate amount VVVV. Genitourinary: voided 10 times fro more than 1L in amount, no pain and discomfort during urination WWWW. Musculoskeletal: slight weakness of body, still needs assistance in some of self care activities such as toileting and dressing.

XXXI.

Patient’s Profile Name: Lopez, Mechele Aguinalde Age: 22 y.o. Sex: Female Address: Rizal Dulag, Leyte Religion: Catholic Civil Stat: Single Date of birth: 07-18-85 Birthplace: Dulag, Leyte Mother: Carmen Aguinalde Father: Melchor R. Lopez Date Admission: 09-10-07 Time of Admission: 6:25 PM Occupation: Student, GM- Sangguniang Brgy. Physician: Dr. Lesiguez/Dr. Omega Chief complaint: Vaginal Bleeding Admitting Diagnosis: Abortion, Incomplete, 10 5/7 weeks AOG, Spontaneous, non-septic, G1P0

XXXII. History a. This is a case of Lopez, Michele, 22 years old, female residing at Dulag, Leyte who was admitted for the first time in this institution with a chief complaint of vaginal bleeding. The condition of the patient started several hours prior to admission as sudden onset of vaginal bleeding, painless and profuse with passing of meaty tissues. No other symptoms were associated. Patient claimed of having a fall 1 day prior to admission, she said she accidentally slipped on their CR. After the incident, pain was noted on her left posterior trunk, she just tried to rest and lie down to relieve the pain. No consult and no medications were taken. The next day when she woke up she just suddenly experienced heavy vaginal bleeding and this continued for many hours. This prompted her to seek consult, hence present admission. Before the incident happened, she was positive of being 2 ½ months pregnant. But no prenatal visits were taken. XXXIII. Past History:

 The patient had complete immunizations when he was still a child. She had chicken pox, measles, and mumps during her childhood.  She has a history of chronic UTI before pregnancy.  The patient had other previous hospitalization in the past and this was last 2005 for the reason of falling from her bicycle. She was admitted at Burauen District Hopsital. No fractures or injuries were noted.  The patient has no known allergy to any food, drug, or animals.  Patient has no history of abortion, asthma, Diabetes Mellitus and other serious medical illnesses in the past.  She did not have any blood transfusions in the past. XXXIV. Lifestyle: a. The patient is a non-smoker and an occasional alcoholic beverage drinker. b. When it comes to her daily food intake, the patient said that she is able to eat just enough, and eats whatever is served. The patient has no difficulty in eating and usually has good appetite. She does not take any vitamins and other supplements. With regards to her fluid intake, she said that she is able to consume about 1 L of water per day. c. Regarding patient’s elimination pattern, she said that she usually bowel eliminates every after 2 days, with a formed stool; brownish in color, With regards to her urinary elimination, she said he usually voids many times a day with no difficulty and pain. d. The patient seldom performs an exercise, if ever she gets the chance to do so she only usually does the stretching in the morning upon awakening. e. With regards to the patient’s sleep pattern, she said she doesn’t have any difficulty in getting asleep. XXXV. Family History: a. The patient has 2 other siblings. 1 elder brother and 1 younger brother. She is the second child and the only girl of the family. The patient’s parents are Mr. Melchor Lopez and Mrs. Carmen Aguinalde. The patient has a family history of hypertension (Fatherside); other illnesses such as TB, Rheumatic heart disease, kidney disease, asthma, cancer, arthritis, Diabetes, and bleeding tendencies are not present in their family. XXXVI. Social Data i. The patient is single and lives with her parents. She was formerly studying as a 4th year commerce student at St. Paul’s Business School but stopped when she found out that she was pregnant. XXXVII. Obstetrical Record  Chief complaint: vaginal bleeding  First day of last menstruation: June 27, 2007  Duration of pregnancy: 2 ½ months  Age of Gestation: 10 5/7  Expected date of confinement: April 3, 2008  Prenatal care: None XXXVIII. Menstrual History  Menarche: 14 y.o.  Cycle: 20 days  Amount: 12 napkins/ 4 days duration  Duration: 4 days  Pain: positive during the first day  Previous menstrual period: May 2007

PHYSICAL EXAMINATION: KKKKK. General Health: patient is a 22 y.o. female adult. Shee is cooperative, easy to talk with, calm and, responds when asked. Body weakness is noted. LLLLL. Vital Signs: BP: 100/70 mm Hg HR: 71 bpm RR: 20 cpm Temp: 36.4°C MMMMM. Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass, absence of nodules. NNNNN. Hair: Inspection: With black strands of hair, evenly distributed, scalp has no infection or infestation; Palpation: thick, resilient hair OOOOO. Nails: Inspection: Convex curvature, capillary bed is slightly pale in color; Palpation: smooth texture, there slight delay in return of capillary refill (about 4 seconds; normal is less than 3 seconds) PPPPP. Skin: Inspection: light brown in color with no presence of edema and active lesions; Palpation: has normal skin temperature, has good skin turgor. QQQQQ. Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no discharges and no discoloration, and sclera appears white and anicteric, pupils

are equally round and reactive to light and accommodation; Palpation: pale palpebral conjunctiva, no periorbital edema, no tenderness over lacrimal gland. RRRRR. Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, has no difficulty in hearing normal voice tones; Palpation: auricles are mobile, firm and not tender SSSSS. Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions TTTTT. Mouth: Inspection: slightly pale in color, able to purse lips, with good set of teeth, no dentures, tongue moves freely; Palpation: soft, moderately dry and smooth texture UUUUU. Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible, no neck vein distention; Palpation: no palpable lymph nodes VVVVV. Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact, symmetric chest expansion, no use of accessory muscles, no retractions, quiet, effortless respiration; Palpation: no tenderness and no masses, Auscultation: no wheeze or crackles WWWWW. Breast: symmetrical, nipples are everted XXXXX. Cardiovascular: Inspection: precordium no abnormal pulsations; Palpation: palpable radial pulse; Auscultation: no abnormal heart sound, no murmurs YYYYY. Abdomen: Inspection: flat and rounded, no evidence of enlargement of liver; Palpation: soft, no tenderness ZZZZZ. Musculoskeletal: Inspection: no contractures, no tremors, with slight weakness of muscles of the body; Palpation: no tenderness or swelling. AAAAAA. Extremities: palms of the hands are pale; no edema, no varicosities, no defects BBBBBB. Mental Status: Oriented to time, place and person, and responsive CCCCCC. Genitourinary: positive for vaginal bleeding, with passing out of meaty tissues DDDDDD. Pelvic exam: Uterus not enlarge; nullipara REVIEW OF SYSTEMS: XXXX. General Health: No weight loss, no fever and chills, slighlty diaphoretic, no colds YYYY. Skin: no pruritus, no itchiness ZZZZ. Head: no headache, not nauseated AAAAA. Eyes: no blurring of vision, no visual disturbances BBBBB. Ears: no ringing of ears, no tenderness CCCCC. Nose: no change in sense of smell, no colds, no bleeding, no difficulty in breathing DDDDD. Mouth: no bleeding gums, no difficulty in swallowing and chewing of food EEEEE. Respiratory: no reports of dyspnea, not out of breath when moving. FFFFF. Cardiovascular: no complaints of abnormal pulsations, no syncope GGGGG. Gastrointestinal: no tenderness, has not yet bowel eliminated, HHHHH. Genitourinary: voided 3 times, no pain and discomfort during urination IIIII. Musculoskeletal: slight weakness of body, easy fatigability Upon Internal Examination:  Result: admits 1 finger to internal right, with palpable meaty tissues and blood clots.  Positive history of passing of meaty tissues and fetus 2 hrs. PTA

XXXIX. Patient’s Profile Name: Badeo, Marlon Espiritu Age: 27 Sex: Male Address: Brgy. Rizal, Dagami Leyte Religion: Catholic Occupation: Pedicab Driver Date of birth: 5-30-80 Birthplace: Dagami, Leyte Mother: Shirley Espiritu Father: Alfredo Badeo Date Admission: 8-30-07 Time of Admission: 6:50 PM XL. History a. This is a case of Badeo, Marlon, 27 years old, male residing at Brgy Rizal Dagami Leyte who was admitted for the second time at EVRMC with a chief complaint of sudden pain on both legs and inability to walk. The condition of the patient started last August 30, Thursday morning , few hours prior to admission as sudden onset of acute pain of his post surgical wound on left upper leg, which later progressed to involve the right leg. Severe and intolerable pain on both legs was noted. The patient claimed that he was not able to move his both legs and was not able to walk. Other associated manifestation noted on the patient was pain on the stomach. He tried to rest but this measure did not alleviate the pain. Maintenance medications that were previously prescribed to him were given and taken by the patient such as Cefalexin and Diclofenac, pain was decreased after taking the said medicines however the pain recurred again. This prompted him to seek consult, hence he was admitted. Past History:  The patient has incomplete childhood immunization particularly the Measles vaccine.  The patient had 2 other previous hospitalizations in the past. The first was last November 2006 at Burauen hospital with the chief complaint of acute pain and swelling of left upper leg, medical treatment was given and pain was alleviated. However, last January 2007 the

XLI.

condition of the patient recurred, this time he sought consult and was admitted at EVRMC surgical ward. Operation was done on his left leg which involved removal of pus that caused the swelling. A small incision was made.  The patient did not experience any accidents or injuries in the past.  The patient has no known allergy to any food, drug, or animals.  Patient has no history of asthma, Diabetes Mellitus, and other serious medical condition  He did not have any blood transfusions in the past.

XLII.

Lifestyle: a. The patient is a non-smoker and an occasional alcoholic beverage drinker. b. When it comes to his daily food intake, the patient said that he is able to eat just enough, and he eats whatever it is that is served but at present he is unable to eat well because of the pain. He has poor appetite and is nauseated at times. He also claimed that he loss his weight. Previously, he takes some Vitamins and Clusivol as his supplement. With regards to his fluid intake, he said that he is able to consume more than a liter of water per day. c. Regarding patient’s elimination pattern, he said that usually he has a regular daily bowel movement with formed stool, but at preset he has not yet bowel eliminated for about two weeks now. With regards to his urinary elimination, he said he usually voids many times a day. At present, he voided more than 5 times since this morning to yellow colored urine, moderate in quantity with no difficulty and incontinence. d. The patient has no particular exercise pattern that he performs. During his leisure time when he was not yet ill he said he used to play basketball with his friends. e. With regards to the patient’s sleep pattern, at present he is not able to sleep well because of the pain. Family History: a. The patient has a family history of heart disease on his paternal side (Grandmother); but has no known family history of hypertension, Diabetes, arthritis, and other degenerative bone diseases. i. Social Data The patient is single and currently lives with his parents at Dagami together with his other 4 brothers and sisters. He was formerly working as a pedicab driver.

XLIII.

XLIV.

PHYSICAL EXAMINATION: EEEEEE. General Health: patient is a 27 y.o male adult. He is cooperative, easy to talk with, calm, responds when asked but a little drowsy. FFFFFF. Vital Signs: BP: 100/70 mm Hg HR: 83 bpm RR: 19 cpm Temp: 38.3°C GGGGGG. Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass, absence of nodules. HHHHHH. Hair: Inspection: black, unwashed hair, evenly distributed, scalp has no infection or infestation; Palpation: thin, resilient hair IIIIII.Nails: Inspection: Convex curvature, capillary bed is pale in color; Palpation: smooth texture, delay in return of capillary refill (about 4 seconds; normal is less than 3 seconds) JJJJJJ. Skin: Inspection: light brown in color, with presence of pressure sore at the buttocks due to immobility; Palpation: skin is warm to touch, moist, has good skin turgor, pale

KKKKKK. Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no discharges and no discoloration, and sclera appears slightly yellowish, pale conjunctiva, pupils are equally round and reactive to light and accommodation, does not use eyeglasses, no visual problems; Palpation: light pink palpebral conjunctiva, no periorbital edema, no tenderness over lacrimal gland. LLLLLL. Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, has no difficulty in hearing normal voice tones; Palpation: auricles are mobile, firm and not tender MMMMMM. Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions NNNNNN. Mouth: Inspection: with dry lips but moist, pinkish buccal membrane, no dentures, tongue moves freely; Palpation: soft mucus membrane and smooth texture OOOOOO. Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible, no neck vein distention, visible pulsation; Palpation: no palpable lymph nodes PPPPPP. Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact, symmetric chest expansion, no use of accessory muscles, no retractions, quiet, effortless respiration; Palpation: no tenderness and no masses, Auscultation: no wheeze or crackles QQQQQQ. Cardiovascular: Inspection: with abnormal pulsations; Palpation: palpable radial pulse; Auscultation: no abnormal heart sound, no murmurs RRRRRR. Abdomen: Inspection: flat and rounded, no evidence of enlargement of liver; Palpation: soft, no tenderness SSSSSS. Musculoskeletal: Inspection: no contractures, no tremors, with generalized body weakness; with poor leg muscle strength and tone; Palpation: with pain on left upper leg, swelling of the previous open surgical wound oozing with a yellowish colored fluid. TTTTTT. Extremities: Inspection: decreased subcutaneous tissue, thin, unable to move both legs UUUUUU. Mental Status: Oriented to time, place and person, responsive, with no discrepancies with past memory.

REVIEW OF SYSTEMS: JJJJJ. General Health: verbalization of weight loss, febrile and diaphoretic, no cough and colds. KKKKK. Skin: pain on left sole of feet and of the open wound on the left upper leg LLLLL. Head: no headache but nauseated at times MMMMM. Face: facial grimacing due to pain NNNNN. Eyes: no blurring of vision, no visual disturbances OOOOO. Ears: no ringing of ears, no tenderness PPPPP. Nose: no change in sense of smell, no colds, no bleeding, no difficulty in breathing QQQQQ. Mouth: no bleeding gums, no difficulty in swallowing and chewing of food, poor appetite RRRRR. Respiratory: no orthopnea, dyspnea, and shortness of breath SSSSS. Cardiovascular: no complaints of chest pain, no syncope TTTTT. Gastrointestinal: pain on the stomach every after eating, has no bowel elimination for 2 weeks now UUUUU. Genitourinary: voided more than 5 times since morning, no pain and discomfort during urination VVVVV. Musculoskeletal: easy fatigability, decreased muscle strength

I.

Patient’s Profile Name: Grejalde, Marlon Age: 54 y.o Sex: Male Address: Brgy. Songco, Borongan E. Samar Religion: Catholic Occupation: MCH driver Date of birth: Jan. 16, 1953 Birthplace: Misamis Oriental Mother: Deceased Father: Deceased Date Admission: 8-14-07 Time of Admission: 3:20 PM Chief Complaint: VA Diagnosis: Fracture, open Tibia-Fibula, Right; Fracture, closed M/3rd, Femur Left

II.

History a. This is a case of Grejalde, Marlon 54 years old, male residing at Brgy. Songco, Borongan E. Samar who was admitted for the first time at EVRMC with a chief complaint of vehicular accident. The incident happened last August 13 2007, Monday at Borongan E. Samar at exactly 11:00 AM. The patient was riding his single motorcycle and was about to live their when he suddenly lose control in driving and accidentally crashed and broke his both legs with some abrasion- contusion on his right forehead. The patient was immediately brought to Borongan provincial hospital. Cast was applied on both legs. On August 14, 2007 the patient was referred to EVRMC for further medical and surgical management. Hence present admission. Past History:  The patient had complete immunizations when he was still a child.

III.

 The patient has only one previous hospitalization in the past (1986) with a chief complaint of fever.  When asked if he experienced any other accidents or injury in the past, he said that this is the first time he had an accident.  The patient has no known allergy to any food, drug, or animals.  Patient has no history of asthma, Diabetes Mellitus, arthritis, hypetensin and other serious medical condition in the past,  He did not have any blood transfusions in the past.

IV.

Lifestyle: a. The patient used to smoke before and said that he was able to consume 1 pack of cigarette per day but quitted just last 2006. He is an occasional alcoholic beverage drinker and stated that he is able to consume about 10 glasses of alcoholic drink. He drinks both hard and light alcoholic beverages. b. Regarding his daily food intake, the patient said that previously he used to have a good appetite but at present he is unable to eat much because of pain. He does not take any vitamins and other supplements. With regards to his fluid intake, he said he is able to consume about 20 glasses of water per day. c. Regarding patient’s elimination pattern, he said that usually he has a daily bowel movement with formed stool, at present since he can’t move about and go to the bathroom he use an adult diaper. He has no problem in bowel elimination and stated that he has just bowel eliminated to a color brown, formed stool. With regards to his urinary elimination, he said he voids many times a day. At present, he voided 6-8 times since morning. with no difficulty and incontinence. d. According to the patient, his usual type of exercise that he performs is walking and he does this every morning around their house. e. With regards to the patient’s sleep pattern, he said that he doesn’t get enough sleep and whenever he is able to close his eyes and sleep he can only do this for just an hour and will wake up again. Family History:  The patient’s parents are both deceased. His mother died of a heart disease and his father was hypertensive. Other diseases such as diabetes mellitus, arthritis, asthma, cancer, and bone diseases are not present in their family. Social Data  The patient is married, and has 3 children who are still living with the. The patient is the breadwinner of the family and works as a tricycle driver at their place.

V.

VI.

PHYSICAL EXAMINATION: 1. General Health: patient is a 54 y.o male adult. He is cooperative, easy to talk with, calm and, responds when asked. 2. Vital Signs: BP: 120/80 mm Hg HR: 84 bpm RR: 23 cpm Temp: 37.6°C 3. Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass, absence of nodules. 4. Hair: Inspection: black hair and evenly distributed, scalp has no infection or infestation; Palpation: thick, resilient hair 5. Nails: Inspection: Convex curvature, capillary bed is pale in color; Palpation: smooth texture, delay in return of capillary refill (about 5 seconds; normal is less than 3 seconds)

6. Skin: Inspection: light brown in color with visible age spots, wrinkled and saggy, no presence of active lesions; Palpation: skin is slightly warm to touch, has senile skin turgor. 7. Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no discharges and no discoloration, and sclera appears white and anicteric, pupils are equally round and reactive to light and accommodation; Palpation: pink palpebral conjunctiva, no periorbital edema, no tenderness over lacrimal gland. 8. Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, has some difficulty in hearing normal voice tones; Palpation: auricles are mobile, firm and not tender 9. Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions 10. Mouth: Inspection: slightly dry lips, moist buccal membrane, able to purse lips, tongue moves freely; Palpation: soft and smooth texture 11. Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible, no neck vein distention; Palpation: no palpable lymph nodes 12. Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact, symmetric chest expansion, use of accessory muscles, no retractions, with deep respiration; Palpation: no tenderness and no masses, Auscultation: crackles positive 13. Cardiovascular: Inspection: precordium no abnormal pulsations; Palpation: palpable radial pulse; Auscultation: no abnormal heart sound, no murmurs

14. Abdomen: Inspection: flat and rounded, no evidence of enlargement of liver; Palpation: soft, no tenderness 15. Musculoskeletal: Inspection: no contractures, no tremors, weakness of muscles of the body; Palpation: with tenderness of the fractured extremities ( Right Tibia-Fibula, Left Femur) 16. Extremities: presence of cast on both legs, 17. Mental Status: Oriented to time, place and person, responsive, with some discrepancies with past memory. REVIEW OF SYSTEMS: WWWWW. General Health: No weight loss, slightly febrile, not diaphoretic, no cough and colds XXXXX. Skin: no pruritus, no itchiness, no cold clammy YYYYY. Head: no headache, not nauseated, experiences orthostatic hypotension when changing position from lying to sitting ZZZZZ. Eyes: no blurring of vision, no visual disturbances, uses reading glasses AAAAAA. Ears: no ringing of ears, no tenderness BBBBBB. Nose: no change in sense of smell, no colds, no bleeding, with difficulty in breathing CCCCCC. Mouth: no bleeding gums, no difficulty in swallowing and chewing of food, poor appetite DDDDDD. Respiratory: with nonproductive cough, no orthopnea, dyspneic at times, visible deep respirations EEEEEE. Cardiovascular: with no complaints of chest pain FFFFFF. Gastrointestinal: no tenderness, has bowel eliminated and uses adult diaper, not constipated GGGGGG. Genitourinary: voided 6-8 times since morning, no pain and discomfort during urination HHHHHH. Musculoskeletal: generalized body weakness, fatigability, poor muscle tone and strength especially lower extremities, restricted movements, limited range of motion

XLV.

Patient’s Profile Name: Verano, Clarito Regaňon Age: 63 y.o Sex: Male Address: 44 Quarry District Tacloban City Religion: Catholic Occupation: None Date of birth: 01-22-44 Birthplace: Sta. Margarita Samar Mother: Deceased Father: Deceased Date Admission: 07-01-07 Time of Admission: 8:00 AM Chief Complaint: Chesty Heaviness History a. This is a case of Verano, Clarito, 63 years old, male residing at Quarry District who was admitted for the third time with a chief complaint of chest heaviness. The condition of the patient started last June 30, Saturday, 1 day prior to admission as sudden onset of chest heaviness, mild and tolerable. No other symptoms were associated. No medications were taken; he tried to rest however the condition was still not relieved. This prompted him to seek consult, hence he was admitted.

XLVI.

XLVII. Past History:  The patient had complete immunizations when he was still a child. He had his chicken pox, measles, and mumps during his childhood. The patient had 2 other previous hospitalizations in the past with the same chief complaint. His first admission was last 2006l due to chest heaviness, however his diagnosis was not determined, The second was last May 11-15, 2007 with the same chief complaint, he was diagnosed with unstable angina and he was admitted at the CICU. He was also given medications during his 2nd hospitalization and these were: (1) Fraxiparine 3,800 “IU” SQ, (2) ASA 80 mg OD, (3) Clopridagril 75 mg OD if fraxipatine is NA, (4) Enalapril 5 mg OD, (5) Metoprolol 50 mg BID, and (6) ISDN 10 mg TID. He had previous elevation of his blood pressure for about a year now and he is positive for recurrent chest pains.  When asked if he experienced any accidents or injury in the past, he said he had several accidents but he can only recall 3 of those accidents he had experienced. First accident that he can remember was a vehicular accident, he was a college student then, he suffered some minor injuries from that accident. The second was during his 30’s, this time he was hit by a jeepney while he was crossing the street, however he did not suffer any serious injury and fractures, no operation was done. He was only hospitalized. The third he recalled was during his 50’s, again he was hit by a vehicle, but according still he did not suffer any serious injury.  The patient has no known allergy to any food, drug, or animals.  Patient has no history of asthma and Diabetes Mellitus in the past.  He did not have any blood transfusions in the past.

XLVIII.

Lifestyle:

a.

b.

c.

d. e.

The patient was a smoker. He started during his first year high school and claimed that he was able to consume about 1 pack per day. It is only 2 years ago that he stopped smoking. He is also an occasional alcoholic beverage drinker and stated that he drinks “tuba”. When it comes to his daily food intake, the patient said that he is able to eat just enough, and he eats whatever it is that is served, and he also claimed that he loves to eat meat. In the past the patient has no difficulty in eating and usually has good appetite. He does not take any vitamins and other supplements. With regards to his fluid intake, he said that during his usual days he is able to consume about 1 L of water per day. Regarding patient’s elimination pattern, he said that usually he has a daily bowel movement with formed stool, but at preset he has not yet bowel eliminated. He also does not frequently experience constipation. With regards to his urinary elimination, he said he usually voids many times a day. At present, he voided twice this afternoon to yellow colored urine, moderate in quantity with no difficulty and incontinence. According to the patient, his usual type of exercise that he performs is walking and he does this every morning around their house. With regards to the patient’s sleep pattern, he said he doesn’t have any difficulty in getting asleep, and at present he usually sleeps many times during the day.

XLIX.

Family History:

a.

The patient has 3 other siblings. 1 elder brother and 2 sisters, but according to him it is only he who has this kind of illness. The patient’s parents are both deceased. His father according to him died when he was still a child, he was shot and killed while he was on his duty in the army. His mother on the other hand died after the delivery of her 4th child. The patient has no family history of asthma, DM, arthritis, TB, and hypertension.

L.

Social Data

i.

ii. iii.

The patient is married, and has 4 children. 2 girls and 2 boys, but it is only his 1st daughter who lives with him together with his grandchildren. He formerly worked in a printing business but after he had his illness he stopped, his wife on the other hand works as a Brgy. kagawad at their place. The patient is a graduate of AB Pol. Sci. at Leyte Colleges. In cases of problems, it is his family who helps him a lot and supports him emotionally.

PHYSICAL EXAMINATION: VVVVVV. General Health: patient is a 63 y.o male adult. He is cooperative, easy to talk with, calm and, responds when asked. WWWWWW. Vital Signs: BP: 130/90 mm Hg HR: 86 bpm RR: 22 cpm Temp: 36°C XXXXXX. Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass, absence of nodules. YYYYYY. Hair: Inspection: With white strands of hair, evenly distributed, scalp has no infection or infestation; Palpation: thin, resilient hair ZZZZZZ. Nails: Inspection: Convex curvature, capillary bed is pale in color; Palpation: smooth texture, slight delay in return of capillary refill (about 5 seconds; normal is less than 4 seconds) AAAAAAA. Skin: Inspection: light brown in color with visible age spots, wrinkled and saggy, no presence of edema and active lesions; Palpation: has normal skin temperature, has senile skin turgor. Cold clammy skin, pallor BBBBBBB. Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no discharges and no discoloration, and sclera appears white and anicteric, pupils are equally round and reactive to light and accommodation, uses eyeglasses; Palpation: light pink palpebral conjunctiva, no periorbital edema, no tenderness over lacrimal gland. CCCCCCC. Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, has some difficulty in hearing normal voice tones; Palpation: auricles are mobile, firm and not tender DDDDDDD. Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions

EEEEEEE. Mouth: Inspection: uniform slight pale, able to purse lips, with some teeth missing and with brown to black discoloration of the enamel of the remaining teeth, no dentures, tongue moves freely; Palpation: soft, moderately dry and smooth texture FFFFFFF. Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible, neck vein distention; Palpation: no palpable lymph nodes GGGGGGG. Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact, symmetric chest expansion, no use of accessory muscles, no retractions, quiet, effortless respiration; Palpation: no tenderness and no masses, Auscultation: no wheeze or crackles HHHHHHH. Cardiovascular: Inspection: precordium no abnormal pulsations; Palpation: palpable radial pulse; Auscultation: no abnormal heart sound, no murmurs IIIIIII. Abdomen: Inspection: flat and rounded, no evidence of enlargement of liver; Palpation: soft, no tenderness JJJJJJJ. Musculoskeletal: Inspection: no contractures, no tremors, with slight weakness of muscles of the body; Palpation: no tenderness or swelling, with good handgrip, KKKKKKK. Mental Status: Oriented to time, place and person, responsive, with some discrepancies with past memory.

REVIEW OF SYSTEMS: IIIIII. General Health: No weight loss, no fever and chills, not diaphoretic, no colds JJJJJJ. Skin: no pruritus, no itchiness, cool and pale KKKKKK. Head: no headache, not nauseated, dizzy at times LLLLLL. Eyes: no blurring of vision, no visual disturbances MMMMMM. Ears: no ringing of ears, no tenderness NNNNNN. Nose: no change in sense of smell, no colds, no bleeding, difficulty in breathing OOOOOO. Mouth: no bleeding gums, no difficulty in swallowing and chewing of food PPPPPP. Respiratory: with reports of orthopnea, with report of dyspnea at times, not out of breath when moving. QQQQQQ. Cardiovascular: with some complaints of mild chest heaviness, no syncope RRRRRR. Gastrointestinal: no tenderness, has not yet bowel eliminated, SSSSSS. Genitourinary: voided 2 times the whole shift, no pain and discomfort during urination TTTTTT. Musculoskeletal: slight weakness of body, easy fatigability

XIII.

Patients Profile: Name: Matacero, Arvin Benerez Age: 19 y.o Sex: M Civil Status: Single Religion: Catholic Date of Birth: Oct. 21, 1988 Birthplace: Capoocan Citizenship: Filipino Address: Capoocan, Leyte Date of admission: 07-03-07 Time of admission: 3:15 PM Diagnosis: CKD stage 5 from CGN T/C hyperthyroidism History of Present Illness b. This is a case of Matacero, Arvin, 19 years old, male residing at Capoocan, Leyte who was admitted for the first time as a referral from a private MD with a chief complaint of dyspnea. The condition of the patient started 1 month prior to admission. The patient was noted with increasing pallor associated with occasional nausea. Other symptoms associated were occasional puffiness of the face especially upon awakening in the morning and bipedal edema which resolves spontaneously. No consult was done and no medications were taken. The patient just tolerated the condition. 2 weeks prior to admission, the patient experienced occasional vomiting of previously ingested food, moderate in quantity and this was associated with headache and dizziness. According to the patient he had less than 1 L/day of urine output. The patient still did sought consult. The symptoms of the patient persisted and now associated with slight dyspnea. This prompted the patient to seek consult of a private MD. The serum creatinine of the patient was taken and was found out to be markedly elevated to 2,069 umol/L. He was given medications to take such as Thiamine mononitrite, ciprofloxacin, Ranitidine, MV + Iron, and Glipizide, he was then referred to EVRMC for further evaluation and management. Past History c. The patient had complete immunizations during his childhood. He aslo recalled having chicken pox, measles and mumps when he was still a child. d. The patient has no other previous hospitalizations; however the patient stated that he experienced an accident when he was 14 years old. He said that he fell from the coconut tree and wounded his left leg. No hospitalization was done; he only treated the wound with an ointment. He did not suffer any fractures, he only obtain a scar from the wound that he had. e. The patient has no history of asthma, Rheumatic heart disease, GI disorders and any serious illness in the past. f. The patient also has no known allergy to any food, drug, or animals. g. He also did not experience having blood transfusions in the past.

XIV.

XV.

XVI.

Lifestyle h. The patient is a non-smoker and a non alcoholic beverage drinker. With regards to his food intake, the patient stated that on usual days he is able to eat a lot and usually has a good appetite. He also does not experience any difficulty in eating and swallowing. At present the patient is not able to eat much because he usually vomits and complains of not having a good appetite. The patient also stated that he is fond of eating junk foods twice daily, and drinking soft drinks two times a day before when he was not yet admitted. With regards to his water intake, he said that he is only able to consume 3 half full glass of water per day. i. With regards to the patient’s elimination pattern, he stated that his usual bowel movement is every other day. He also said that he frequently experience being constipated. At present the patient has not yet bowel eliminated. Regarding his urine output, the patient said that he voided twice during the whole shift and still has a decrease amount of urine. No difficulty or pain was noted during urination. j. During patient’s free time, he usually plays basketball with his friends, and this is only the form of exercise he engages into. k. According to the patient, before he was hospitalized he usually is able to sleep right away continuously, however at present the patient complains of not being able to sleep well at night. He said that it is only around 4 AM that he is able to sleep. Family history

XVII.

l.

The patient has 10 other siblings and all of them are in good physical condition. However, he stated that the 5th child of their family has asthma, and his grandmother has diabetes and hypertension which makes him at risk of acquiring these diseases. On the other hand, he also claimed that he has no family histoey of arthritis, heart disease, and mental illness.

XVIII. Social Data m. The patient is 19 years old, single and is currently living with his parents together with his other 3 siblings. He stopped schooling and worked as a waiter. His father works as a farmer while his mother works as a laundry washer. n. When problem arises, he usually seeks help from his friends and parents.

PHYSICAL EXAMINATION: 1. General Health: Patient is a 19 y.o male adolescent, awake, cooperative, answers to questions and is easy to talk with, but appear fatigued. 2. Vital Signs: BP: 140/80 mm Hg HR: 91 bpm RR: 22 cpm Temp: 36°C 3. Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass, absence of nodules. 4. Hair: Inspection: black hair, evenly distributed, scalp has no infection or infestation; Palpation: thick, resilient hair 5. Nails: Inspection: Convex curvature, capillary bed is pale in color; Palpation: smooth texture, delay in return of capillary refill (about 6 seconds; normal= less than 4 seconds) 6. Skin: Inspection: light brown in color, with pallor of the palms of both hands, diaphoresis; Palpation: with cold clammy and dry skin, with slightly poor skin turgor. 7. Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no discharge and no discoloration, and sclera appears white and anicteric, pupils are equally round and reactive to light and accommodation, no visual disturbances; Palpation: light pink conjunctiva, with periorbital edema, no tenderness over lacrimal gland. 8. Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, able to hear effectively with normal voice tones; Palpation: auricles are mobile, firm and not tender 9. Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions 10. Mouth: Inspection: pallor, dry mucus membrane, able to purse lips, complete set of teeth, no dentures, tongue moves freely; Palpation: soft, moderately dry and smooth texture 11. Neck: Inspection: able to flex, hyperextend and rotate; Palpation: no palpable lymph nodes

12. Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact, no retractions, with non-productive cough; Palpation: with burning chest pain at xiphoid area, no masses, Auscultation: no crackles and wheeze 13. Cardiovascular: Inspection: with heaves; Palpation: with palpitations, full bounding pulse 14. Abdomen: Inspection: flat and rounded. Palpation: soft, no evidence of enlargement of liver, no tenderness, episodes of vomiting (watery in consistency, yellowish in color, moderate in amount) 15. GUT: hematuria, decreased urine putput 16. Musculoskeletal: Inspection: no contractures, no tremors, with slight weak muscle tone; Palpation: no tenderness or swelling, with good handgrip, 17. Mental Status: Oriented to time, place and person, drowsy but responsive, able to recall past memories, fatigued, no difficulty in walking, able to balance. REVIEW OF SYSTEMS: UUUUUU. General Health: no fever and chills, not diaphoretic VVVVVV. Skin: no pruritus, no itchiness; heat intolerance (diaphoretic) WWWWWW. Head: no headache, no dizziness, not nauseated XXXXXX. Eyes: no blurring of vision, no visual difficulties, no use of eyeglasses YYYYYY. Ears: no ringing of ears, no tenderness, no difficulty in hearing ZZZZZZ. Nose: no change in sense of smell, no colds, no bleeding AAAAAAA. Mouth: no bleeding gums, no difficulty in swallowing and chewing of food, with poor appetite BBBBBBB. Respiratory: not dyspneic, with non-productive cough, has no difficulty in breathing, Cardiovascular: no syncope, with burning pain on chest at xiphoid area CCCCCCC. Gastrointestinal: no tenderness, has no bowel movement yet, with poor appetite, with nausea, vomited to a yellow colored vomitus, water in consistency, moderate in amount. DDDDDDD. Genitourinary: voided 2 times this afternoon with still dercreased amount of urine, no pain and discomfort during urination was noted. EEEEEEE. Musculoskeletal: slight weakness of body, body malaise,

FFFFFFF.

Neurologic: with feeling of body weakness, no paralysis of any body part, no numbness, no tremors.

DIAGNOSTIC EXAMS Name of Patient: Verano, Clarito Regaňon. Date Admitted: 7-1-07 Age: 63 y.o Time admitted: 8:00 AM Sex: Male C/C: Chest Heaviness Diagnosis: Acute Myocardial Infarction Date 7-01-07 Lab Exam Hematology Result Hct= 0.38 WBC= 6.6 x 10~9/L Differential Ct.: Segmenter= 0.83 Lymphocyte= 0.16 Monocyte= 0.01 Troponin I= (-) Normal Values 0.40-0.54 4.5-11.3 0.45-0.65 0.20-0.35 0.02-0.06 Negative Significance >Decreased in anemia >Normal >Increased in tissue necrosis (Myocardial Infarction) >Decreased in immunosuppression and corticosteroid therapy >Decreased by drug therapy >Normal

Clinical Chemistry Date 7-03-07 Lab Exam Hematology

Urinalysis

Result Hgb= 107 g/L Hct= 0.31 Erythrocyte= 3.84 x 10~12/L Leukocyte= 5.70 x 10~9/L Granulocyte= 0.75 Lymphocyte= 0.20 Monocyte= 0.05 MCV= 80 fl MCH= 27.80 pg MCHC= 350 Color= pale yellow Transparency= slight turbid Spc. Gr.= 1.010 pH= 6.0 Gluc/Albu/Blood= (-) Pus cells= 0-2/hpf RBC= 0-2/hpf Epith. Cells= some Bacteria= few M. threads= some A. Urates= few Glucose= 4.6 mmol/L

Normal Values M: 135-170 M: 0.40-0.54 M: 4.6-6.2 4.5-10 0.500-0.750 0.200-0.350 0.020-0.060 80-96 27-31 320-360 Pale yellow-deep amber Clear 1.002-1.035 4.5-8.0 Negative <3/hpf Negative

Significance >Decreased in anemia >Decreased in anemia >Decreased in anemia >Normal >Normal >Normal >Normal >Normal >Normal >Normal >Normal

>Normal >Normal >Normal >Normal

Blood Chemistry (Serum)

4.2-6.4

>Normal

Creatinine= 230.5 umol/L Cholesterol= 4.8 mmol/L Triglyceride= 0.7 mmol/L

53-97

< or = 5.7 0-1.71

>Increased in cardiac disorder that adversely affect renal circulation >Normal >Normal

Date 7-04-07

Lab Exam PROTIME

Result Test= 12.6 sec

Normal Values 9.5-12 sec

Significance >Slightly prolonged with low levels or deficiencies of fibrinogen, clotting factors 11, V, Vii, & X

Control= 12.0 sec INR= 1.1

DIAGNOSTIC EXAMS Name of Patient: Matacero, Arvin Benerez Date Admitted: 7-03--07 Age: 19 y.o Time admitted: 3:15 PM Sex: Male T/C hyperthyroidism Date 7-02-07 Lab Exam Blood Chemistry Urinalysis Result Creatinine= 2,069 umol/L Color= Yellow Transparency= hazy Sp. Gr.= 1.030 pH= 5.0 Albumin= +++ RBC= 1-2/hpf Sugar= (-) WBC= 6-8/hpf Epith. Cells= many M. threads= many Bacteria= moderate FBS= 8.36 mmol/L Result Hgb= 34 g/L Hct= 0.17 WBC= 5.35 x 10~9/L Sementer= 0.74 Lymphocyte= 0.26 Blood type “A” RH(+) Date Lab Exam Result Normal Values 53-97 Pale yellow-deep amber Clear 1.002-1.035 4.5-8.0 (-) <3/hpf (-) 0-5/hpf Significance >Increased in nephritis & chronic renal disease >Normal

Diagnosis: CKD stage 5 from CGN

>Normal >Normal >Increased in glomerular disease and nephropathy >Normal >Normal >Increased in infection

Miscellaneous Date 7-03-07 Lab Exam Hematology

none 4.2-6.4 Normal Values M: 135-170 M: 0.40-0.54 4.5-11.3 0.45-0.65 0.200-0.350

>UTI >Increased in nephritis Significance >Decreased in anemia >Decreased in anemia >Normal >Increased in inflammatory disease or bacterial infection >Normal

Normal Values

Significance

7-04-07

Urinalysis

Color= Light yellow Transparency= Clear Sp. Gr.= 1.025 pH= 5.0 Pus cells= 1-4/hpf RBC= 4-6/hpf Epith. Cells= Occasional Bacteria= Some A. Urates= Moderate Glucose= (+) Albumin= ++++ Blood= ++ Coarse granular casts= 0-1/hpf Others: No dysmorphic RBC seen Urea (BUN)= 11.3 mmol/L Creatinine= 2332.6 umol/L Hgb= 36 g/L Hct= 0.10 Erythrocyte= 1044x 10~12/L Leukocyte= 4.80 x 10~9/L Granulocyte= 073 Lymphocyte= 0.20 Monocyte= 0.07 MCV= 70 fl MCH= 25.30 pg MCHC= 364

Pale yellow-deep amber Clear 1.002-1.035 4.5-8.0 <3/hpf

>Normal >Normal >Normal >Normal >Increased in IgA nephropathy, infection, renal artey thrombosis

None (-) (-) (-) 0-4/hpf

>Present in UTI

>Increased in nephritis and glomerular disease >Increased in nephropathy >Normal

Clinical Chemistry

2.5-7.5 53-97 135-170 M: 0.40-0.54 M: 4.6-6.2 4.5-10 0.500-0.750 0.200-0.350 0.020-0.060 80-96 27-31 320-360

>Increased in renal failure >Increased in Nephritic and chronic renal disease >Decreased in anemia Decreased in anemia Decreased in severe anemia >Normal >Normal >Normal >Normal >Decreased in microcytic anemia >Decreased in hemoglobin deficiency, hypochromic anemia >Increased when cells are oversized (fewer cells can be packed together within 1 dl)

Hematology

I. PATIENTS PROFILE Name: Glenn Raphael Dolina Case No: 030883 Age: 1 month old Sex: Male Civil status: Single Address: Brgy. Buri, Palo, Leyte Religion: Roman Catholic Nationality: Filipino Birthday: Decmber 13, 2007 Birthplace: EVRMC Tacloban City Date of Admission: January 28, 2008 Time: 11:07 AM Mother: Cheryl Dolina Occupation: Receptionist Attending Consultant: Dr. Monterde/ Dr. Almaden Chief Complaint: “ Parang nahihirapan siyang huminga at parang merong sound yung paghinga niya” as verbalized by the mother Diagnosis: R/O Hyaline Membrane Disease II. History Present Illness This is a case of Glenn Raphael Dolina, a 1-month old baby, male, infant, Roman Catholic, Filipino and currently residing at Brgy. Buri Palo, Leyte. He is admitted for the first time at our center.

Patient was born last December 13, 2007 at EVRMC at 34 weeks AOG via C/S delivery. After birth, the patient was noted to have grunting and disrupted feeding, nasal flaring, and jaundice. So they patient underwent blood transfusion of about 250 cc of blood. After, the patient was discharged along with his mother. The above symptoms (except for jaundice) persisted and so mother brought the patient to this center for consult, hence admission. III. Past History The patient has no past hospitalization, operation and has no allergy to any food, drug and plants. He has not experienced any childhood diseases such as measles, chicken pox or mumps. After he was born, he was immunized with Hepatitis B one dose, BCG, DPT one dose, OPV one dose. This is his first time to be hospitalized since he was born. After birth, the patient had fever as a normal reaction to the immunization so mother gave Paracetamol. IV. Family History According to his mother, the only heredofamilial disease they have is diabetes milletus from his grandparents. V. Psychosocial History The patient’s mother originally lives in Metro Manila. Last month, she came to Tacloban for a vacation. VI. Birth History A. Pre-natal- During her 2nd month pregnancy, Ms. Dolina had a urinary tract infection. According to her she took some medications as per consult with a doctor but was unable to recall. She takes vitamins everyday. She did not experience any vaginal bleeding and the duration of her pregnancy is only 34 weeks. B. Natal- Baby Glenn was born via C/S delivery to a G1P1 26 years old mother. Her birthweight was 3.7 kg. C. Neonatal- The patient had jaundice after he was born and underwent blood transfusion of about 250 cc of whole blood. VII. Feeding History Patient is bottlefed since birth. After birth her milk formula was Bona but mother switched to S26 formula (5-6X/ day at 4 ounce each).

LABORATORY EXAMINATIONS I. January 28, 2008- Chest APL Haziness in the inner lung zones. Heart is not enlarged. Thoracic cage diaphragm and costophrenic sulci are unremarkable. Impression: bronchopneumonia II. January 28, 2008- Urinalysis Exam Result Color Transparency pH Yellow Clear 6.0 Normal Findings Colorless to dark yellow Clear 5.0-7.0 Significance Normal Normal Normal

Specific gravity Albumin Sugar Pus cells Red blood cells Epithelial cells Bacteria A.urates Mucus threads

1.005 Negative Negative 0-1/hpf 0-1/hpf Rare Few Few Few

1.001-1.020 Negative Negative 0-1/hpf 0-1/hpf No significance None No significance No significance

Normal Normal Normal Normal Normal Normal Normal Normal Normal

III. January 28, 2008- Fecalysis Color: Yellow Character: Soft - No significant finding IV. January 29, 2008- Hematology Remarks: Blood type “A”; Rh (+) Exam Hemoglobin Result 110 g/L Normal Values Significance Male: 140-175g/L Decreased in Female: 120- hemodilution(fluid 160g/L overload), anemia, recent hemorrhage Male: 0.42-0.50 Decreased in Female: 0.36- hemodilution, 0.46 anemia, and acute massive blood loss. 9 5-10x10 /L Normal 150-450X10 g/L Normal 0.57-0.65 Decreased in viral diseases. Leukemias, agranulocytoss and aplastic anemia. 0.25-0.35 Increased in inflammatory disease, tissue necrosis, anemia, allergic reactions. 0.04-0.08 Decreased in renal failure, aplastic anemia and leukemia. 0.03-0.05 Normal

Hematocrit

0.30

WBC Platelets Neutrophils

7.75 432 0.26

Eosinophils

0.68

Lymphocyte s Monocytes

0.02

0.04

REVIEW OF SYSTEMS General: No weight loss, fever and chills, fatigue Skin: No rashes, pruritus, bruising, change in color Head: No headaches, injury, tenderness, dizziness Eyes: No change in visual field, glasses, contact lenses Ears: No Change in hearing, tinnitus, pain, discharge, dizziness Nose: No Allergies, sinus problem, obstruction, polyps, loss of sense of smell, sneezing, epistaxis with nasal flaring

Throat: No toothaches, loose teeth, bleeding gums, mouth sores Respiratory: Subcostal retractions, occasional crackles Cardiovascular: no Chest pain, pressure/ tightness, palpitations GIT: No dysphagia, heartburn, ulcer, indigestion, diarrhea, constipation, abdominal pain, GUT: No urgency, frequency, nocturia, dysuria, hematuria, UTI, incontinence Endocrine: No Heat/cold intolerance, weight change, fatigue Musculoskeletal: No weakness.

PHYSICAL EXAMINATION Vital Signs Pulse Rate: 145 bpm Respiratory rate: 35 breaths/min Temperature: 37°C Weight: 3.7 kilograms General Survey: Conscious, cuddled by mother with an IVF of D5 0.3 NaCl at 12 ugtts/min per soluset. Integument: Inspection: Pinkish in complexion, uniform in color through out body Palpation: Fair skin turgor, warm to touch Nails: Inspection: smooth, nail plate-convex curvature Palpation: Thin, capillary refill = 3 seconds. Head: Inspection: Normocephalic skull with thin hair Palpation: Smooth skull contour Eyes: Inspection: Symmetrical, pinkish palpebral conjunctiva, pupils equally round and reactive to light. Ears: eye Nose: Inspection: Symmetrical at midline Palpation: Non tender sinus Throat and Mouth: Inspection: Moist oral mucosa Inspection: Symmetrical, auricles aligned with the outer canthus of the Palpation: No discharge, non tender.

Chest & Lungs: Inspection: Symmetrical chest, irregular respiratory rhythm, tachypnea (RR=35cpm), subcostal retractions Palpation: Non-tender, symmetric chest expansion, no nodules nor mass. Auscultation: Crackles Heart: Inspection: Not observable apical pulse Percussion: Dullness over heart Auscultation: Regular heart rhythm, good S1 and S2.

I. PATIENTS PROFILE Name: Alegar Montallana Moralles Case No: 72902-2008 Age: 16 years old Sex: Male Civil status: Single Address: Brgy. Pangudtan, Oras Eastern Samar Occupation: Student (4th Year HS) Religion: Roman Catholic Nationality: Filipino Birthday: 6/17/1991 Birthplace: Oras Eastern Samar Date of Admission: February 7, 2008 Time: 3:46 PM Father: Olegario Moralles Age: 49 Occupation: “Nagsasabong” Mother: Almira Moralles Age: 42 Occupation: Housewife Attending Consultant: Dr. Francisco Caboboy Chief Complaint: “Mabanhod an akon kamot tas masakit hiya labi na kun nakikiwa.”As verbalized by the patient. Diagnosis: Fracture, closed, displaced, distal 3rd radius-ulnar Operation Performed: Open reduction Plating, radius-ulna right II. History Present Illness This is a case of Alegar Moralles, 16 years old, male, roman catholic, Filipno, a 4 th year high school student, residing at Brgy. Pangudtan Oras Eastern Samar, who is admitted for the first time in this center due to fracture of his right arm. 2 days PTA, patient was playing basketball in their school. After doing a lay up, he fell badly on the ground and broke his 3rd distal radius-ulnar on the right arm. Patient immediately complained of pain and so his classmates brought him home. Parents decided to bring him to the hilot and the affected area was massaged. And advised them to have an x ray of his arm. Parentst decided to give the patient Amoxicillin and Mefenamic Acid. A day PTA, patient complained of swelling, pain, redness and deformity. So parents decided to sought consult at this center. III. Past History Patient has no previous trauma, surgery and accidents. He had measles, chicken pox and mumps during his childhood. His mother verbalized that he had complete immunizations. He has no allergies to any food, plant and animals. This is the first time he was hospitalized. And he has no maintenance medications. IV. Family History Patient has a family history of hypertension, cardiomegaly and asthma on his paternal side. V. Lifestyle Patient drinks Beer about 2 grande but only during occasion. He does not smoke. His usual ADL is going to school, attending his classes, playing basketball, doing his homework, watching TV and going out with his barkada. He loves to eat meat but also eats fish and vegetables especially mongos. He has no problems or difficulty with his sleeping. He usually sleeps at around 9PM and wakes up at around 5 AM. Her hobbies includes going out with his friends and playing basketball.

VI. Social Data The patient has 4 siblings and he is the youngest. He has good relationship with his family. He is currently a 4th year high school student. He lives in a house made of cement with 2 rooms. Their house is about 50 meters from the main road with electricity and water supply from deep well.

LABORATORY EXAMINATION: February 7, 2008 Chest PA View • Impression: Dextroscoliosis, thoracic spine otherwise normal chest study. February 7, 2008 Urinalysis Exam Result Color Yellow Transparency pH Specific gravity Protein Sugar Pus cells Red blood cells Epithelial cells Bacteria A.urates Mucus threads Turbid 6.0 1.020 Negative Negative 0-1/hpf None None Few Many Few Normal Findings Colorless to dark yellow Clear 4.6-8.0 1.006-1.030 Negative Negative 3-5/hpf 2-4/hpf Rare/Few/None Rare/Few/None Rare/Few/None Rare/Few/None Normal Values Male: 140-175g/L Female: 120-160g/L Male: 0.42-0.50 Female: 0.36-0.46 4.5-11.3x109/L 0.45-0.65 Significance Normal Due to presence of pus cells Normal Normal Normal Normal Normal Normal Normal Normal Normal Significance Normal Normal Normal Increased in acute infections, inflammatory disease and tissue damage Normal Normal

February 7, 2008 Hematology Exam Result Hemoglobin 154 Hematocrit WBC Neutrophils 0.46 8.6 0.71

Lymphocytes Monocytes

0.23 0.06

0.20-0.35 0.02-0.06

February 11, 2008 Right Forearm APL Follow-up study to an outside film now shows metallic plates and screws transfixing the fractures on the radius and ulna. REVIEW OF SYSTEMS: General: No weight loss, fever and chills, fatigue Skin: No rashes, pruritus, bruising, no change in color Head: No headaches, injury, tenderness, dizziness

Eyes: No change in visual field, glasses, contact lenses Ears: No Change in hearing, tinnitus, pain, discharge, dizziness Nose: No Allergies, sinus problem, obstruction, polyps, loss of sense of smell, sneezing, epistaxis with nasal flaring Throat: No toothaches, loose teeth, bleeding gums, mouth sores Respiratory: No cough, no crackles or rales Cardiovascular: no Chest pain, pressure/ tightness, palpitations GIT: No dysphagia, heartburn, ulcer, indigestion, diarrhea, constipation, abdominal pain, GUT: No urgency, frequency, nocturia, dysuria, hematuria, UTI, incontinence Endocrine: No Heat/cold intolerance, weight change, fatigue Musculoskeletal: No weakness. PHYSICAL EXAMINATION: Date of Examination: February 10, 2008 General Survey: Symmetrical body, with no attached IVF, with cast on right arm and lying on bed asleep. Vital signs: BP= 120/70mmhg HR= 65 bpm RR= 21cpm Temperature= 37°C

Integument: Inspection: Brown in complexion, uniform in color through out body, dry and pallor Palpation: Fair skin turgor, warm to touch Nails: Inspection: Trimmed clean fingernails, smooth, nail plate-convex curvature Palpation: Thick, capillary refill = 5 seconds. Head: Inspection: Normocephalic skull, Blackevenly distributed hair, no infestation Palpation: Smooth skull contour Eyes: Inspection: Symmetrical, pinkish palpebral conjunctiva, pupils equally round and reactive to light; pupils dilatation: 3-4mm, can read newsprint. Ears: Inspection: Symmetrical, auricles aligned with the outer canthus of the eye, cannot hear normal voice tone. Palpation: No discharge, non tender. Nose: Inspection: Symmetrical at midline with clear discharges and frequent sneezing. Palpation: Non tender sinus, patent nasal passages. Throat and Mouth: Inspection: Moist oral mucosa, able to purse lips, Pinkish tongue, moves freely, reddened uvula, non-inflamed tonsils, no dysphagia. Neck: Inspection: Coordinated movements with no discomforts, thyroid gland not visible. Palpation: Non-enlarged lymph nodes, palpable thyroid gland Chest & Lungs: Anterior:

Inspection: Symmetrical chest, regular respiratory rhyth Palpation: Non-tender, symmetric chest expansion, no nodules nor mass. Percussion: Resonance Auscultation: Clear breath sounds Posterior: Inspection: spine on midline. Palpation: Non-tender, no nodules nor mass. Percussion: Resonance Auscultation: Clear breath sounds Heart: Inspection: Not observable apical pulse Palpation: No thrills, PMI at 5th ICS Midclavicular Percussion: Dullness over heart Auscultation: Regular heart rhythm, good S1 and S2. Abdomen: Inspection: Uniform color, round in shape. Auscultation: Regular bowel sound (7 per min.) Percussion: Dullness over liver, tymphany over stomach. Palpation: No tenderness, non-palpable spleen and kidneys. Extremities: Upper: • With good sensation • With reflexes on the right • Palpable peripheral pulses • No resistance at left upper arm. Lower: • With good sensation • With reflexes • Palpable peripheral pulses • With less resistance on left extremities.

I. PATIENTS PROFILE Name: Gregoria Patris Casil Case No: 72954-2008 Age: 52 years old Sex: Female Civil status: Married Address: Brgy. Cabungaan BayBay Leyte Occupation: Housewife Religion: Roman Catholic Nationality: Filipino Birthday: 11/11/1955 Birthplace: BayBay Leyte Date of Admission: February 7, 2008 Time: 2:52 PM Husband: Jose Casil Age: 56 Occupation: Farmer Attending Consultant: Dr. Blas Chief Complaint: Ningsakit man ang akong tiyan ug likod.” As verbalized by the patient. Diagnosis: Acute prelonephritis with nephrolithiasis II. History Present Illness This is a case of Gregoria casil, 52 years, married, a Roman Catholic, Filipino, residing at Baybay Leyte is admitted for the first time in this institution due to abdominal pain. 1 week PTA, patient had colicky pain on the right lower quadrant. It was intermittent accompanied by dysuria, frequency,and hematuria. Patient took Mefenamic acid to relieve the pain and went to the hilot and was given herbal medications. But the above symptoms persisted hence prompted the patient to sought consult in this institution. III. Past History

The patient has no previous trauma, injury nor accidents. She remembered to have had chicken pox, measles and mumps. She has allergies to shrimps. She was hospitalized for three times already. And she has a maintenance medication of centrum. IV. Family History Patient’s family has a history of hypertension, and asthma. V. Lifestyle Patient drinks tuba and coffee occasionally but unable to count up to how many glasses. She does not smoke. Her usual ADL is cleaning the house, cooking, washing clothes and other household chores because she is a housewife and she loves doing these chores for her children and husband. She usually do some morning walking about 30 minutes. She loves to eat vegetables. She usually sleeps at around 8Pm and wakes up at 3 AM and does not complain of any difficulties with sleeping. VI. Social Data The patient has 8 children. She is a high school graduate. She sometimes helps his husband in doing some chores in the farm. LABORATORY EXAMINATION: 2/4/08 Ultrasound Conclusion:  Nephrolithiasis right associated with grade IV hydronephrosis  Normal sonographic evaluation of the left kidney and urinary bladder. 2/7/08 X-ray Impression: Fibrocalcific density as described likely due to previous healed pulmonary infection. 2/8/08 ECG Sinus rhythm and non-specific P wave. 2/7/08 Hematology Exam Hemoglobin Hematocrit WBC Neutrophils Lymphocytes Monocytes 2/7/08 Clinical Chemistry Exam Creatinine Result 71.12 Normal Values Male: 71-115 umol/L Female: 53-106 umol/L Significance Normal Result 127 0.39 5.5 0.57 0.36 0.07 Normal Values Male: 140-175g/L Female: 120-160g/L Male: 0.42-0.50 Female: 0.36-0.46 4.5-11.3x109/L 0.45-0.65 0.20-0.35 0.02-0.06 Significance Normal Normal Normal Normal Normal Normal

2/8/08 Clinical Chemistry Exam Sodium Potassium Uric-E Gluc-D Chol-E Trig-E HDL LDL Result 146.2 3.53 0.19 5.47 6.5 0.56 1.23 5.0 Normal Values 135-148mmol/L 3.5-5.3mmol/L 0.17-035mmol/L 3.90-6.40mmol/L 3.9-6.7mmol/L 0.46-1.88mmol/L 0.00-1.68mmol/L Normal Significance Normal Normal Normal Normal Normal Normal

2/8/08 Hematology Exam Bleeding Time Clotting Time 2/10/08 Urinalysis Exam Color Transparency pH Specific gravity Protein Sugar Pus cells Red blood cells Epithelial cells Bacteria A.urates Mucus threads 2/11/08 Miscellaneous Exam TSH FT3 FT4 Result Straw Clear 6.0 1.005 Negative Negative 0-4/hpf 0-1/hpf Few Few Few Few Result 1.30 4.42 19.86 Normal Findings Colorless to dark yellow Clear 4.6-8.0 1.006-1.030 Negative Negative 3-5/hpf 2-4/hpf Rare/Few/None Rare/Few/None Rare/Few/None Rare/Few/None Normal Values 0.25-5.0 IU/mL 4.0-8.3pmol/L 9-20pmol/L Result 12.9 sec 121.6% 0.89 INR 15.6 sec 88% 1.14 INR Test: 43.5 sec Control: 37.7 sec Significance Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Significance Decreased in secondary hypothyroidism and high level of dopamine Normal Normal Result 2 mins. 15 sec. 3 mins Normal Values 1-4 mins. 2-6 mins. Significance Normal Normal

2/11/08 Protime and APTT Exam Protime

Control

APTT with mixing

REVIEW OF SYSTEMS: General: weight loss, fatigue, with no fever and chills Skin: No rashes, pruritus, bruising, no change in color Head: headaches and no injury, tenderness, dizziness Eyes: No change in visual field, glasses, contact lenses Ears: No Change in hearing, tinnitus, pain, discharge, dizziness Nose: With Allergies to shrimp, No sinus problem, obstruction, polyps, loss of sense of smell, sneezing, epistaxis with nasal flaring Throat: No toothaches, loose teeth, bleeding gums, mouth sores, polyps on the vocal folds Respiratory: No cough, no crackles or rales, dyspneic Cardiovascular: Chest pain, pressure/ tightness GIT: No dysphagia, heartburn, ulcer, indigestion, diarrhea, constipation, but with abdominal pain. GUT: urgency, frequency, dysuria, hematuria. Endocrine: weight change, fatigue Musculoskeletal: slight weakness. PHYSICAL EXAMINATION: Date of Examination: February 10, 2008

General Survey: Symmetrical body, with an IVF of D5MM 1 liter newly hooked at 20 gtts/min. Vital signs: BP= 110/80mmhg HR= 69 bpm RR= 81cpm Temperature= 36.5°C

Integument: Inspection: Brown in complexion, uniform in color through out body, dry and pallor Palpation: Fair skin turgor, warm to touch Nails: Inspection: Trimmed clean fingernails, smooth, nail plate-convex curvature Palpation: Thick, capillary refill = 5 seconds. Head: Inspection: Normocephalic skull, grayish evenly distributed hair, no infestation Palpation: Smooth skull contour Eyes: Inspection: Symmetrical, pinkish palpebral conjunctiva, pupils equally round and reactive to light; pupils dilatation: 3-4mm, can read newsprint. Ears: Inspection: Symmetrical, auricles aligned with the outer canthus of the eye, cannot hear normal voice tone. Palpation: No discharge, non tender. Nose: Inspection: Symmetrical at midline with clear discharges and frequent sneezing. Palpation: Non tender sinus, patent nasal passages. Throat and Mouth: Inspection: Moist oral mucosa, able to purse lips, Pinkish tongue, moves freely, reddened uvula, noninflamed tonsils, no dysphagia., with polyps on the vocal folds. Neck: Inspection: Coordinated movements with no discomforts, thyroid gland not visible. Palpation: Non-enlarged lymph nodes, palpable thyroid gland Chest & Lungs: Anterior: Inspection: Symmetrical chest, irregular respiratory rhythm (RR=28 cpm) Palpation: Non-tender, symmetric chest expansion, no nodules nor mass. Percussion: Resonance Auscultation: Clear breath sounds Posterior: Inspection: spine on midline. Palpation: Non-tender, no nodules nor mass. Percussion: Resonance Auscultation: Clear breath sounds Heart: Inspection: Not observable apical pulse Palpation: No thrills, PMI at 5th ICS Midclavicular Percussion: Dullness over heart Auscultation: Regular heart rhythm, good S1 and S2. Abdomen: Inspection: Uniform color, round in shape. Auscultation: Regular bowel sound (7 per min.) Percussion: Dullness over liver, tymphany over stomach. Palpation: No tenderness, non-palpable spleen and kidneys. Extremities: Upper: • With good sensation

• With reflexes on the right • Palpable peripheral pulses • No resistance at left upper arm. Lower: • With good sensation • With reflexes • Palpable peripheral pulses • With less resistance on left extremities.

I. PATIENTS PROFILE Name: Fernando Oria Case No: 73509-2008 Age: 79 years old Sex: Male Civil status: Married Address: Brgy. Rawis, Arteche E. Samar Occupation: Farmer Religion: Roman Catholic Nationality: Filipino Birthday: 5/15/1928 Birthplace: Arteche Eastern Samar Date of Admission: February 8, 2008 Time: 11:10 PM Wife: Dela Paz Oria Occupation: Housewife Attending Consultant: Dr. Jose Carlo Del Pilar Chief Complaint: “Inatake man ini hiya tas natumba” as verbalized by SO. Diagnosis: Right hemipharesis secondary to cerebral insufficiency probably left MCA thrombosis HPN II Essential COPD. II. History Present Illness This is a case of Fernando Oria, 79 years old, male, married, Filipino, a Roman Catholic and residing in Brgy. Rawis Arteche Eastern Samar, admitted for the first time due to right body weakness. 1 week PTA, patient was riding on a small boat to his farm along with nephew, when suddenly he fell on the boat. SO immediately brought him to a hospital in Arteche Eastern Samar. According to the SO, patient did not feel any discomforts or problems with his health. What happened was just sudden. During his stay in Arteche, patient was treated as a case for CVA. And after 4 days was discharged. Patient stayed at home for a day then SO decided to bring patient to this institution for further evaluation and management. III. Past History Patient has no previous trauma, surgery and accidents. He had measles, chicken pox and mumps during his childhood. SO was unable to recall any immunization of the patient since it was a long time ago. He has no allergies to any food, drug or plants. He has no maintenance medications previously. IV. Family History Patient has a family history of hypertension and asthma. V. Lifestyle According to So, patient drinks alcoholic beverage but on moderation and occasionally. He does not smoke. He loves to eat fish and other salty foods but denies esting meat too much. He usual do a morning exercise about 30 minutes on the seashore everyday. He has no sleeping difficulties. VI. Social Data The patient was not able to go to school. He can write but unable to read. He has 9 children and most of them has their own families and are already professionals. Patient has no problems with his neighborhood.

LABORATORY EXAMINATION: February 7, 2008 Chest PA View • Impression: APL is suggested for further evaluation. • Cardiomega;y 2/8/08 ECG Sinus rhythm, LVH 2/9/08 Cranial CT scan • Acute cerebral infarction, left temporo-parietal lobes • Cerebral atrophy 2/10/08 Clinical Chemistry Exam Sodium Potassium Gluc-D Exam HgbA1C Result 138.1 4.07 10.33 Result 4.1% Normal Values 135-148mmol/L 3.5-5.3mmol/L 3.90-6.40mmol/L Normal Values 4.5-5.3 Significance Normal Normal Increased in DM and nephritis

Significance Decreased in anemia

2/9/08 Clinical Chemistry Exam Sodium Potassium Crea-B Gluc-D Chol-E Trig-E HDL LDL 2/9/08 Clinical Chemistry Exam Calcium Result 1.92 Normal Values 2.15-2.57 mmol/L Significance Decreased in malabsorption of Calcium from the GIT Result 138.1 3.92 124.2 7.13 3.0 1.22 0.31 2.1 Normal Values 135-148mmol/L 3.5-5.3mmol/L 53-115 umol/L 3.90-6.40mmol/L 3.9-6.7mmol/L 0.46-1.88mmol/L 0.00-1.68mmol/L Significance Normal Normal Increased in CHF Increased in DM Decreased in starvation and malabsorption Normal Normal

2/11/08 Urinalysis Exam Color Transparency pH Result Dark yellow Turbid 6.0 Normal Findings Colorless to dark yellow Clear 4.6-8.0 Significance Normal Due to pus cells Normal

Specific gravity Protein Sugar Pus cells Red blood cells Epithelial cells Bacteria A.urates Mucus threads REVIEW OF SYSTEMS

1.015 Positive Negative Many Loaded Some Some ++ +++

1.006-1.030 Negative Negative 3-5/hpf 2-4/hpf Rare/Few/None Rare/Few/None Rare/Few/None Rare/Few/None

Normal Proteinuria; cardiac disease Normal Renal disease Normal Normal

General: Weight loss; fever, no chills, no night sweats. Skin: pruritus, no bruising, no changes in color. Head: no Headache, no injury, no tenderness. Eyes: Unable to read or concentrate Ears: Change in hearing. Nose: Clear nasal discharges, sneezing, no epistaxis, no loss of sense of smell. Throat and Mouth: pale and dry mucosa, cannot speak Respiratory: no non productive cough, no chest pain, dyspnea, crackles Cardiovascular: No chest pain, no palpitations, no shortness of breath. Gastrointestinal: no indigestion, no food intolerances, no diarrhea, and no abdominal pain, dysphagia Genitourinary: Hematuria. Musculoskeletal: edema on right hand, right hemipharesis. PHYSICAL EXAMINATION Vital Signs Heart Rate: 65 bpm Respiratory rate: 32 breaths/min Temperature: 36°C Blood Pressure: 120/70 mm Hg General Survey: Fairly groomed, drowsy and sleeps most of the time, with an ongoing IVF of PNSS 1 liter at 20 gtts/min, with o2 inhalation at 5 liters/min, with NGT intact and in place. Integument: Inspection: Brown in complexion, uniform in color through out body, brown “age spots” on exposed body areas, dry and pallor. Palpation: Fair skin turgor, warm to touch Nails: Inspection: Untrimmed, dirty fingernails, smooth, nail plate-convex curvature Palpation: Thick, capillary refill = 5 seconds. Head: Inspection: Normocephalic skull, grayish evenly distributed hair, no infestation Palpation: Smooth skull contour, dry brittle hair Eyes: Inspection: Symmetrical, cannot read newsprint. Ears:

Inspection: Symmetrical, auricles aligned with the outer canthus of the eye, cannot hear normal voice tone. Palpation: No discharge, non tender. Nose: Inspection: Symmetrical at midline with clear discharges. Palpation: Non tender sinus, patent nasal passages. Throat and Mouth: Inspection: Pale oral mucosa, smooth yellow tooth enamel, dysphagia, cannot move tongue freely. Unable to speak. Neck: Inspection: thyroid gland not visible. Palpation: Non-enlarged lymph nodes, palpable thyroid gland Chest & Lungs: Inspection: Barrel chest, irregular respiratory rhythm, tachypnea (RR=32cpm) Palpation: Non-tender, not symmetric chest expansion, no nodules nor mass. Percussion: Adventitious breath sounds Auscultation: fine crackles Heart: Inspection: Not observable apical pulse Palpation: No thrills, PMI at 5th ICS Midclavicular Auscultation: irregular heart rhythm. Abdomen: Inspection: Uniform color. Auscultation: irregular bowel sound Percussion: Dullness over liver, tymphany over stomach. Palpation: No tenderness, non-palpable spleen and kidneys. Extremities:

Neurologic System: Not oriented to place and time, oriented to person, affect not appropriate to situation, irritable at times and confusion, right hemipharesis

I. PATIENTS PROFILE Name: Angeles Orbaneja Raagas Case No: 22103-2005 Age: 84 years old Sex: Female Civil status: Widow Address: Brgy. San Vicente Dulag Leyte Occupation: Houseewife Religion: Roman Catholic Nationality: Filipino Birthday: 5/10/1923 Birthplace: Marabut Eastern Samar Date of Admission: February 22, 2008 Time: 9:26 AM Attending Consultant: Dr. Felicisimo Abuyabor Chief Complaint: Din inubo ako hin usa na ka simana tapos din hirantan gihap.” As verbalized by the patient. Diagnosis: CAP R/O UTI II. History Present Illness This is a case of Angeles Raagas, 84 years old, female, a widow, Filipino, Roman Catholic, a resident of Brgy. San Vicente Dulag Leyte, is admitted in this institution due to fever, cough and chills. A day PTA, patient had onset of fever associated with chills. This was accompanied by occasional cough and chest and abdominal pain. Patient took medications at home but unable to recall the name. Few hours PTA, patient’s symptoms persisted, hence prompted consult at this institution. III. Past History Patient has previous accidents but unable to recall. She also cant remember her childhood illness and immunizations since it was along time ago. She has no allergies to food, drugs or plants. She has been hospitalized before. IV. Family History Patient has a family history of Diabetes mellitus and heart disease. V. Lifestyle Patient is a non-alcoholic drinker and non-smoker since she was young. She loves to eat salty foods. Her usual diet consists of fish, rice and vegetables. She has no sleeping difficulties. When she got married, she was a plain housewife. She has no exercise regimen and does not love to drink coffee. VI. Social Data The patient has 6 children and a widow. Some of his children is not living with her anymore since they have their won family. She now relies on her children for financial support. She has good communication and relationship with her family and neighborhood. LABORATORY EXAMINATION: February 22, 2008 Chest PA View Hazy infiltrates are seen in right lower lung field. The heart is slightly enlarged. The rest of the visualized chest structures are unremarkable. • Impression: Right basal interstitial pneumonia • Cardiomegaly February 22, 2008 Urinalysis Exam Color Transparency pH Specific gravity Protein Sugar Pus cells Red blood cells Epithelial cells Bacteria A.urates Mucus threads Result Light yellow Slight turbid 6.0 1.010 Negative Negative 35-48/hpf 0-2/hpf Some Rare Some Few Normal Findings Colorless to dark yellow Clear 4.6-8.0 1.006-1.030 Negative Negative 3-5/hpf 2-4/hpf Rare/Few/None Rare/Few/None Rare/Few/None Rare/Few/None Normal Values Male: 140-175g/L Female: 120-160g/L Significance Normal Due to presence of pus cells Normal Normal Normal Normal Increased Normal Normal Normal None Normal

February 2, 2008 Hematology Exam Result Hemoglobin 100

Significance Decreased in Anemia

Hematocrit WBC Neutrophils Lymphocytes Monocytes Platelets February 22, 2008 ECG Ventricular rate: 100 Normal ECG

0.30 5.0 0.92 0.06 0.02 269

Male: 0.42-0.50 Female: 0.36-0.46 4.5-11.3x109/L 0.45-0.65 0.20-0.35 0.02-0.06 140-440

Decreased in anemia Normal Increased in acute infections Decreased renal failure and anemia Normal Normal

February 22, 2008 Clinical Chemistry Exam Result Sodium Potassium Chloride 138.8 5.40 108.4

Normal Values 135-148mmol/L 3.5-5.3mmol/L 98-107 mmol/L

Significance Normal Increased in acute renal failure Increased in kidney dysfunction Significance Increased in renal failure Increased in acute renal failure Increased in DM Decreased in starvation and malabsorption Normal Normal Normal

February 23, 2008 Clinical Chemistry Exam Result Uric-E Crea-B Gluc-D Chol-E Trig-E HDL LDL 0.65 674.5 7.46 2.6 0.80 0.58 1.7

Normal Values 0.17-0.35mmol/L 53-115 umol/L 3.90-6.40mmol/L 3.9-6.7mmol/L 0.46-1.88mmol/L 0.00-1.68mmol/L <2.6 mmol/L

REVIEW OF SYSTEMS: General: No weight loss, with fever and chills, fatigue Skin: No rashes, pruritus, bruising, no change in color Head: No headaches, injury, tenderness, dizziness Eyes: No change in visual field, glasses, contact lenses Ears: No Change in hearing, tinnitus, pain, discharge, dizziness Nose: No Allergies, sinus problem, obstruction, polyps, loss of sense of smell, sneezing, epistaxis with nasal flaring Throat: No toothaches, loose teeth, bleeding gums, mouth sores Respiratory: with cough and rales but no wheeze. Cardiovascular: With Chest pain, no pressure/ tightness, palpitations GIT: No dysphagia, heartburn, ulcer, indigestion, diarrhea, constipation, but with abdominal pain, GUT: No urgency, frequency, nocturia, dysuria, hematuria Endocrine: No Heat/cold intolerance, weight change. Musculoskeletal: No weakness. PHYSICAL EXAMINATION: Date of Examination: February 24, 2008 General Survey: Fairly groomed with IVF of D5LR at 12gtts/min. Vital signs: BP= 160/90mmhg HR= 83 bpm RR= 20cpm Temperature= 38.5°C

Integument: Inspection: Brown in complexion, uniform in color through out body, dry and pallor Palpation: Fair skin turgor, warm to touch

Nails: Inspection: Trimmed clean fingernails, smooth, nail plate-convex curvature Palpation: Thick, capillary refill = 5 seconds. Head: Inspection: Normocephalic skull, Black not evenly distributed hair, no infestation Palpation: Smooth skull contour Eyes: Inspection: Symmetrical, pinkish palpebral conjunctiva, pupils equally round and reactive to light. Ears: Inspection: Symmetrical, auricles aligned with the outer canthus of the eye, cannot hear normal voice tone. Palpation: No discharge, non tender. Nose: Inspection: Symmetrical at midline with clear discharges and frequent sneezing. Palpation: Non tender sinus, patent nasal passages. Throat and Mouth: Inspection: Moist oral mucosa, able to purse lips, Pinkish tongue, moves freely, reddened uvula, noninflamed tonsils, no dysphagia. Neck: Inspection: Coordinated movements with no discomforts, thyroid gland not visible. Palpation: Non-enlarged lymph nodes, palpable thyroid gland Chest & Lungs: Inspection: Symmetrical chest, regular respiratory rhythm Palpation: tender, symmetric chest expansion, no nodules nor mass. Auscultation: rales Heart: Inspection: Not observable apical pulse Palpation: No thrills, PMI at 5th ICS Midclavicular Percussion: Dullness over heart Auscultation: Regular heart rhythm, good S1 and S2. Abdomen: Inspection: Uniform color, round in shape. Auscultation: Regular bowel sound (7 per min.) Percussion: Dullness over liver, tymphany over stomach. Palpation: No tenderness, non-palpable spleen and kidneys. Extremities: Upper: • With good sensation • With reflexes on the right • Palpable peripheral pulses Lower: • With good sensation • With reflexes • Palpable peripheral pulses

I. PATIENTS PROFILE Name: Albert Padul Case No: 371272 Age: 13 years old Sex: Male Civil status: Single Address: Sta.Rosa Balangiga Eastern Samar Occupation: Pupil Religion: Roman Catholic Nationality: Filipino Birthday: February 5, 1995 Birthplace: Olongapo City Date of Admission: February 28, 2008 Time: 5PM Father: Nicandro Padul Mother: Ma. Teresa Padul Chief Complaint: “ Meada man nagawas ha iya talinga ngan nareklamo hiya hin kasakit.” As verbalized by the SO. Diagnosis: T/C Brain Abscess, Chronic otitis media, AS II. History Present Illness This is a case of Albert Padul, 13 years old, male, child, Roman Catholic, Filipino, a resident of Sta.Rosa Balangiga Eastern Samar, was admitted for the first time in this institution due to HA and ear pain. 2 years PTA when the condition started. Patient had onset of local swelling with yellowish ear discharge from the right ear. There was no pain, fever or any other associated symptoms. So no consult was done nor meds taken. 2 months PTA, the above symptoms now associated with low grade fever, HA and ear pain. Patient took Paracetamol 1 tab was given but no consult was done. Still the medicine given temporarily relieved the fever. 34 days PTA, there was increase in the swelling of the right ear which prompted the parents to sought consult at the nearest hospital, which was the Balangiga District Hospital. Patient was admitted and stayed there for 8 days. He was given medicines but so was unable to recall. Then patient was discharged in an improved condition, with no ear discharge, ear pain nor HA and fever. 3 days PTA, fever recurred now associated with HA. No consult done but was given Paracetamol 500mg 1 tab every 6 hours which temporary relieve the fever. 2 days PTA, at the height of the fever, patient had seizure attack. This was characterized with upward rolling of the eyeballs and flexion and extension of both the upward and downward extremities lasted for 3 minutes. This was associated with ptosis of the left eyelid but still no consult was done. With the persistence of the above symptoms, sought consult at Balangiga Eastern Samar and was referred to this institution for further evaluation and management. III. Past History Patient was previously hospitalized at Balangiga District Hospital in Eastern Samar due to the present illness. He has no allergies to food or drugs. And has a positive history for cough and colds. IV. Family History Patient and family negates having a heredofamilial history of diseases like asthma, hypertension, diabetes milletus and etc. V. Maternal History Born to a G6P6 mother with regular prenatal check up at the Barangay Health Center. With intake of Multivitamins and FeSO4. Negated presence of illness during entire course of pregnancy. Delivered full term, cephalic via NSVD at home. This was assisted by the hilot. There was no difficulty in delivery with good suck and eating after birth. There was no jaundice, no cyanosis noted. Breastfeeding was from birth until 1 year old. Then at 6 months, was given lugaw, and at 1 year old given with rice, fish and fruits and vegetables. With complete immunization and growth and development at par with age. VI. Psychosocial Data

Patient and family lives in a house made of light materials with electricity and water sealed toilet located outside the house. Source of daily water is from the public faucet abd not boiled. Garbage are disposed through burning. REVIEW OF SYSTEMS General: Complains of fever, chills, fatigue but negates weight loss. Skin: Negates rashes, pruritus, bruising and active lesion but with dryness Head: Negates headaches, injury, tenderness, dizziness Eyes: Negates change in visual field, glasses, contact lenses, diplopia, pain, excessive discharge, dry eyes. Ears: Negates Change in hearing, tinnitus and dizziness. With foul smelling discharge on the right ear with tenderness and swelling behind the ear. Nose: Negates allergies, sinus problem, obstruction, polyps, loss of sense of smell, sneezing, epistaxis. Throat: Negates toothaches, loose teeth, bleeding gums, mouth sores, hoarseness, dysphagia, ulcerations, lesions. Respiratory: Negates chest pain, dyspnea, cough, hemoptysis Cardiovascular: Negates Chest pain, pressure/ tightness, and palpitations. GIT: Negates dysphagia, heartburn, ulcer, indigestion, diarrhea, and constipation. GUT: Negates urgency, frequency, nocturia, dysuria, hematuria, UTI, incontinence. Endocrine: Negates heat/cold intolerance, weight change. PHYSICAL EXAMINATION Pulse Rate: 90 bpm Respiratory rate: 20 breaths/min Temperature: 38°C Blood Pressure: 90/50mmHg General Survey: Fairly groomed lying on bed. Integument: Inspection: Brown in complexion, uniform in color through out body, dry and pallor Palpation: Fair skin turgor, warm to touch Nails: Inspection: Trimmed fingernails, smooth, nail plate-convex curvature Palpation: Thick, capillary refill = 5 seconds. Head: Inspection: Normocephalic skull, black evenly distributed hair, no infestation Palpation: Smooth skull contour, dry brittle hair Eyes: Inspection: Symmetrical, glossy, pinkish palpebral conjunctiva. Ears: Inspection: Symmetrical, auricles aligned with the outer canthus of the eye, with foul smelling discharge at right ear. Palpation: with tenderness and swelling on right ear. Nose: Inspection: Symmetrical at midline with clear discharges and frequent sneezing. Palpation: Non tender sinus, patent nasal passages. Throat and Mouth: Inspection: Moist oral mucosa, able to purse lips, whitish tongue, moves freely, reddened uvula, noninflamed tonsils, no dysphagia. Neck: Inspection: Coordinated movements with no discomforts, thyroid gland not visible. Palpation: Non-enlarged lymph nodes, palpable thyroid gland Chest & Lungs: Inspection: Symmetrical chest, regular respiratory rhythm Palpation: Non-tender, symmetric chest expansion, no nodules nor mass. Percussion: Resonance Auscultation: Clear breath sounds Heart: Inspection: Not observable apical pulse Palpation: No thrills, PMI at 5th ICS Midclavicular

Percussion: Dullness over heart Auscultation: Regular heart rhythm, good S1 and S2. Abdomen: Inspection: Uniform color, round in shape, flat Auscultation: Regular bowel sound (7 per min.) Percussion: Dullness over liver, tymphany over stomach. Palpation: No tenderness, non-palpable spleen and kidneys. Neurologic:

CNI: No anosmia CN II, III: (+) papilledema, (+)ptosis of the left eyelid CN III,IV,VI: Full EOM CN V: (+) blink reflex CN VII: (-) focal asymmetry CN VIII: able to hear loud conversation CN IX,X: (+) gag reflex CN XI: able to shrug shoulder CN XII: tongue at midline (+) Brudzinki’s sign and nuchal rigidity