You are on page 1of 10

1 of 8

Name: Rhaffy B. Rapacon Date of Interview: August 14, 2013
Year: MED III Time of Interview: 4:00 PM
MEDICAL HISTORY
I. GENERAL DATA:

This is a case of E.R, 60 years old, Male, Married, Roman Catholic, Filipino, born on July 18, 1953 and a
resident of Brgy. Rizal, Pala-Pala, Iloilo City. This is his 7th admission at IDH.

II. INFORMANT:

The informant was the patient’s daughter with 88% reliability.
III. CHIEF COMPLAINT:

Difficulty in breathing

IV. HISTORY OF PRESENT ILLNESS:

Four days PTA, patient experienced non-productive dry cough, undocumented fever, shortness of breath
especially during exertion and dimming of vision. Patient sought consultation at health center. He was prescribed
with Ciprofloxacin HCl (Cifloxin) 500mg/tab 1 tab OD x 7 days and Salbutamol for PAI every 4 hours for 3 days with
good compliance but no relief was noted. No other associated signs and symptoms noted.

Three days PTA, patient experienced productive cough with thick, viscid, whitish, blood-streaked sputum
amounting to more than 1 tablespoon per expectoration. Associated with fever of 38°C and took Paracetamol
(Biogesic) 500 mg/tab 1 tab TID, relief of fever noted. He also experienced sleeping difficulty due DOB. He sleeps
on high fowler’s position. Cough is most noted at night.
On the day of admission, above signs and symptoms persisted. At around 5 pm he experienced coughing
of fresh blood amounting to almost 50 cc, progressive dimming of vision worsened. At around 7am patient
complained of air hunger accompanied with chest pain, thus patient was rushed to IDH-ER. Patient vomited
significant amount of blood approximately 150cc accompanied with pallor, diaphoresis and shortness of breath.
He was examined and was subsequently admitted.

V. PAST MEDICAL HISTORY:

In 2008 Patient experienced difficulty of breathing especially when lying down, loss of appetite, weight
loss, weakness and easy fatigability. Patient also had frequent abdominal pain and had history of several episodes
of vomiting with blood. Chest x ray was done relieved a lung mass. He also undergone endoscopy revealed a
stomach ulcer. Unrecalled medication was given. He was also diagnosed to have Hypertension and Diabetes
Mellitus and was prescribed maintenance medications, Nifedipine (Calcibloc) 30 mg/tab 1 tab OD and Metformin
500mg/tab 1 tab BID. He was discharged after 2 weeks in good condition.
In 2009- Patient was admitted for 15 days due to elevated blood pressure and Pneumonia.

In 2010- Patient had Pneumonia and was admitted for 10 days at WVSUMC.

In June 2011- Patient experienced persistent productive cough for almost 2 weeks, no medications were
taken. He was diagnosed to have Pneumonia.
2 of 8

In January 2013 patient experienced frequent headaches and shortness of breath especially when waking
up in the morning, patient just ignored it. Patient was also noted to have some facial edema, prominent neck veins
and slight swelling of extremities. No consultation was done.
In March 2013 underwent Chemotherapy every 21 days, 7 cycles. Patient had monthly check-up and blood
works done. He had his last Chemotherapy session last September 2013.
In October 2013- Patient had his routine CXR and found out that he had Pneumonia. Patient was treated as
out-patient and was given Prednisone for 1 week, as claimed.

VI. PERSONAL HISTORY

Patient was 4rth among five siblings. He is an elementary graduate. He sells sells fruits and vegetables for
living. He sleeps 5 hours per day as verbalized. His usual diets consist mostly of dried fish, grilled pork, 3 cups of
rice per meal and sometimes vegetables. He drinks 4-5 glasses of water per day. Patient is smoker with 92 pack-
years and started to quit 3 years ago but was unsuccessful and alcoholic drinker for almost 45 years, consuming
whiskey and most of the time beer with a minimum of 12 bottles a day. No allergies to food and drugs noted.

VII. FAMILY HISTORY

His father died of lung cancer and unknown heart disease at the age of 75 and his mother at the age of 73
due to asthma attack. His eldest brother had polyp and colonic mass. The rest of his siblings have history of heart
disease and asthma, as claimed. No other heredo-familial noted.

VIII. SOCIOECONOMIC HISTORY
Patient lives in a congested urban area. He lives in a concrete with 6 occupants, 2 bedrooms and 1 toilet
rooms. They bought mineral water for drinking and deep well for household use. The source of income is from
selling vegetables.

IX. REVIEW OF SYSTEMS
GENERAL:
(+) weight loss
(+)dizziness
(-) decrease of appetite
(-) weakness
(+) fever
SKIN:
(-) jaundice
(-) pallor
(-) rashes
(-) itching
(-) swelling
(-) sweating
(-) dryness
(-) pigmentation
HEAD & NECK:
(+) dizziness
(-) stiffness
(-) head injury
(+) headache
(-) swelling / tightness

EYES: (-) yellowish discoloration
(+) blurring of vision

EARS: (-) vertigo
(-) tinnitus
(-) pain
(-) discharges
(-) change in hearing acuity

NOSE: (-) changes in olfaction
(-) congestion/ colds
(-) epistaxis
(-) dryness
(-) pain
(-) nasal discharges
MOUTH& THROAT:
(-) yellowish discoloration of mucosa
(+) denture
(-) sore throat
(-) swallowing difficulty
(-) bleeding gums
(-) hoarseness of voice
NECK:
(-) lumps
(-) pain
(-) stiffness
BREAST:
3 of 8

(-) gynecomastia
(-) lump
(-) nipple discharge
RESPIRATORY SYSTEM:
(-) cough
(+) shortness of breath
(-) dyspnea
(-) hemoptysis
(-) pain upon breathing
CARDIOVASCULAR SYSTEM:
(+) high blood
(-) orthopnea
(-) palpitations
(-) chest pain
(-) edema
GASTROINTESTINAL SYSTEM:
(-) constipation
(-) dysphagia
(-) hematemesis
(+) abdominal distention
(-) hematochezia
(-) melena
(-) nausea
URINARY SYSTEM:
(-)Difficulty in urination
(-) polyuria
(-) pain in urination
(-) hematuria
(-) incontinence
GENITAL:
(-) penile discharge
(-) itching
(-)STI
PERIPHERAL VASCULAR:
(-) leg cramps
(-) varicose veins
(-) Bruises
MUSCULOSKELETAL:
(-) arthritis
(-) muscle or joint pain
(-) stiffness
(-) weakness
(-) Limitation of motion
NERVOUS SYSTEM:
(+) dizziness
(-) tremors
(-) changes in cognition
(-) sensory disturbance
(-) numbness
HEMATOLOGIC:
(-) anemia
(+) blood transfusions
(-) bruising
PSYCHIATRIC:
(-)Mood changes
(-) memory changes
(-)Suicide attempts
4 of 8

PHYSICAL EXAMINATION

GENERAL SURVEY:

Patient was seen and examined on his 3rd day of admission, November 11, 2013. Patient
was seen awake lying on bed in semi-fowlers position, conscious and coherent with appropriate affect
and oriented to time, place, person and current condition. Patient was afebrile responsive, shows good
hygiene and dressed appropriately. He is of medium built and well nourished. IVF inserted at left hand
vein.

Vital Signs
Temperature: 36.5 degrees Celsius
Cardiac Rate: 89 beats per minute (5th intercostal space, left midclavicular line)
Pulse Rate: 82 beats per minute
Respiratory Rate: 21 cycles per minute; regular in rhythm
Blood Pressure: 130/90 mmHg taken in sitting position

Height: 5’3 ft.
Weight: 63 kgs (138.6 lbs)
BMI: 24.4 kg/m
2
Normal



Skin:
Inspection: pale , no yellowish discoloration, bruises or other skin lesions noted.
Palpation: Skin is warm to touch, with good skin turgor of <2 seconds. No
palpable mass noted.
Hair:
Inspection: Hair is short and black evenly distributed. No infestation of nits and lice. No redness or
flaking of scalp noted.
Palpation: Hair is thin and fine textured.

Nails:
Inspection: clean and well-trimmed nails, cuticles intact, no hemorrhagic lesion or clubbing noted.
Palpation: Not brittle with good capillary refill (more than 2 seconds).

Head:
Inspection: normocephalic, symmetric and coordinated facial features. No facial deformities, no
spasm or tics, and facial edema noted.
Palpation: Skull is rounded with smooth skull contour. No prominences, swelling or mass noted.

Eyes:
Inspection: eyes are wide open, symmetrical with anicteric sclerae. Pupils are equally rounded and
reactive to light and accommodation with pinkish conjunctivae. Cornea is transparent,
shiny and smooth, details of iris are visible. Eyelashes equally distributed. No edema
over lacrimal gland, no presence of tearing and abnormal discharge noted.
Palpation: No tenderness and lumps noted; no periorbital edema noted.
Funduscopic Examination: (+) red-orange reflex noted on both eyes: no hamorrhage
5 of 8


Ears:
Inspection: Auricles are symmetrical and aligned with outer canthus of eye. No discharges, pus or
swelling noted.
Palpation: No mass, lumps noted. Auricles are firm and mobile, not tender.
Otoscopic examination: Intact white tympanic membrane with good cone of light with presence flaky
serumen of minimal cerumen on both ears.

Nose:
Inspection: Symmetrical, no discharges, no mucus or swelling noted. Nasal septum is intact and at
midline.
Palpation: No mass or sinus tenderness noted.

Mouth and Throat:
Inspection: lips and gums are dark, with discoloration of teeth (tar) noted; with dentures noted, no
swelling of salivary ducts, no tongue deviation or lesions, Uvula located at midline, no
tonsillar swelling. Pharynx not inflamed. Gag reflex noted.
Palpation: No tenderness or lymph node enlargement noted.

Neck
Inspection: no enlargement of cervical lymph nodes, Jugular vein distention and very visible
pulsations on left neck vein noted.
Palpation: supple, the trachea is at midline of the body ,thyroid isthmus is soft, rest of the gland is
non- palpable, (+) doughy, soft, painless, irregular in shape mass approximately 4 cm in
diameter above the left clavicle
Auscultation: bruit sound noted.
Chest and Lungs:
Inspection: rapid, deep and labored breathing with neck veins prominent on respiration; increased
respiratory rate with use of accessory muscles.
Palpation: Increased tactile fremitus on both upper lung fields noted; abnormal prominences/mass
on 6
th
ICS, anterior axillary line, 1.5 cm in diameter noted.
Percussion: Dullness noted on both upper and lower lung fields.
Auscultation: Increased vocal fremitus on both upper and lower lung fields.

Breast
Inspection: no scars, no ulcerations noted
Palpation: no lumps

Cardiovascular system:
Inspection: adynamic precordium, no precordial bulging
Palpation: no thrill or heave at the precordial area, Point of maximal impulse is felt on 6
th
ICS left
midclavicular line
Percussion: Cardiac dullness between the 3
rd
and 5
th
ICS left midclavicular line
Auscultation: regular rate and rhythm; S1 is best heard on the apex; S2 is best heard at the base.
(+) Grade 3 murmur with blowing quality (best heard at apical area)
JVP: 8cm above the sternal angle with the head of bed elevated to 30 degrees.

Abdomen:
6 of 8

Inspection: abdomen is protuberant; umbilicus is at the midline and not protruding, no ulcerations
noted. no striae, no telangiectasia or caput medusa noted.
Auscultation: normoactive bowel sound; with 28 bowel sounds heard. No bruit sound noted.
Percussion: (-) fluid wave, tympanitic on all quadrants with liver span of 11 cms midclavicular and 8
cms parasternal line.
Palpation: Direct and rebound tenderness not noted

Extremities:
Inspection: no bruises, mass or varicosities noted.
Palpation: Skin is warm to touch, no swelling, edema noted

Pulses:

Pulses Right Extremities Left Extremity
Carotid 2+ 2+
Brachial 2+ 2+
Radial 2+ 2+
Femoral Not assessed Not assessed
Popliteal 2+ 2+
Posterior tibial 2+ 2+
Dorsalis pedis 2+ 2+

Nervous system:
GCS: 15, Eye opens to pain, comprehensive verbal response and obeys command, no motor response.
Consciousness: conscious and coherent with appropriate affect and oriented.
Comprehension: can follow instruction such as flexing extremities.
Speech : with comprehensible speech.

Cranial Nerves:
I sense of smell intact
II pupils are equally round and reactive to light and accommodation; + pupillary
light reflex; + direct and consensual reflex

III, IV, VI + direct and consensual reflex; no ptosis; intact extraocular movement

V Able to open mouth

VII Able to blink; no facial asymmetry

VIII No hearing loss noted; Romberg’s test not done

IX, X able to swallow

XI 5/5 strength of sternomastoid and trapezius muscles.

XII able to stick out tongue

7 of 8

Sensory: able to determine pain and light touch.

Motor no fasciculations, no tics and spasms, no rigidity; with strength of 5/5 in the
upper extremities; 5/5 in the lower extremities; able to move both toes

Reflexes Muscle stretch reflexes are intact; negative for babinski reflex.

Motor System:
Upper extremities:
Right Left
Elbow flexion 5/5 5/5
Elbow extension 5/5 5/5
Wrist extension 5/5 5/5
Wrist flexion 5/5 5/5
Hand grip 5/5 5/5

Lower extremities:
Right Left
Hip flexion 5/5 5/5
Knee flexion 5/5 5/5
Knee extension 5/5 5/5
Ankle dorsiflexion 5/5 5/5
Ankle plantar flexion 5/5 5/5







Deep tendon reflex:
Right Left
Biceps 2+ 2+
Triceps 2+ 2+
Brachioradialis 2+ 2+
Knee Not assessed Not assessed
Ankle Not assessed Not assessed
Reflex: negative on babinski reflex









8 of 8

PROBLEM LIST:



DISCUSSION:
Differential Diagnosis:
Pulmonary Tuberculosis
I consider pulmonary TB because, like other lung disease TB is strongly related to smoking.
Presence of signs and symptoms like cough, fever, hemoptysis, and weight loss are also some of the
clinical manifestation of TB. TB can also be present with masses which is also present in or patient. In
order to rule out TB patient should undergone several confirmatory exam like mantoux text, and chest
x-ray.
COPD
I consider COPD as may differential diagnosis because our patient is high risk of developing
COPD. Our patient is a smoker with 92 pack-years, and also exposed to dust and other air pollution due
to his occupation. The three most common symptoms in COPD like cough, sputum and exertional
dyspnea are present in our patient. I ruled it out because tumors are not risk factor of COPD. COPD
patient usually does not manifest hemoptysis.
Focal bronchiectasis
I consider focal bronchiectasis as may differential diagnosis because focal bronchiectasis can be
a consequence of obstruction of the airway like tumor which is present in our patient. Some signs and
symptoms of focal bronchiectasis are also present in our patient like persistent productive cough with
ongoing production of thick sputum and crackles can hear during auscultation. I ruled it out because
patient with focal bronchiectasis does not manifest with fever and pleural effusion, which can be found
in our patient.

Problem Date Identified Date Resolved
Difficulty of breathing November 8, 2013 Unresolved
Persistent productive cough November 8, 2013 Unresolved
Hemoptysis November 8, 2013
Chest pain November 8, 2013
Pallor November 8, 2013 Unresolved
9 of 8

Primary Impression:
DOB secondary to pleural effusion secondary to community acquired pneumonia moderate risk
secondary to small cell lung CA.
I considered Small cell lung CA because, small cell carcinomas are usually centrally located and
may cause irritation and/or obstruction of the major airways. Common symptoms resulting from local
tumor growth include cough, dyspnea, and hemoptysis which are present in our patient. According to
Harrison patients with small cell lung CA may present with swelling of the face and upper extremities,
laryngeal edema, headache and dizziness, which he experienced during his past medical history.
Compression of the phrenic nerve causes paralysis of the hemidiaphragm, contributing to shortness of
breath in which the main reason why patient sought medical consultation. Tumor growth may lead to
obstruction of major airways, with distal collapse leading to postobstructive pneumonitis, infection, and
fever. I considered community acquired because the signs and symptoms are present before the patient
was hospitalized. Moderate risk because according to Algorithm by Philippine task force of community
acquired pneumonia:










Our patient is under moderate risk and need to be hospitalized because he has co-morbid
conditions like small cell lung CA, hypertension and DM. Pleural effusion is an abnormal collection of
fluid in the pleural space due to imbalance between hydrostatic and oncotic forces in the visceral and
parietal pleural vessels and extensive lymphatic drainage due to Pneumonia infection.
DIAGNOSTICS:
 CBC - The complete blood count (CBC) consists of several tests that allow for the evaluation of
different cellular components of the blood on a broad range of clients. Increase WBC suggests
infection and low RBC suggest anemia due to vomiting of blood.
 Bronchoscopy with biopsy- to view if there are obstructions, to obtain specimens for special
microbiologic studies for pathogens. For determine what stage of tumor the patient have.
 Chest X-ray PA and LV- May show cardiomegaly, pulmonary venous hypertension, pleural
effusion and features typical of consolidation. Help in locating the affected part of the lung. To
10 of 8

help rule out differential diagnosis. A new parenchymal infiltrate in the chest radiograph
remains the reference diagnostic standard for pneumonia. A chest x-ray should be done in
patients suspected to have CAP to confirm the diagnosis.
 ECG – to detect electrical malfunction of the heart.
 G/S, C/S- to determine specific microorganism that is present and provide specific treatment.
 ABG - The arterial blood gas test measures the dissolved oxygen and carbon dioxide in the
arterial blood and reveals the acid-base state and how well the oxygen is being carried to the
body. To know how much oxygen will be needed to treat the patient.
 Pulmonary function test - Diagnosis and monitor the progress of pulmonary dysfunction
(asthma, bronchitis, bronchiolitis obliterans, emphysema, and myasthenia gravis); quantify the
severity of known lung disease; evaluate the effectiveness of medications (bronchodilators);
MANAGEMENT:
 O2 @ 2 LPM during period of dyspnea to maintain the O2 saturation of patient to 100%
 IVF of D5LR 125 cc/hr
 V/S, MIO q shift and record
 Full diet as tolerated
 Refer for any untoward signs & symptoms such as dyspnea, chest pain, fever
 Chest Physiotherapy – will help loosen secretion for easy expectoration.
 Increase oral fluid intake – water is the universal mucolytic.
 Smoking cessation
 Bed rest
 Pneumococcal vaccination and Influenza vaccination
- Because patient is immunocompromised patient needs protection to avoid infection.
THERAPEUTICS:
 Empiric Therapy
- Cefuroxime (zegen) 750mg every 8 hours IV plus Levofloxacin (Levox) 750 mg tab OD PO x 5-7
days
 Switch therapy:
- IV antibiotic treatment may be shifted to oral antibiotics after 3 days if the patient have lees
cough and resolution of respiratory distress, the temperature is normalizing, the etiology is not a
high risk pathogen, there is no unstable co-morbid conditions and oral medications are
tolerated.
 Furosemide 20mg IV q12H
- Diuretics, Loop, indicated to relieve the pleural effusion of the patient.
 Paracetamol (biogesic) every 4 hours PRN
 Acetylcysteine (Fluimucil) 100 mg or 200 mg sachet dissolved in ½ glass H2O TID.