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Name of Patient: LC

Ward/bed/room no: 307 Tamayo Towers
Informant: Daughter-in-Law
Reliability: 85%
Dept. of Medicine
Preceptor: Dr.Evaristo
Date of History: December 1, 2014
Year: 2nd year Medical Students
Group 1

Date of Interview: December 1, 2014
Informant: Daughter-in-Law
Reliability: 85%

GENERAL DATA
This is the case of LC, a 60 year-old Female, married, Catholic, Filipino, Presently
residing at Brgy.Balibago Santa Rosa City, Laguna and was admitted for the fourth time at
University of Perpetual Help Medical Center on November 28,2014.

CHIEF COMPLAINT:“Low Hemoglobin Count.”

PAST HEALTH HISTORY Hypertension . the patient had her routine check-up on our institution and routine CBC analysis was done which still revealed low hemoglobin count accompanied by body weakness. 2nd to 3rd month prior to admission. Home medications of Omeprazole given once a day and Metoclopramide as PRN basis for nausea and vomiting were taken as prescribed. this prompted the patient to seek consultation on our institution and there she was advised to have a mammogram then underwent needle aspiration biopsy and eventually excision biopsy. She was advised for a blood transfusion.Uncontrolled. 1 day prior to admission. CVD . After every chemotherapy session she felt body weakness and anorexia accompanied by nausea. 2014) (+) Blood Transfusions (2014) (-) allergies to food and drugs (-) PTB.Breast.HISTORY OF PRESENT ILLNESS 7 months prior to admission. DM. the patient noticed a palpable mass on her left breast when she was doing self-breast examination. The mass was located on the left upper quadrant and was estimated to be the size of a five peso coin. MRM (July 18. 2013) Cancer. (2004) non-compliant to medication for 9 years Maintenance medications: Losartan 50 mg OD and Amlodipine 5 mg(December. hence admitted and was discharged. 6 months prior to admission. she underwent Modified Radical Mastectomy to have the mass removed preceded by six sessions of chemotherapy with a 21-day interval between sessions. anorexia. 4th to 5th month prior to admission. Asthma. mouth sores and fever which prompted for admission. the patient had her third and fourth chemotherapy session and the routine CBC analysis revealed a low hemoglobin count with no other associated signs and symptoms. the patient had her first and second chemotherapy session with the drug of Doxorubicin and one unrecalled drug as OPD patient on our institution. 1 month prior to admission she had her fifth chemotherapy session still revealing a low hemoglobin count on her CBC analysis and was re-admitted on our institution and underwent Blood Transfusion for the third time and was discharged.

(-) urethral discharge Extremities: (-) edema. (-) incontinence. low fat diet. (+) pallor HEENT: (-) dizziness. (-) hoarseness Neck: (-) pain. (-) Cancer The patient has four children having three daughters and a son. (-) nose bleeding. (-) stiffness. She normally eats vegetables.Paternal side (+) Asthma – Maternal side (+) Diabetes Mellitus. (-) tinnitus.Maternal side (-) Pulmonary Tuberculosis (-) CVD. (-) genital pruritus. (-) sore throat. chicken and fish and is maintained on a low salt. (-) lacrimation (-) deafness. (-) presence of mass Cardiovascular: (-) substernal pain. (-) urgency. (-) nasal discharge. Their drinking water is purified. (-) vertigo(-) pain. (-) ear discharge(-) change in smell. (-) gum bleeding. (-) palpitations. (-) chills Skin: (-) itchiness. (-) numbness. bought from the water station. (-) tenderness (-) limitation of movement . (-) urinary frequency. (-) fever. (-) hematuria. all are apparently well. (-) orthopnea. (-) polyuria.She does not drink any alcoholic beveragesand smoking. (-) excessive dryness. (-) hesitancy.(-) toothache. The garbage is collected once a week. No complications noted PERSONAL AND SOCIAL HISTORY LC lives with herfamily in a well ventilated-concrete bungalow type of house in a peaceful and non-polluted environment. (-) syncope. (-) limitation of movement. MATERNAL AND OBSTETRIC HISTORY Menopause at age 50 G4P4 (4004) All pregnancy delivered full term via NSD by a traditional hilot. (-) swelling of joints. (-) blurring of vision. REVIEW OF SYSTEMS Constitutional symptoms: (-) significant weight change. (-) murmur Genitourinary: (-) dysuria.(+) sore on lower gums (-) disturbance in taste.FAMILY HISTORY (+) Hypertension. She used to run a sari-sari store before and she enjoys watching television during her free time. (-) nasal obstruction. (-) paroxysmal nocturnal dyspnea.

Cranium Head is normocephalic. (-) syncope. with intact nail folds and no lesions with capillary refill time of 3 seconds C. (-) numbness.Neurologic: (-) headache. (-) confusion Hematologic: (-) bleeding tendency. Has visible dilated blood vessels on the dorsum of the palm and at the inner forearm No lesions noted The nails are cyanotic. (-) slurring of speech. no lesions noted  Cornea is transparent. no lesions  Iris is brown and round . (-) excessive weight gain or weight loss. (-) polydipsia PHYSICAL EXAMINATION General Survey The patient is alert. awake. Temporal arteries are not visible but palpable with strong equal pulsations. (-) loss of memory. no lice. elastic and mobile. evenly distributed and no matting  Eyeball is not protruding or sunken  Palpebral conjunctiva is pale. well-kempt and neat not in cardio-respiratory distress. no dandruff. Head and Neck 1. smooth. Eyes  Alopecia noted on eyebrows with few gray strands of hair unevenly distributed  Eyelids: no edema.(-) easy bruising Endocrine: (-) intolerance to heat and cold. (-) focal weakness. (-) loss of consciousness. no lesions. wall not thickened and smooth 2. place and person. clean scalp. (-) lidlag  Palpebral fissure is normal in width and symmetrical  Eyelashes are thin. Vital Signs BP: 140/90mmHg Skin     CR: 74bpm RR: 24cpm Temp:36. no involuntary movements 3. cooperative and accommodating. Face Face is oval. no slurring of speech. Oriented to time. (-) paralysis. outward growth. (-) paresthesia. no mass and no tenderness noted. no lesions noted  Sclera is white. no gross deformity seen.6 ˚C Skin is brown. has alopecia with fewgraystrands of hair unevenly distributed. has congruent mood and affect. ptosis and tremors noted. slightly moist.

no lesions and symmetric  Buccal mucosa and gums are pale. flat and translucent  (+) Visible cone of light 5. no visible dilated blood vessels. Lens transparent. Lymph Nodes With non-palpable Lymph nodes  Left axillary lymph nodes not palpable/removed (MRM)  8. No tenderness upon palpation  Mastoid: no tenderness upon palpation  Otoscopy: External canal is pinkish. Symmetrical chest expansion. no tenderness. no lesions and no exudates 7. (-) egophony. patent and no discharge seen  Tympanic membrane is pearly white. symmetrical. normal muscle tone. vesicular breath sounds. no visible mass. with no discharges and turbinates are flat and dry  Frontal and maxillary sinus – no tenderness noted  Frontal and maxillary sinus (+) transillumination. no crackles. no palpable mass. can move from side to side  Hard and soft palate are pinkish with no lesions  Uvula at midline  Tonsils are not enlarged.  Trachea in midline. 6. straight at the midline. Ears  Auricles are symmetric. . Neck:  Neck is normal in size. intact. no deformity. with hyperpigmented surgical site on left chest extending to left axillary area. no perforation and no lesions noted  Nasal cavity is patent. thyroid gland not visible or palpable  No carotid bruit noted D. with lesions on lower inner portion of the lip noted  Incomplete set of teeth on both upper and lower gums  Tongue is symmetric. Thorax is symmetrical. no opacity noted 4. no wheezes. normal and equal tactile fremitus.  (-) bronchophony. Oral Cavity  Lips are pale. and dry. full range of motion.  Pupils are equally rounded. pinkish. no exudates  Posterior pharynx is pinkish. pinkish with rough papillae. No tenderness. (-) whispered pectoriloquy. reacted to light and accommodated. Chest / Lungs:  Skin is brown. has no deformities and lesions noted. Nose and Paranasal Sinus  Has symmetrical nose and no flaring of alanasi  Nasal septum is pinkish.

Abdomen    Soft and non-tender abdomen With normo-active bowel sound Globular in shape H.E. (-) murmurs. (-) lift. Cardio  Apex beat at 6th ICS midclavicular line  (-) palpitation. Extremities  Grossly normal extremities  Full and equal pulses  (-) cyanosis and discoloration  (+) hematoma on left antecubital area  Full range of motion G. (-) thrills  Within normal rate and regular rhythm of heart beat F. (-) heave. Genito-urinary System and Nervous System (patient refused) .

thyroid. leukemia (some types). liver. testis (germ cell). uterus. neuroblastoma. lymphomas. ovary. 2014 Second Third Fourth Fifth September 16.Side effect of drug Chemotherapy Schedule Number of Session Date First August 26. multiple myeloma. breast.Pertinent Positives - Body Weakness/ Fatigue Pale conjunctiva Capillary refill time. 2014 Chemotherapy Drug: Doxorubicin - Doxorubicin is part of a group of chemotherapy drugs known as anthracycline antibiotics. stomach.3 seconds with pale/ bluish/ cyanotic nail beds (+) lesion/sore on the inner portion of the lower lip-Side Effect of Drug (+) Anorexia/ Loss of Appetite (+) Alopecia. . lung. head and neck. mesothelioma. It slows or stops the growth of cancer cells. Cancers treated with Doxorubicin include: bladder. 2014 November 18. 2014 October 28. pancreas. sarcomas. 2014 Sixth December 9.2014 October 7. prostate.

Your white and red blood cells and platelets may temporarily decrease. The syringe needle is placed directly into the vein or central line and the drug is given over several minutes. Onset: 7 days Nadir: 10-14 days Recovery: 21-28 days   Mouth sores Hair loss on the scalp or elsewhere on the body (called alopecia). anemia and/or bleeding. The following side effects are less common (occurring in 10-29%) for patients taking Doxorubicin: Early: (within one week after treatment begins)  Eyes watering  Urine may appear red. Doxorubicin is given by injection into an artery. Nadir: Meaning low point. But your hair will grow back after treatment is completed.- Doxorubicin is given through a vein by intravenous injection (IV). red-brown. Side Effects of Doxorubicin: The following side effects are common (occurring in greater than 30%) for patients taking Doxorubicin: Early Side Effects: (within one week after treatment begins)   Pain along the site where the medication was given Nausea or vomiting Later Side Effects: (within two weeks after treatment begins)  Low blood counts. This can put you at increased risk for infection. nadir is the point in time between chemotherapy cycles in which you experience low blood counts. . Most patients do lose some or all of their hair during their treatment. Doxorubicin can also be given by continuous infusion. orange or pink from the color of the medication for one to two days after you receive a dose. There is no pill form of Doxorubicin. Rarely.

Later: (within two weeks after treatment begins)  Darkening of the nail beds. . (occurs in about 10% of both men and women – this should be discussed with your doctor prior to therapy). Talk to your doctor about this risk. Side effects that are very rare – occurring in less than 10 percent of patients – are not listed here. You can receive only up to a certain amount of Doxorubicin during your lifetime. advancing age. A serious but uncommon side effect of Doxorubicin can be interference with the pumping action of the heart.  Problems with fertility – ability to bear children. and use of other heart-toxic drugs. Dose-related heart problems can occur as late as 7 or 8 years after treatments have ended. Delayed Effects of Doxorubicin: There is a slight risk of developing a blood cancer such as leukemia years after taking Doxorubicin. This “lifetime maximum dose” may be lower if you have heart disease risk factors such as radiation to the chest. Your doctor will check your heart function before you may take any Doxorubicin and will monitor your heart closely during your treatment. This list includes common and less common and important side effects for those taking Doxorubicin. But you should always inform your health care provider if you experience any unusual symptoms.  Darkening of the skin where previous radiation treatment has been given.

JOSE G. TAMAYO MEDICAL UNIVERSITY Sto. Laguna COLLEGE OF MEDICINE . Binan City.UPH – DR. Nino.

Antonio. Eliza Paula P. Ambatali. Allen S. Waldemar C. Roselily Ann B.MEDICINE I – Decury Submitted by: Leader: Alzona. Amita. Jose Vien S. Members: Adove. John Dale C. Evaristo . NouellaVeannaMarie O. Araña. Angela Loui V. Submitted to: Dr. Bacud.