Identifying data:

This is a case of R.G, an 81 year old, Female, Widow, Roman Catholic, from Sibulan, Negros Oriental admitted for
the first time this year. The informant is the patient herself and her daughter with 95% reliability.

Chief complaint:
Fever and cough

History of Present Illness:

12 days prior to admission, the patient had onset of nonproductive cough with no associated symptoms. No fever, or
episodes of dyspnea was noted. The patient sought no consult. Took no medications. The patient tolerated the
symptoms.

10 days prior to admission, the patient noted cough was now productive with yellowish sputum now associated with
body malaise, low appetite, dyspnea on exertion and post- tussive chest pain with a pain scale of 5/10 stabbing and
nonradiating in character aggravated by cough and relieved by rest. Still no consult was done and no medications were
taken. The patient tolerated the symptoms.

1 week prior to admission, the patient decided to seek consult. The patient was seen in a local clinic and was given a
7 day course of unrecalled medication with good compliance. There were no improvement of symptoms as claimed.

On the day of admission, the patient noted a sudden onset of documented fever of 39 oC. No medications were taken
and was brought to this institution for admission.

Past Medical History:

The patient is a known Hypertensive and Diabetic diagnosed 2015.

The patient has no known food and drug allergies.
The patient is maintained on Triplixam 5/12.5/10mg 1 tab OD, Clopidogrel 75mg 1 tab OD, Coralan 75mg 1 tab
BID, Trajenta 5mg 1 tab OD, Rosalta 10mg 1 tab OD, Aldactone 25mg 1 tab OD
The patient has unrecalled childhood vaccinations.
The patient was admitted in SUMC (2015) with diagnosis of Shingles and SUMC (2017) with diagnosis of
Community Acquired Pneumonia- Moderate Risk

Family History:

The patient has a family history of Hypertension (Paternal side), Diabetes (Paternal) and Arthritis (Maternal side).
The patient is the sixth of 8 siblings and has four children. The patient’s mother and father died of natural causes as
claimed.

Personal and Social History:

The patient is a nonsmoker and nonalcoholic drinker. The patient lives with her daughter and grandchildren in Sibulan,
Negros Oriental, with her diet composed mostly of meat and rice. Coffee is noted to be taken 4 times a day. The
patient has approximately 7 hours of rest per day and watches TV in her leisure time.

OB History:
The patient is a G4P4(4-0-0-4) with the all deliveries via home birth with no complications. The patient's menarche,
interval and duration of menses are unrecalled. Patient claims no associated symptoms such as dysmenorrhea. The
patient's menopause is at 50 years of age. She denies contraceptive use. The patient noted no history of sexually
transmitted diseases. She claims to have only one sexual partner. The patient cannot recall to have undergone Pap’s
smear or Mammogram tests.
Review of Systems:

General
(+) Change in weight 20% (+) Fever, Chills and Sweats (+) Change in appetite
Skin
(-) Itching (-) Moles (-) Color (-) Rash (-) Pigmentation (-) Vasomotor changes (-) Photosensitivity (-) Paleness

Endocrine
(-) Thyroid gland (-) Salt cravings
(-) Unusually hot/cold (-) Excessive thirst
(-) Loss of sexual drive

Hematopoietic
(-) Abnormal bleeding (-) Pica (-) Bruising (-) Frequent infection
(-) Anemia (-) Swelling/Lumps/Bumps (-)Adenopathy

Musculoskeletal
(-) Joint stiffness (-) Kyphosis (-) Low back pain (-) Wasting (-) Trauma
(-) Swelling (-) Scoliosis (-)Lordosis ‘ (-) Frequent fractures

Head and Neck

(+) Headache (-) Neck stiffness
(-) Head injury

Eyes
(-) Bright flashes/Light (-) Spots in visual fields
(-) Changes in vision (-) Double vision
(-) Blind spot bordered (-) Pain by shimmering light

Ears, Nose, Sinuses, Mouth, Throat

(-) Sore throat (-) Difficult speech (-) Ringing in the ears
(-) Painful tooth (-) Hoarseness (-) Tinnitus
(-) Decrease or change (-) Nasal drainage or nosebleeds
in sense of taste (-) Change or loss of hearing

Respiratory
(+) Cough
(+) SOB
(-) Wheezing
(+)Tightness in your chest

Neurologic
(- ) Loss of feeling/sensation (-) Memory disorder
(-) Seizures (-) Headaches
(-) Weakness on one or both (-) Dizziness
sides of the body (-) Loss of balance/Lack of coordination
(-) Tremors (-) Sleep disorder

Psychiatric
(-) Nervousness/Anxiety (-) Intrusive thoughts (-) Auditory hallucinations
(-) Depression (-) Loss of good judgment or insight
(-) Mania (-) Visual hallucinations

Physical Examination:
The patient is awake, conscious, coherent, not in respiratory distress.
Vital signs:
BP: 130/90 HR: 90bpm RR: 20 breaths per minute Temp: 36.7oC
BMI: 18.7 Height: 5’5 Weight: 50kgs O2 sat: 97%

Skin: No active lesions. Good turgor. Warm to touch.

HEENT: Anicteric sclera, Pale conjunctiva, No sinus tenderness, No TPC
Neck: No NVE, No LAD, No tracheal deviation,
Chest and Lungs: ECE, CBS, No retractions, No wheezing, No rales
Abdomen: Flat, soft, NABS, Nontender, No palpable mass
CVS: Adynamic precordium, PMI at 5th LICS MCL, Distinct heart sounds, No murmurs
GUT: (-) KPS bilaterally
Extremities: Strong peripheral pulses, CRT 2seconds
Neurologic:
CNI- Olfactory intact
CNII- PERRLA, no visual field defects
CNIII, CNIV, CNVI- EOM intact, no ptosis, no diplopia, no nystagmus
CNV- (+) Corneal reflex
CNVII- No facial asymmetry
CNVIII- Hearing intact
CNIX, CNX - Uvula at midline, intact gag reflex
CNXI- Bilateral shoulder strength intact
CNXII- Tongue at midline

Motor: Sensory: DTR:

Cerebellar: (-) Ataxia (-) Incoordination

Meningeal signs: (-) Nuchal rigidity (-) Kernig’s sign (-) Brudzinski’s sign

ADMITTING IMPRESSION:
Community acquired Pneumonia with moderate risk; Type II DM; HCVD
Management:
Admit the patient.
Secure consent to care.
Problem: Fever, Cough, Dyspnea
Diet as tolerated.
Start IV PNSS 1L at 33ggts/min
Diagnostics:
Routine- CBC, Na, K, Crea, Chest xray PA, Urinalysis, Uric acid, SGPT, 12L ECG
Medications:
Paracetamol 500mg tablet q4hours as needed for fever.
Salbutamol nebulization 1 nebule q6hrs for dyspnea.
Cefuroxime 750mg IVTT TID after negative skin test for cough.

Watch out for drug reactions or allergies.