IM WARD SECTION 3C - DR.

SAM UY
General Data:
Date of Interview: August 9, 2018 Informant:
Patient
History taken by: Ma. Danica Louise M. Luna Patient reliability: 90%

Identifying data:
Guevarra, Nicomedes D.C., 68 years old, male, widowed, retired security officer, Filipino, Roman Catholic, Born on
February 28, 1950 in Camarines Norte, currently residing at 023 San Miguel St. Payatas A, Quezon City, admitted for the first
time at FEU-NRMF on August 7, 2018

Chief Complaint: DIZZINESS

History of Present Illness:

The present illness started 1 week prior to admission, the patient experienced sudden onset of dizziness while walking
on the market which lasted for about a minute, non-rotatory. No associated nausea, vomiting, headache. Several hours later,
while lying supine, he had a sudden onset of 1 episode of non-projectile vomiting which was described as black in color
amounting to 1/2 cup. There was associated nausea. No associated headache, epigastric pain, diarrhea, melena, hematochezia.
No medications were taken and no consult was done. The patient also mentioned that he started taking Buscopan 6 months
ago whenever he experience sudden onset of abdominal pain.
6 days prior to admission, still with dizziness but no recurrence of vomiting, the patient had one episode of melena of
unknown amount. This prompted him to seek consult at the OPD of this hospital. CBC was done. He was diagnosed to have
Peptic Ulcer Disease and was prescribed with Pantoprazole 40 mg twice daily by the attending physician. Patient was advised
for admission however, he signed for discharge against medical advice.
4 days prior to admission, still with dizziness, but now with improvement in the color of the stool. No associated
vomiting, nausea, headache. Patient was still on Pantoprazole 40 mg. No consult done.
Few hours prior to admission, the patient still experience occasional dizziness. This prompted him for consult at the
OPD. CBC was requested and showed decreased levels of hemoglobin and hematocrit. Due to the persistence of dizziness, the
patient was subsequently admitted.

Past Health Illness:

The patient cannot recall having mumps, measles, chicken pox and German measles. Immunization unrecalled. He had been
diagnosed as hypertensive in AFP Medical Center on 2012, maintenance drug is Losartan mg of the drug cannot recall, he takes
it once a day, he self-medicated with Metropolol 50 mg/ tablet. At 2012 he was diagnosed of type 2 Diabetes Mellitus and he
was currently on Metformin 500mg twice a day. He was also diagnosed to have Glaucoma on both eyes and is taking Tafluprost
15mg/ml.
Early this year 2018, he went for a consult and the physician considered gouty arthritis, he self-medicated with colchicine. Six
months ago, Buscopan, whenever he experiences sudden onset of abdominal pain.

He had a history of self-inflicted accident he had a gunshot in his right lateral thighs superficial only, he had it removed
immediately under local anesthesia at East Avenue Medical Center.
No history blood transfusion excluding this current admission, no allergies and psychiatric conditions.

Family History:

Mother: deceased in 2012 at 90

Father: deceased at 84, had asthma
Siblings: 10 siblings, 1st sibling, died of CAD complicated by uncontrolled Diabetes, youngest sibling has arthritis and bleeding
ulcer, all other siblings are apparently well.
Children: 1st, 32 yo, male apparently well; 2nd, male, deceased in 2015 at 27 due to vehicular accident; 3rd, 27 yo, male,
apparently well

Paternal side: no known history of heredo-familial diseases

Maternal side: no known history of heredo-familial diseases

Has family history of Hypertension, Diabetes Mellitus, Heart diseases, Arthritis; No history of stroke, cancer, Blood disorders,
Obesity, Psychiatric Illness, Seizure Disorders, Kidney Diseases, Tuberculosis, Sexually Transmitted Infections.

Personal and Social History:

Patient is a retired member of the Philippine Constabulary and worked in the Armed Forces of the Philippines for six years. After
working in the government, he worked as a bodyguard to certain government officials for 154 months.

Lives with his 2 children in a semi-concrete bungalow house. Garbage is segregated and collected every evening. Drinking water
is from NAWASA and powered by meralco.

No history of travel.

Patient sleeps at around 9 pm to 7 am (10hours) and eats balanced meal of meat and vegetables.

No other family members with the same signs and symptoms.

No identifiable breeding sites of mosquito around the house.

Has a regular exercise of jogging and running once a week

He started smoking at age 23 and consumes 10 sticks per day, but he started to limit his cigarette consumption to 10 sticks per
week two years ago. An occasional alcoholic drinker.. Drinks 1-2 cups of coffee a day. No history of drug substance abuse and
sexually transmitted infections.

Review of Systems:

Constitutional Symptoms
(-) weight loss (-) fatigue (-) chills (-) inc appetite

Skin
(-) itchiness; (-) excessive sweating; (-) change in color (cyanosis, pallor, jaundice, erythema)

Eyes
(-) pain; (-) blurring of vision; (-) double vision; (-) lacrimation; (-) photophobia; (+) use of eyeglasses

Ears
(-) earache; (-) deafness; (-) tinnitus; (-) ear discharge

Nose and Sinuses

(-) changes in smell; (-) nose bleeding; (-) nasal obstruction; (-) nasal discharge; (-) pain around paranasal sinus
Mouth and Throat
(-) toothache; (-) gum bleeding; (-) disturbance in taste; (-) sore throat; (-) hoarseness

Neck
(-) pain; (-) limitations of movement; (-) presence of mass
Respiratory System
(-) chest pain; (-) cough; (-) sputum production; (-) hemoptysis;

Cardiovascular System
(-) substernal pain; (-) palpitations; (-) orthopnea; (-) paroxysmal nocturnal dyspnea; (-) easy fatigability

Gastrointestinal
(-)- dysphagia; (-) constipation; (-) hematemesis; (-) regurgitation

Genitourinary Tract
(-) dysuria; (-) polyuria; (-) hematuria; (-) incontinence; (-) genital pruritus; (-) urethral discharge

Extremities
(-) edema (-)swelling of joints; (-) stiffness; (-)numbness; (-)intermittent claudication;(-) limitation of movement

Nervous System
(-) vertigo; (-) syncope; (-) loss of consciousness; (-) paralysis; (-) numbness; (-) paresthesia; (-) speech disorder; (-) loss of
memory; (-) confusion

Hematologic
(-) bleeding tendencies; (-) pallor; (-) easy bruising

Endocrine System
(-) heat/cold intolerance; (-) excessive weight gain/loss; (-) polyuria; (-) polydipsia

Physical Examination

General Survey
The patient is conscious, alert and responds to verbal tactile and painful stimuli. He is oriented to time, place, and person. Looks
his stated age and appears to be well kempt. Cooperative and responsive to all questions that were asked. He did not have any
difficulty of speaking and was able to talk spontaneously and comprehend, communicate and express his ideas. His memory
was intact, with a euthymic mood, and had an appropriate affect. Has normal weight and well nourished. Hypersthenic. There
were no signs of distress

Vital Signs
Patient is normotensive (120/80). The pulse rate (60 bpm) , respiratory rate (20 cpm) and temperature (36.5 C) are normal

Skin
Skin is brown, normal degree of moisture, elasticity, mobility and thickness with good skin turgor. Nails are smooth and pink,
with normal nail folds.

Head
Hair is thick, black with grayish area, evenly distributed,coarse and dry. Head is normocephalic symmetrical, without swelling,
no tenderness and masses. Temporal arteries are not visible but palpable with strong equal pulsations. Walls not thickened.
Face
Face is oval, symmetrical, brown. Normal facie and no involuntary facial movements, no visible mass.

Eyes
Evenly distributed eyebrows and eyelashes, curled outward without matting. Eyelids have intact skin, no discharge or
discolorations, no ptosis. They close symmetrically with bilateral blinking. Negative lid lag. Palpebral conjunctivae are pinkish.
Normal set of eyeballs, no exophthalmos nor enophthalmos, no nystagmus. Non Icteric sclera. Corneas are transparent, no
lesions. Patient’s pupils are equal in size, round and has smooth border. Iris is flat and round. Patient’s direct and consensual
light reaction is normal. Lenses are transparent. Fundoscopic exam revealed (+) ROR 2:3 AV ratio.

Ears
The patient has symmetrical auricles, auditory canal is patent, with minimal brownish discharge on both ears, walls are pink
without lesions, tympanic membrane is pearly white and intact, normal contour with visible cone of light and has no
perforation.

Nose and Paranasal sinuses

Symmetrical without lesions, deformities and tenderness, ala nasi not flared. Nasal septum is in the midline, without
perforations, mucosa is pinkish and turbinates are flat and dry. Nasal cavity is patent without discharges. Frontal and maxillary
sinuses exhibit no tenderness and positive transillumination.

Mouth and Pharynx

Lips are pink, dry, symmetrical, without lesions. Buccal mucosa is pink and smooth. Tongue is at the midline, no fasciculation
nor lesion. Hard and soft palate is pinkish, no lesions, uvula is at the midline.

Neck
Neck is normal in size, symmetrical without visible mass,swelling or deformation with full of range of motion. No neck vein
distention. Trachea is in the midline, no palpable lymph nodes. Thyroid gland is neither visible nor palpable.

Thorax and Lungs

The skin is brown with a brown papule on the left parasternal line, thorax is elliptical and symmetric in shape with good
expansion; no kyphosis. No deformity and chest muscles are well developed and chest wall movements are symmetrical, with
no use of accessory muscles. No retractions. Chest has no scars. No dilated blood vessels. No chest wall tenderness. No costo-
vertebral angle tenderness. Normal tactile fremitus, equal over all lung fields. Lung sounds resonant over all fields. Vesicular
breath sounds are heard in all lung fields, no rales and rhonchi present. No bronchophony, egophany, or whispered
pectoriloquy noted.

Cardiovascular
No visible neck vein. Flat precordium. Carotid arteries pulsation is strong, regular rhythm, equal pulsations and soft consistency
of the wall. Apex beat is adynamic, located at 5th ICS, 1 cm from LMCL, approximately 1x2 cm in diameter, normal amplitude.
No abnormal precordial pulsations, thursts, lifts, heaves, thrills and palpable heart sounds. Normal intensity of heart sounds
appreciated, no abnormal heart sounds.
Symmetrical arms and legs, warm to touch. No edema, pallor, pigmentation, hair loss, dilated varicosities and lesions. Brachial
and radial artery palpable at 3+. Popliteal and dorsalis pedis with full pulsations at 3+. Regular rhythm, equal pulsations and soft
consistency.

Abdomen
Abdomen is symmetrical, light brown, flat, inverted umbilicus. No visible pulsations, peristalsis and dilated vessels. No lesions,
scars, and bulging flanks. Normoactive bowel sounds. No bruit heard over the epigastrium, right and left paraumbilical area. All
abdominal quadrants are tympanitic on percussion. No abdominal mass upon palpation. Liver is non palpable. Spleen is not
palpable. Right and Left Kidneys are not palpable. No pain was elicited when performing Kidney Punch. Negative Rebound
tenderness, Psoas sign, Obturator sign and Murphy’s sign.
Neurologic Evaluation

Cerebrum:
The patient has GCS: E:4 V:5 M:6, conscious, cooperative, appropriately groomed, oriented to time, place, and person. Is able to
recall memory, appropriate mood and affect and no emotional lability. Can understand and communicate in spoken and written
language, able to recognize an object by the use of primary senses, and has the ability to conceive, formulate and execute
complex, purposive, skilled, volitional acts on command.

Cranial nerves:
CN I: nose is patent, can identify the smell of tobacco
CN II: can read the smallest letters of the Jaeger chart at a distance of 14 inches, (+)ROR, clear media, and distinct disc margin.
Normal AV ratio, no hemorrhages, no visual field defect
CN III, IV, VI: both pupils constrict briskly reactive to light both direct and indirect. Adduction of both eyes and constriction of
both pupils on accommodation. Equal and complete opening of both eyes, can move eyes in 6 cardinal directions of gaze
CN V: can feel pain and light touch equally on both sides. Prompt and equal blinking of both eyes in corneal reflex. Can clench
teeth equally on both sides
CN VII: can frown, raise the eyebrows, and close eyes equally on both sides. Nasolabial folds are equal
CN VIII: intact gross hearing, responsive to verbal sounds
CN IX & X: no dysphonia, uvula at midline, equal elevation of palate on phonation, (+) gag reflex
CN XI: can turn head from side to side against resistance, can elevate shoulders equally
CN XII: no atrophy nor fasciculation, tongue midline on protrusion, can move tongue from side to side

Cerebral Function:
Normal finger-nose-finger test, is able to perform rapid alternating movement by patting her knees with the palm and the back
of her hands by pronation and supination, smooth movement and the heel remain on the shin (-) dysmetria, romberg’s test
and tandem walking was not performed.

Motor Function:
Size and consistency of the the muscle are normal. No atrophy or fasciculation. Normal symmetry of postures, muscles contours
and outlines. Normal muscle tone. There are no resistance to passive movements, no latent paralysis, no pronation drift, and no
involuntary movements. Flexion, extension and other movements through the major joints without resistance and with
resistance are graded with grade 5/5 on all extremities.