IM WARD SECTION 3C - DR.

SAM UY

General Data:
Date of Interview: November 22, 2018 Informant: Patient
History taken by: Patient reliability:

Identifying data:
Efren Rufo Antonio, 61 years old, male, single, PE instructor, Filipino, Roman Catholic born on Nov 25,
1957 in Pantihan, Malabon City, and presently residing in 18A, Robreso St., Tugatog, Malabon City, admitted for
the first time in FEU-NRMF Medical Center on Nov 5, 2018

Chief Complaint: Swollen feet and legs

History of Present Illness: OKAY NA

6 days PTA, patient’s left leg appeared to be edematous which he thought it’s just an arthritis. He self-medicated
with Colchicine and Prednisone. The pain was not relieved but bearable. No associated fever, headache. No
consult was done.
5 days PTA, the edematous leg was aggravated and developed a red blister on his soles and at the back of his
middle toe. The foot with blisters was warm and swollen. The pain, graded as 3/10, was described as
“pumipintig”, non-radiating, recurring, and cramping. No medications taken. No associated symptoms. Still no
consult was done.
4 days PTA, still with persistence of the above symptoms but now with a pain scale of 4/10. No medications taken.
Still no consult done.
2 days PTA, patient sought consult to PGH due to the persistence of pain and swelling of the left leg. No
laboratory exams were done and no medications taken. He was advised to come back the following day.
1 day PTA, patient sought consult to a private clinic and was given an unrecalled antibiotic and a pain reliever
taken for 7 days. Still with the above symptoms but now with a pain scale of 10/10. No other associated
symptoms.
Few hours PTA, due to the progression of the left leg swelling and pain, the patient decided to seek consult at
FEU-NRMF Medical Center Emergency Department. Laboratory tests such as CBC, ECG, X-ray, and ultrasound
were done and was subsequently admitted.

Past Health Illness:

Childhood diseases- mumps, chicken pox
Immunizations received: OPV, anti-TB vaccine (?)
Adult Past Illness:
Medical:
Arthritis, takes Colchicine and Prednisone during attacks
Hypertension, Amlodipine 10 mg OD, since 2003
Surgeries and other procedures:
Cataract surgery on both eyes in 2016 at OLFU Hospital
Accidents and Injuries:
Several stitches on 3rd finger of the left hand, MCU Hospital
Medications:
Arthritis, takes Colchicine and Prednisone during attacks
Hypertension, Amlodipine 10 mg OD, since 2003
 Blood transfusions: (-)
Allergies: (-)
Psychiatric: (-)

Family History: ok
● Father, deceased at 74yo due to stroke
● Mother, deceased at 78yo due to stroke
● 2nd out of 5 children, all siblings have hypertension
● No other heredofamilial diseases such as diabetes, bronchial asthma, cancer, liver problems nor
autoimmune diseases

Personal and Social History: ok

Patient is a graduate of Philippine Normal University in the year 1978, and he currently works as a PE teacher for
the last 38 years. He lives in a 2-floor apartment along with his sister and nephew. He gets 8 hours of sleep and
regular exercise everyday. He prefers eating vegetable and fish, and he regularly drinks milk and rarely coffee. He
was previously a 7-pack year smoker but he quit smoking in 2017. He drinks 2 glasses of Emperador on special
occasions. He denies history of illicit drug use and sexually transmitted diseases.

Review of Systems: (Shanie-. Ok)

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
(-) abdominal pain; (-)- dysphagia; (-) diarrhea; (-) constipation; (-) hematemesis; (-) melena; (-) hematochezia; (-)
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
(-) headache; (-) 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 Exam

General Survey (LUNA - OKUUURT)

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. Patient is overweight and well nourished. Hypersthenic. There were no signs of distress

Vital Signs (LUNA - OKUUURT)

Patient is hypertensive (140/90). The pulse rate (102 bpm) , respiratory rate (21cpm) and temperature (36.8 C)
are normal

Skin (LUNA - OKUUURT)

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 (LUNA - OKUUURT)

Hair is thin, white in color, 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 (LUNA - OKUUURT)

Face is oval, symmetrical, brown. Normal facie and no involuntary facial movements, no visible mass.
Eyes (Lim - Okay)
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 red orange reflex

Ears (Lim- Okay)

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 (Lim- okay)

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 (Lim - okay)

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 (Lim - okay)

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

Thorax and Lungs (aira- okok)

The skin is fair, 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. Diaphragms
descend 4 cm bilaterally. Vesicular breath sounds are heard in all lung fields except over in 1st and 2nd
interspaces anteriorly and between scapula which is bronchovesicular while in area of manubrium bronchial
breath sound is heard; no rales and rhonchi. No bronchophony, egophany, or whispered pectoriloquy.

Cardiovascular (morcilla okay na)

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.
No gross deformities, full and equal pulses on the upper extremities, 1+ (weak or thready) pulse on the left lower
extremity, CRT <2 seconds. With erythematous swelling and edema on the left leg. Right ABI: (1) generally
normal, Left ABI: (0.8) mild to moderate peripheral disease.

Abdomen
Abdomen is symmetrical, light brown, globular, 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. Liver is non palpable and
has a span of 9 cm qt MCL. Spleen is not palpable. Right and Left Kidneys are not palpable. No pain was elicited
when performing Kidney Punch. Positive RUQ tenderness. Negative Rebound tenderness, Psoas sign, Obturator
sign and Murphy’s sign.

Neurologic Evaluation okey na.

Cerebrum:
The patient has GCS: E:4 V:5 M:6, conscious, coherent, 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: can identify smell of coffee
CN II: funduscopic findings: +ROR, clear media, and distinct disc margin, no hemorrhages
CN III IV & VI: both pupils constrict briskly reactive to light both direct and indirect; (+) doll’s eye reflex,
extraocular muscles can move eyes in 6 cardinal directions of gaze(-) nystagmus
CN V: (+) corneal reflex
CN VII: symmetrical face at rest, normal facial expression
CN VIII intact gross hearing
CN IX & X: Normal in phonation and articulations, midline uvula, equal elevation of the palate on phonation, (+)
gag reflex
CN XI: can turn head from side to side against resistance
CN XII: no atrophy nor fasciculations, tongue at midline on protrusion, moves 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 both upper extremities, and
right lower extremities. On his left lower extremities patient was only able to demonstrate movement on his toes.

100% 100% 5/5 5/5 +2 +2

100% 100% 5/5 5/3 +2 unable to perform

MENINGEAL SIGNS: (-) Nuchal rigidity (-)Brudzinski’s sign (-)Kernig’s sign

PATHOLOGIC REFLEXES: (-) Babinski