“MARIO”

I. Patient Information
Name : Mario
Address: Pulupandan, Neg. Occidental
Age: 70 years old
Sex: Male
Date of Birth: February 7, 1951
Civil Status: Single
Educ. Attainment: Vocational- Auto Mechanic
Occupation: none
Religion: Roman Catholic

II. Other Information

No. of children: none
Date of Admission: June 3, 2021
Chief Complaints: Forgetfullness Frequent coughing, wheezing, shortness of breath
Admitting Diagnosis : COPD
Attending Physician: Dr. Ray Bautista

Health History
During his earlier years he worked as an auto mechanic, with the nature of his work, he was exposed to carbon monoxide
coming from the exhaust of the motor vehicle. He was a chain smoker too and made it a regular schedule to drink one bottle
of rum after work He was a spiritual man was highly satisfied with his life and had no regrets. He had visited quite a many
religious places.

He came to the facility, as someone told him about the old age home. He has no relative to stay with.

Diagnostic Test:
Chest X- ray PA view:
Result:
Lung hyperinflation with flattening of both hemi diaphragms as seen. The retrosternal airspace is increased and there is an
increased lucency (lunacy) of the lungs bilaterally. Cystic shadows are also noted in the left lower zone and bulla is present
in the right upper zone.

V/S prior to check up:

T= 38.4 C
P= 98 bpm
R= 24cpm
BP= 150/80 mmHg
SPO2= 95% at room air
Wt= 52 kg
Ht= 1.58 m

Medications:
1. Tiotropium 2.5 mcg; 2 puffs OD pc lunch x 7days
2. Doxophylline 400 mg/tab; 1 tab OD x 7days
3. Azithromycin 500mg/tab; 1 tab OD x 7days