Case 1 (A1)

Members: Abieras, Addury, Aguja, Alonzo, Amago

Date & time of Interview: 7/13/2020 ; 10:00 AM

Source of Information: Patient
Reliability: 95%
Referral: None

IDENTIFYING DATA

A.C., 23 year old, male, single, Filipino, Roman Catholic, a construction worker, from Alang-alang Leyte
was admitted for the 1st time at this center.

CHIEF COMPLAINT

Cough and Dyspnea

HISTORY OF PRESENT ILLNESS

5 days PTA, the patient started having non-productive cough associated with undocumented
fever. TSB was done and he self-medicated with a tablet of Paracetamol 500 mg/tab taken every 4 hours
affording temporary relief of fever. No chest pain, dyspnea, colds and vomiting noted. No consult was
done.

3 days PTA, still with non-productive cough and recurrent undocumented fever now associated
with chest pain aggravated with coughing, relieved at rest, and with a PRS of 3/10. He self-medicated
with a capsule of Carbocisteine 500mg/cap taken every 8 hours affording no relief. A tablet of
Paracetamol 500mg/tab was taken and continued TSB to relieve his fever. Denies of hemoptysis. Still no
consultation was done.

A day PTA, he developed progressively worsening dyspnea prompting them the decision to seek
consult and was then subsequently admitted at EVRMC on July 13, 2020.

PAST MEDICAL HISTORY

 Childhood Illnesses:

(+) Asthma – diagnosed since 2009

(+) Measles
(+) Rubella
(+) Mumps
(-) whooping cough
(-) Chickenpox
(-) Rheumatic fever
 (-) Polio

 Childhood immunization: The patient claims to have a complete immunization record.

 Adult Illness:

I. MEDICAL
(+) Asthma – partly-controlled with the use of Salbutamol inhalation for as-needed
relief of breakthrough symptoms.
(-) Hypertension
(-) Diabetes
(-) HIV
II. SURGICAL OPERATIONS: None
III. PSYCHIATRIC: none
 Previous hospitalizations: 2009 - due to asthma attack
 Allergies: (+) allergy to seafoods and Mefenamic acid
 Health Maintenance:
I. IMMUNIZATION
 February 2020 – Tdap vaccine
II. SCREENING TESTS: none

FAMILY HISTORY

Paternal-side- father has (+) asthma; with Salbutamol Inhaler PRN for attacks

Maternal-side- mother is (+) hypertensive; with maintenance medication and claims to have good
compliance

Siblings: 3 siblings with asthma; has Salbutamol Inhaler PRN for attacks

1 sibling-diagnosed with PTB on 3rd month of ongoing treatment with good compliance

Other heredofamilial disease: None

PSYCHOSOCIAL HISTORY

Patient is a high school graduate and currently works as a construction worker. He lives with his
parents and siblings in a concrete single-storey house with 1 bedroom and 2 windows. They have a
water-sealed toilet. The family utilize mineral water for consumption while for the general use is from
the faucet. The family practice waste segregation, their garbage are being collected in their community
by a garbage truck.

He starts his day at around 7am and drinks coffee and sometimes paired with pandesal
then goes to work at around 8am. He would usually use a piece of shirt to cover his head and
nose to protect himself from the sunlight and dust in his workplace. He usually ends his work at
around 5pm and eats his dinner by 6pm. During his free time, he watches TV and bonds with his
family. He is fond of eating sweet and salty foods. He is a smoker with an exposure of 4 pack-
 years and occasional alcoholic beverage drinker. He occasionally drinks around 1 liter of beer
during special events. He drinks at least 8-10 glasses of water per day. He denies of illicit
recreational drug use.

REVIEW OF SYSTEMS

General survey: negates weight loss, (+) body malaise since onset of illness, febrile

Skin: No itchiness, no recurrent skin lesions, (-) redness

Head: Had headache, no dizziness, no head injury, no lightheadedness

Eyes: No blurring of vision, does not wear eyeglasses, (-) discharges

Ears: (-) hearing loss, (-) pain

Nose/Sinuses: (+) recurrent colds noted mostly early morning associated with sneezing, (-) loss of
smell, (-) pain

Mouth and throat: (-) pain, (-) dysphagia, (-) hoarseness, (+) recurrent throat itchiness

Neck: (-) mass, no stiffness

Breast: no lumps, no nipple discharge, no pain, no discomfort

Respiratory: (+) wheezing, (-) orthopnea,

Heart: (-) palpitations, (+) easy fatigability, (-) paroxysmal nocturnal dyspnea

Abdomen: (+) anorexic since onset of illness, (-) abdominal pain, (-) BM changes, Defecates 1x per day
with formed stools

GUT: (-) dysuria, (-) hematuria, (-) urinary frequency, (-) flank pains, urinates (yellow color)
approximately 200ml/void 5-6x a day

Genitals: no hernias, no unusual discharge, no sores, no testicular pain, no scrotal pain

Extremities: (-) joint pains, (-) swelling or edema

Endocrine: (-) no frequent urination, (-) polydipsia, no frequent thirst, (-) heat and cold intolerance

Hematologic: no easy bruising, (-) gum bleeding

Peripheral vascular: (-) intermittent claudication, (-) recurrent pain on extremities, (-) numbness, (-)
cramps

Musculosketal: (-) myalgia, (-) bone pains

Psychiatric: no history of depression, no mood swings, no nervousness

Neurologic: (-) seizures, (-) recurrent headache, (-) dizziness, (-) loss of consciousness, (-) head trauma
 PHYSICAL EXAMINATION
GENERAL SURVEY:
The patient was examined sitting on bed awake, conscious, coherent, and
oriented to time, person, place and circumstances; cooperative; mesomorphic, well-
developed, fairly nourished and well-groomed, talks in words, agitated and is in
respiratory distress with following VS:
Vital signs Actual Normal Value Interpretation
Blood Pressure (BP) 80/60 mmHg 90-120/60-80 mmHg Hypotensive
Heart Rate (HR) 118 bpm 60-100 bpm Tachycardic
Respiratory Rate (RR) 29 cpm 16-20 cpm Tachypneic
o
Temperature 38.9 C 36.5 – 37.5 ⁰C febrile
O2 sat (room air) 88% 95 to 100% low

ANTHROPOMETRICS:
Weight: 62 kg
Height: 5 feet and 5 inches
BMI: 23 kg/m2 (Based on WHO International Classification, normal is 18.5-24.9 kg/m 2.)

INTEGUMENT:
Skin: brown in complexion, no changes in skin color, (-) rashes, (-) peripheral cyanosis, moist,
warm to touch, good skin turgor, no active skin lesions
Hair: dry, black, short (2 inches), thin, evenly distributed, no lice or nits infestation
Scalp: no dandruff, no lumps, lesions, nor redness, no tenderness
Nails: capillary refill <2 sec, no clubbing of fingernails, smooth with no ridges nor breaks

HEENT:
Head and Face: Head is normocephalic and atraumatic; smooth without lesions and fractures.
No swelling, tenderness and crepitation noted. No swelling or enlargement and
tenderness of the lymph nodes.
Eyes:
Eyebrows: black, evenly distributed, symmetrical, no lesions
Eyelashes: two rows of black hair, oriented outward
Eyelids: no periorbital edema, no lesions, no ptosis, (-) eye discharges
Pupils: symmetrical; 2-3 mm in diameter; equally round, reactive to both direct and
consensual light and accommodation; visual acuity (20/20 both left and right
eye); peripheral vision intact
Iris: brown
Conjunctiva: pinkish conjunctiva
 Cornea: no lesions, no ulceration, no opacities
Sclera: anicteric sclerae, no hemorrhage, no lesions
EARS: symmetrical; with moist, impacted cerumen in both ears; no lesions; has a good acuity to
whispered and spoken voice
Nose: pinkish nasal mucosa, nasal septum at midline, no lesions, (-) turbinates not inflamed, (-)
nasal discharge, no stuffiness, no swelling, no tenderness
MOUTH: moist buccal mucosa, no oral lesions/ulcers
Lips: pinkish, dry, no cheilosis, no ulcerations, no angular deviation
Teeth: dental caries present; only 2nd molar on lower teeth remains
Gums & Gingival: pinkish, no hemorrhage, no lesions
Tongue: at midline, pinkish, no fissures, no ulcerations
Throat: uvula at midline, no lesions, tonsils not enlarged
NECK: supple, trachea at midline, neck veins not distended, no visible pulsations, thyroid gland
not palpable, no palpable lymph nodes, (-) NVE

BREAST AND AXILLAE: no lumps, no discharges, no tenderness, no palpable lymph nodes

CHEST AND LUNGS:

Inspection: no lagging, (+) subcostal retraction, normal chest contour
Palpation: Symmetrical lung expansion, decreased tactile fremitus on the right
Percussion: (+) dullness on the right basal areas upon percussion, resonant upon percussion
over the left lung
Auscultation: (+) expiratory wheeze, decreased breath sounds on right lower lung field, (+)
crackles on bilateral basal areas, and no pleural friction rub

HEART:
Inspection: Adynamic precordium, (-) visible pulsations, no precordial bulging
Palpation: PMI at 5th ICS LMCL, (-) heave, (-) thrill
Auscultation: S1 is greater than S2 at the apex; S2 is greater S1 at the base. No adventitious
sounds, with regular rate and rhythm,
(-) murmur

ABDOMEN:
Inspection: full, symmetric, (-) scar, no localized bulging, no visible pulsation, no venous
engorgement, no petechial rashes, no scars
Palpation: no palpable mass, soft, (-) tenderness, non-palpable liver, spleen and kidneys, no
guarding/rigidity, no rebound tenderness, no costovertebral angle (CVA) tenderness,
(-) Murphy’s sign, (-) succussion splash, (-) fluid wave, (-) ballottement
Percussion: tympanitic in all quadrants but dull on liver and spleen, (-) hepatosplenomegaly,
liver span of 6 cm along RMCL, splenic span of 5cm along 10 th to 11th rib
Auscultation: NABS, no venous hum, no bruit
BACK AND SPINE:
Inspection: no abnormal deviation, no bulging or masses noted
Palpation: no paravertebral mass

EXTREMITIES:
Dry and warm skin, no cyanosis, no atrophy, no edema, no limitation of
movement in all extremities, (-) deformity, (-) edema, faint pulses, extremities of equal
length; muscle strength graded 5/5 on all extremities; joints without tenderness and
crepitus.
Puls Brachi Radi Poplite Posterior Dorsalis
e al al al Tibial Pedis
Righ 1+ 1+ 1+ 1+ 1+
t
Left 1+ 1+ 1+ 1+ 1+

RECTUM (Digital Rectal Exam): Patient refused to allow this examination.

NEUROLOGIC EXAMINATION

MENTAL STATUS: Patient is alert, attentive and oriented to person place and time; has clear
fluent speech with normal comprehension; able to provide clear account of historical
and recent events MMSE performed is 30, normal.
CRANIAL NERVES
CN I – intact
CN II – pupils 2-3 mm in diameter; equally round, reactive to both direct
and consensual light and accommodation; without nystagmus
CN III, IV, VI – EOMs intact
CN V – Corneal reflex is intact. Facial sensations are intact and
symmetrical. Jaw movements are adequate.
CN VII – no facial asymmetry, can clench teeth, can smile, puff cheeks, can
frown
CN VIII – no nystagmus, normal gross hearing
CN IX and X – (+) gag reflex, uvula at midline
CN XI – able to shrug shoulders, turn face against resistance
CN XII – tongue midline upon protrusion

MOTOR FUNCTION: No atrophy, no involuntary movements, muscle strength 5/ 5 throughout

SENSORY FUNCTION: Light touch, pinprick, and position sense
intact bilaterally. Two-point discrimination normal.
REFLEXES:
Pathologic
(-)Ankle clonus
(-)Babinski reflex
CEREBELLAR: No involuntary movements, proprioception intact, (+) rapid alternating
movement, (+) finger to nose test
MENINGEALS
(-) Brudzinki’s sign
(-) Kernigs sign
AUTONOMIC
No excessive sweating, no urinary incontinence

SALIENT FEATURES

DEMOGRAPHICS HPI FINDINGS OTHER FINDINGS PE FINDINGS

 23 years old  5 days non-productive
 Male cough
 Construction  5 days recurrent
worker undocumented fever
 Chest pain aggravated
with coughing, relieved
at rest, and with a PRS
of 3/10
 Progressive worsening
of dyspnea
 No hemoptysis
 History of asthma since 2009
 Allergy to seafood and
Mefenamic acid
 Sibling with PTB on 3rd month
treatment
 Known smoker (4 pack-year)
 Exposure to dust
 weight loss
 body malaise since onset of
illness
 Febrile
 recurrent colds noted mostly
early morning associated
with sneezing
 recurrent throat itchiness
 anorexia since onset of
illness
 (+) easy fatigability
 BP : 80/60 mmHg (hypotensive)
 HR : 118 bpm (tachycardic)
 RR : 29 cpm (tachypneic)
 T: 38.9 C (febrile)
 O2 Sat (room air) : 88% (low)
 BMI : 23 kg/m2
 Presence of subcostal retractions
 Decreased tactile fremitus on
the Right
 Dullness on the right basal areas
upon percussion
 Presence of expiratory wheeze
 Crackles on bilateral basal areas