La Consolacion University Philippines

College of Medicine
Internal Medicine Preceptorial

Medical History

Date: _September 1, 2022_

Time: _____11:00am_____
General Data:
Patient C.B. is a 74 year-old-female, Widowed, Roman Catholic, from Sta. Maria
Bulacan. She was admitted for the 2nd time at Bulacan Medical Center last August 29, 2022.

Informant: Patient/Granddaughter
Reliability: 70%

Chief Complaint: Difficulty of Breathing

History of Present Illness:

The present condition started 3 weeks ago prior to consultation when the patient
developed a dry cough described by her granddaughter. Consulted a private physician at a
Mendoza General Hospital in Sta. Maria. She was prescribed with an unrecalled name of the
medication TID affording no relief to the patient’s condition.

2 weeks prior to consultation, she consulted for a second opinion from another doctor
and was assessed with Pneumonia and prescribed medication but was not able to avail due to
financial incapability. The patient has no appetite and is unable to perform activities of daily
living without assistance.

1 day prior to consultation, the patient still has a persistent dry cough with no resolution
since 3 weeks ago.

A few hours prior to consultation, the patient experienced difficulty in breathing described
as gasping for air and this prompted consultation and was subsequently admitted.

Past Medical History:

Diseases:
2016:
● Diabetes Mellitus
● Hypertension

Unrecalled date:
● Myocardial Infarction
○ Clonidine 1 tab sublingual prn for chest pain
On maintenance medication which includes the following:
1. Furosemide (Diuspec) 20mg tablet
2. Clopidogrel Bisulfate 75mg tablet
3. Enalapril Maleate (Brand: Hypace) 5mg tablet
4. Linagliptin (Trajenta) 5mg tablet
5. Carvedilol (Cardipres) 12.5mg tablet
6. Ranolazine (Razine) 500mg tablet
7. Dibencozide (Heraclene Forte) 3mg capsule - Supplement
8.. Ultima Multivitamins and Minerals with Ginseng capsule - Supplement

Previous Hospitalization: Usually admitted for 3 days and discharges with resolution of complain
2022:
January - Mendoza General Hospital
Reason: Difficulty of breathing, Unknown final Dx - discharge with home meds
February: Bagbaguin
Reason: Difficulty of breathing, Unknown final Dx - discharge with home meds
June 22: Mendoza General Hospital
Reason: Difficulty of breathing, Unknown final Dx - discharge with home meds
June 23: Bulacan Medical Center
Reason: Transfer from Mendoza (DOB)

Immunization:
• Childhood vaccines - unrecalled
• Pneumonia vaccine – unrecalled

Screening test:
August 2022
● ECG
● Chest Xray

Family History:
Maternal:
● Diabetes Mellitus
Paternal:
● None
Siblings:
1st (Deceased Male) - Asthma
2nd (Deceased Male) - Heart attack deceased @ 37 y/o
3rd (Female) - Diabetes Mellitus
5th (Female) - Diabetes Mellitus
Personal and Social History:
Patient finished grade 1 student in elementary school, she formerly worked as a laundry
aide. She has been widowed for 18 years, has been blessed with 7 children, and is currently
living with her fifth son in a two-story, four-room house in a neighborhood with decent sanitation,
enough lighting, and ventilation. They receive clean drinking water from the Maria Water
District at their door from a water station. Unrecalled from the date when she first began
smoking, she began smoking 5 sticks per day. She quit smoking 36 years ago. a non-user of
illicit drugs and a drinker of non-alcoholic beverages. Other than her husband, she had no other
sexual partners.
Patient resides on the ground floor of their house. They purchased prepared foods; she
preferred veggies and meat. Prior to leaving the house for work in the morning, her son
prepares her 8 maintenance medications. Due to her health, she was unable to go for a walk
outside the house. She needs support to perform her ADLs.

Obstetric-Gynecologic History:
Menarche: Unrecalled
Duration of menstruation: 3 days menstruation
● Uses 3 cloth napkins in 24 hrs
● Not experiencing dysmenorrhea
● LMP and PMP: not asked
Menopause: 54 year old
OB Score: G7P7 (7007)
G1 - Female, NSD, at home, midwife, Full term, no complications
G2 - Male, NSD, at home, midwife, Full term, no complications
G3 - Female, NSD, at home, midwife, Full term, no complications
G4 - Female, NSD, at home, midwife, Full term, no complications
G5 - Male, NSD, at home midwife, Full term, no complications
G6 - Male, NSD, at home midwife, Full term, no complications
G7 - Male, NSD, at home midwife, Full term, no complications
● No Gynecologic History of diseases, infection and screening

Review of Systems: (change font color to red if present if your patient)

General:
□ Weight loss ( %) □ Fatigue □ Fever
□ Weight gain ( %) □ Weakness □ Chills
□ Trouble sleeping

Skin:
□ Rashes □ Lumps □ Itching
□ Dryness □ Color changes □ Moles
□ Hair and nail changes
Head:
□ Headache □ Head injury □ Dizziness
□ Lightheadedness

Eyes:
□ Vision □ Glasses or contact lenses □ Pain
□ Redness □ Blurred or double vision □ Flashing lights
□ Specks □ Glaucoma □ Cataracts
□ Last eye exam (2021) □ Excessive tearing

Ears:
□ Decrease hearing □ Ringing in ears (Tinnitus) □ Vertigo
□ Use of hearing aids □ Earaches □ Discharge

Nose and Sinuses:

□ Nasal Stuffiness □ Discharge □ Itching
□ Hay fever □ Nosebleeds □ Sinus pain
□ Frequent colds

Throat (Mouth and Pharynx):

□ Teeth □ Gums □ Bleeding gums
□ Dentures □ Sore tongue □ Dry mouth
□ Sore throat □ Hoarseness □ Oral Thrush
□ Non-healing sores □ Last dental exam

Neck:
□ Lumps □ Swollen glands □ Pain
□ Goiter □ Stiffness of the neck

Breasts:
□ Lumps □ Pain or Discomfort □ Nipple discharge
□ Breast-feeding □ Self-examination practices

Respiratory:
□ Cough (dry or wet, productive)
□ Coughing up blood (hemoptysis)
□ Wheezing
□ Last Chest X-ray (8/29/22)
□ Sputum (whitish and scanty)
□ Shortness of breath (dyspnea)
□ Pain with deep breath (Pleuritic pain)
Cardiovascular:
□ Chest pain or discomfort/Tightness □ High blood pressure
□ Palpitations □ Shortness of breath with activity
□ Need to use pillows at night to ease breathing (Orthopnea
□ Sudden awakening from sleep with shortness of breath (Paroxysmal Nocturnal Dyspnea)
□ Swelling in the hands, ankles or feet (Edema)
□ Results of past Electrocardiogram (ECG) or other cardiovascular tests (PVC) 8/29/2022

Gastrointestinal:
□ Swallowing difficulties □ Heartburn □ Change in appetite.
□ Nausea □ Rectal bleeding □ Change in bowel habits
□ Stools color and size □ Pain with defecation □ Constipation
□ Diarrhea □ Abdominal Pain □ Food intolerance
□ Hemorrhoids □ Excessive belching or passing of gas
□ Yellow eyes or skin (Jaundice) □ Liver or gallbladder problems

Urinary:
□ Frequency of urination □ Urgency □ Polyuria
□ Nocturia □ Incontinence □ Flank pain
□ Blood in urine (hematuria) □ Reduced caliber or force of the urinary stream
□ Hesitancy □ Burning or pain during urination
□ Dribbling

Genital: Male
□ Pain with sex □ Hernias □ Penile discharge
□ Sores □ Masses or pain □ Erectile dysfunction
□ STD’s □ Testicular pain □ scrotal pain or swelling

Genital: Female
□ Pain with sex □ Vaginal dryness □ Hot flashes
□ Vaginal discharge □ Itching or rash □ STD’s

Peripheral Vascular:
□ Leg cramps □ Intermittent leg pain with exertion (Claudication)
□ Varicose veins □ Swelling in calves, legs or feet
□ Swelling with redness or tenderness
□ Color change in fingertips or toes during cold weather

Musculoskeletal:
□ Muscle or joint pain □ Stiffness □ Back pain
□ Redness of joint □ Swelling of joints □ Trauma
□ Limitation of motion or activity

Neurologic:
□ Dizziness □ Vertigo □ Seizure
□ Changes in mood, attention , or speech □ Weakness
□ Changes in orientation, memory, insight or judgment □ Headache
□ Numbness □ Fainting □ Tremors
□ Weakness □ Paralysis □ Tingling

Hematologic:
□ Ease of bruising □ Ease of bleeding □ Anemia
□ Past transfusions □ Transfusion reactions

Endocrine:
□ Head or cold intolerance □ Excessive Thirst (Polydipsia)
□ Excessive Sweating □ Frequent urination (polyuria)
□ Change in appetite (polyphagia)

Psychiatric:
□ Nervousness □ Depression □ Memory loss
□ Tension □ Suicidal ideations □ Mood
□ Past counseling, psychotherapy or psychiatric admissions

Physical Examination:

GENERAL SURVEY
The patient is lying on bed in a semi fowler’s position, conscious, coherent with a low pitched
voice, oriented, not in respiratory distress but with shallow breathing.

VITAL SIGNS
Blood pressure:130/60 Heart Rate: 82bpm Respiratory Rate:28cpm Temperature: 37.6
O2 Saturation: 97% Height: no data Weight: 49kg BMI: no data

SKIN
Skin is normal in color, dry, warm to touch, smooth, with good turgor. No pallor, no edema, no
jaundice, scattered macules and papules at different areas of the body.

HEAD AND NECK

Normocephalic, no deformities, lesions or masses. Hair is generally normal in texture. No scalp
tenderness. Facial features are symmetrical. Skull and face are symmetrical. No cervical
lymphadenopathy noted.

EYES
Anicteric sclerae, lids are symmetrical, pink palpebral conjunctiva. No noted discharge, redness,
swelling, no lens opacity.

EARS
Normoset external ear. No skin tags and deformities. No discharge and lesions noted. Cone of
light is present. Dried cerumen on both ears noted.

NOSE
Nose is symmetrical, no lesions, masses, deformities. No discharge. No alar flaring. Nasal
septum midline. Hook to O2 via nasal cannula at 2 ipm.

MOUTH AND PHARYNX

Lips and mucosa are pinkish, palates are intact, tongue is symmetrical, uvula is at midline and
not inflamed with angular cheilitis on right and left commissures. The oropharynx is pink with no
tonsillar erythema or exudate. There was no evidence of abnormal masses or leukoplakia. No
bleeding. No oral lesions. No cleft lip or cleft palate. Incomplete teeth and visible angular
cheilitis at left lateral lip.

CHEST AND LUNGS

Symmetric Chest expansion. Sagging breasts. No nipple discharge. Not in respiratory distress
but with shallow breathing. Tachypneic. No Retraction. No lesions or masses present. No
abnormality on thoracic wall. No palpable masses or tenderness on anterior and posterior chest
but with visible veins, erythematous macules and beefy red papules noted. Decreased vocal
Fremitus on left lung base. Resonant in percussion. Clear breath sound, negative crackles or
any other abnormal lung sounds but with decreased breath sounds on the left lung upon
auscultation.

CARDIOVASCULAR
Adynamic precordium, PMI 6th left ICS slightly lateral to the anterior axillary line, no lifts, no
thrills, no heaves, S1 heard best at apex, S2 heard best at base, normal rate, regular rhythm,
systolic murmurs are best described at the mitral area (was not able to determine if split S2
sound).

ABDOMEN
Flat or Globular. No ascites noted. No skin discoloration, 8 papules noted. Normal bowel sound
noted, Negative abdominal bruits. No tenderness in all quadrants. Normal Liver size. No
palpable mass. Not a distended bladder. No tenderness upon palpation of both Kidneys.
Negative kidney punch test.

RECTAL EXAMINATION (Not assessed)

No rashes, lesions, sores. No palpable mass and tenderness noted. (Skipped)

GENITALS
No rashes, normal color, no lesions, no discharges. With indwelling foley catheter Fr. 16
connected to a urine bag at 700ml level.

EXTREMITIES
With edema 3+ on both lower extremities below the knees up to the dorsal area of the foot. No
pallor. No lesions or ulceration. Capillary Refill Time less than 2 seconds.

NEUROLOGICAL EXAMINATION

Cerebrum: Conscious, coherent, oriented to time, place and person; and able to follow simple
commands

Cerebellum: Patient able to do: (Skipped)

1. Finger to Nose test
2. Heel to Shin test
3. Rapid alternating movements of arms
4. Walk across the room or down the hill

CN I: able to identify odor of different substances e.g. coffee

CN II: 2-3mm, equally reactive to light and accommodation
CN III, IV, VI: intact EOMs, (-) nystagmus
CN V: (+) corneal reflex
CN VII: no facial asymmetry
CN VIII: intact gross hearing
CN IX, X: (+) Gag reflex
CN XI: can weakly shrug and elevate shoulders
CN XII: tongue in midline

(-) Babinski
(-) Nuchal rigidity
(-) Kernig’s, (-) Brudzinski

Fundoscopy: (+) Red-Orange Reflex, (-) Papilledema

Primary Impression and basis: Congestive Heart Failure secondary to Hypertensive

Cardiovascular Disease: Left Ventricular Hypertrophy; Coronary Artery Disease, Type 2
Diabetes Mellitus, Anemia
Based on the patient’s pertinent data. The presence of gradual onset of difficulty in breathing
with the concurrent myocardial infarction and long standing hypertension and diabetes mellitus.
There is also evidence on familial history with these diseases. On the physical examination, the
patient is assessed with chest discomfort with shallow breathing having a RR of 28cpm. Systolic
murmur is also evident on cardiovascular PE. Upon inspection of lower extremities, edema is
present from the lower extremities below the knees up to the dorsal area of the foot. Pale
palpebral conjunctiva is also seen with angular cheilitis. These findings are evidence for the
initial impression.

Differential Diagnosis:
Acute Respiratory Distress syndrome: In considering ARDS based on the symptoms of the
patient and finding with SOB of the patient. It is to be assessed further with chest and lung PE
which will give more evidence to the manifestation of the disease. While cardiogenic pulmonary
edema typically begins centrally in the bilateral perihilar areas, ARDS usually causes more
uniform opacification. Pleural effusions are not typical of ARDS but often present in CHF.
Temporally, radiographic abnormalities usually closely parallel cardiogenic pulmonary edema,
while the chest radiograph in ARDS may remain unremarkable for up to twelve hours and
usually stabilize after the first thirty-six hours.

Chronic Renal Failure: with the current history of the patient and finding in the PE. Edema,
weight loss, presence of uncontrolled DM, it is to be considered if the patient’s condition worsen
and progress to have renal problems. Heart failure (HF) is highly prevalent in patients with
chronic kidney disease (CKD) and is strongly associated with mortality in these patients.

Plans (Diet, Diagnostics, Drugs, Disposition):

Plans of Treatment:
● Complete bed rest without bathroom privileges
● Keep patient on semi fowler’s position
● Continue O2 inhalation per nasal cannula at 2-3 LPM
● Maintain indwelling of Foley catheter fr.16
● NGT NPO if in respiratory distress or RR>= 20; otherwise with reduce intake of salt and
fat in diet
● IV diuretics: Furosemide q8, hold oral furosemide
● Inotropic Therapy: Dobutamine, Digoxin
● Continue with the prescribed maintenance meds

Diagnostics:
● Complete blood count
● Lipid profile
● Serum Creatinine
● Hba1c
● B-Type natriuretic peptide (BNP) and N-terminal pro-BNP
● 2D echocardiogram with doppler

Disposition: Patient should be admitted to the hospital for additional monitoring and evaluation
if the symptoms continues and worsen the condition of the patient

Name of Medical Student: __Ignacio, Jose Mari S.___

Year level 3
Date: September 2, 2022