MEDICINE 1

DARLENE JOY SUBOC

Date of Interview: Aug. 22, 2023

I. GENERAL DATA

This is the case of M.T., 49 year old, male, married, Filipino, Roman Catholic and a
resident of Brgy. Sto. Rosario Ajuy.

This is his first admission. He was admitted last August 16, 2023 at Iloilo Doctors’
Hospital and was seen and examined during his seventh day in the hospital. The patient is the
informant himself and with 85% reliability.

II. CHIEF COMPLAINT

SLURRING OF SPEECH

III. HISTORY OF PRESENT ILLNESS

One day prior to admission, the patient experienced dizziness and was brought to the
school clinic. His blood pressure was 170/100mHg. He was prescribed 1 Losartan 100mg tablet.
Patient was not relieved by medication. Patient took a rest to alleviate his condition. Blood
pressure was not measured after taking medication. No other associated symptoms such as
headache, vomiting, fever, cough, shortness of breath and loss of balance was noted.

On the day of admission, the patient’s condition persisted and was brought to the school
clinic. His blood pressure was 180/110 mmHg. A few moments later, the patient experienced
slurring of speech, weakness on the left submalar,mandibular and submental region of the face
and muscle weakness in the left arm with difficulty in performing fine motor skills. He rated his
muscle strength with 3 out of 5 as the highest. No medications were given. No other associated
symptoms such as headache, vomiting, fever, cough, shortness of breath and loss of balance
was noted. He was immediately admitted to Iloilo Doctors’ Hospital.

IV. PAST MEDICAL HISTORY

The patient claimed he had Astrazeneca COVID-19 vaccine 2 doses and no booster,
Influenza vaccine, and tetanus toxoid vaccine. He had chicken pox and measles during his
childhood. The patient took Metformin 500 mg tablet and 2 unrecalled medicines and stopped
taking 4 months ago for his diabetes. He took Losartan 100 mg tablet for hypertension but took it
irregularly. He is taking multivitamins and herbal supplements irregularly.

The patient’s past admissions were due to measles in a public hospital. His second
admission was due to high blood pressure, low potassium and had thoracentesis in a public
 hospital. He had history of vehicular accident and had patellar dislocation. He went to physical
rehabilitation once a month for 3 months. He was diagnosed with hypertension last 2017 and was
diagnosed with Diabetes last 2022. No history of cancer and asthma noted. No known allergies to
food and drugs. No surgical history was noted.

V. FAMILY HISTORY
The patient’s father and mother are both deceased. The patient’s father had history of
hypertension, diabetes, mild stroke and. No history of cancer, cardiovascular disease, asthma,
and psychological disorder. The patient’s mother had history of hypertension and stroke. No
history of cancer, cardiovascular disease, asthma, and psychological disorder.

The patient has four siblings and he is the fourth child among the five of them. Their
eldest had history of mild stroke and the third sibling had a stroke. Four of them had history of
hypertension.

VI. PERSONAL HISTORY

The patient is a college undergraduate. He is working as a security guard in Iloilo
Doctors’ College for two years and worked as farmer before in the province.

The patient eats a full meal three times a day. His meal consists of adobong pusit and
white rice. His diet is mostly fatty food and sweet food. He drinks alcoholic beverage such as
beer and whiskey consisting of 5-7 bottles of 500 ml per day two times a week. He is a
non-smoker. No history of illegal drug use. He drinks coffee and tea occasionally, and drinks more
than 8 glasses of water daily. He had regular bowel movement twice a day. The patient urinate
frequently per day. He plays basketball and jog in his spare time. No recent travels stated.

VII. SOCIO-ECONOMIC AND ENVIRONMENTAL HISTORY

His source of income is his salary as security guard. The patient lives with his wife and
two kids in a bungalow house made of concrete and wood with 3 bedrooms, and 1 comfort room,
pail system. Source of water for household use is from a deep well and for drinking is from a
water refilling station. Garbage is dumped in a compost pit. Patient has 3 dogs and 2 are
vaccinated.

VITAL SIGNS

Respiratory rate 17 bpm

Pulse rate 92 bpm

Oxygen saturation 97%

Blood pressure 140/90

Weight 66 kg
Height 5’7 ft

Temperature 36.8 C

REVIEW OF SYSTEMS

General

[+] Weight loss [-] Change in appetite [+] Energy loss

[+] Trouble sleeping [-] Fever [-] Chills

[+] Weakness [-] Fatigue

Skin

[-] Pallor [-] Itching [-] Jaundice [-] Swelling

[-] Rashes [-] Lumps [-] Changes in hair or nails

Head

[-] Dizziness [-] Swelling [-] Headache [-] Lightheadedness

Eyes

[+] Blurring of vision [-] Cataract [-] Excessive tearing

[-] Pain [-] Redness [-] Itching

Ears

[-] Tinnitus [-] Change in hearing [-] Infection

[-] Discharge

Nose and sinuses

[-] Congestion [-] Discharge [-] Itching

[-] Sinus problems

Throat, mouth and pharynx

 [-] Difficulty swallowing [+] Dry mouth [-] Sore throat

[-] Hoarseness [-] Bleeding gums

[-] Use of dentures

Neck

[-] Lymph enlargement [-] Lump [-] Discomfort

Breast/Chest

[-] Lumps [-] Discomfort [-] Discharge [-] Pain

Respiratory

[-] Dyspnea [-] Cough [-] Hemoptysis

[+] Sputum Production [-] Wheezing [+] Difficulty of breathing

Cardiovascular

[-] Chest pain [-] 2-pillow Orthopnea [-] Palpitations

[-] Nocturnal Paroxysmal dyspnea [-] Edema [-] Varicosities

Gastrointestinal
[-] Swallowing difficulties [-] Heartburn [-] Change in appetite

[-] Nausea [-] Change in bowel habits. [-] Rectal bleeding

[-] Constipation [-] Diarrhea [-]Yellow eyes or skin (jaundice)

[+] Difficulty of chewing

Urinary

[-] Nocturia [-] Polyuria [-] Pain [-] Hematuria

[-] Incontinence

Peripheral Vascular

[-] Leg pain/cramps [-] Edema

Genital
 [-] Pain [-] Discharge [-] Sores

Musculoskeletal

[-] Joint pain [-] Muscle pain [-] Cramps [-] Fracture

Neurologic

[-] Numbness [-] Weakness [-] Coordination Disturbance

[+] Slurring of speech [-] Blackouts [-] Tremors

[-] Seizures

Hematologic

[-] Anemia [-] Easy bruising [-] Easy bleeding

Psychiatric

[-] Irritable [-] Memory change [-] Anxiety

[-] Hallucinations

Endocrine

[-] Cold intolerance [-] Tremors [+] Excessive thirst (Polydypsia)

[-] Excessive sweating [-] Excessive hunger

[+] Frequent urination (Polyuria)