CASE STUDY NO.

7 Page |1

Patient’s Name: Patient C.A.

Age: 28 years old

Sex: Male
Address: Pasil, Kalinga
Civil Status: Single
Occupation: Farmer
Nationality: Filipino
Religion: Roman Catholic
Educational attainment: Did not attend school

General Data:
Cosme Apaling, 28 years old, single, Filipino, Roman Catholic, farmer, born on
January 12, 1991 and presently residing at Pasil, Kalinga, brought by older sister and
admitted last November 7, 2019.

Chief Complaint:
According to Significant Other: “nahihirapan syang huminga…”
Significant Other:
Rosita Apaling Laoyan, 29 years old, female, older sister, elementary graduate,
does not live with the patient.

History of Present Illness:

Three weeks PTA, October 17, 2019, the patient felt worried due to his unhealed
right knee injury so he decided to go to Kalinga Provincial Hospital (KPH) for a check-
up. The wound was acquired by the patient last August when he was harvesting beans
and he accidentally cut his knee using the bolo. No tests were given but he was asked
to take antibiotics. The patient was discharged after the check-up.
Two weeks PTA, October 23, 2019, patient felt intense pain and swelling in his
right knee. The patient was once again brought to KPH and was given antibiotics (e.g
ceftriaxone) due to suspected infections bought by his wound. Later on, the patient
was subjected to knee surgery in order to remove the necrotic tissue that causes delay
in the healing of his wound. The patient was advised to stay longer in the hospital for
monitoring.

CABAUATAN | DELA CRUZ | MENDOZA | PAGDILAO | QUIRIMIT | ROLLON | TUBBAN MD 2A

CASE STUDY NO. 7 Page |2

Twenty four (24) hours PTA, while waiting for his release, patient felt difficulty of
breathing. Due to lack of medical facilities, the patient was transferred to Cagayan
Valley Medical Hospital (CVMC) using the NDRRMC ambulance.

Past Medical History:

Childhood illness: The patient has no history of childhood disease like chicken pox,
mumps and measles. He has no history of whooping cough, rheumatic fever, scarlet
fever, and polio.
Adult illness:
Medical: The patient had history of asthma. He has no history of diabetes, hepatitis
and hypertension. He has no history of sexually transmitted infection. In 2016, the
patient was brought to Baguio General Hospital (BGH) due to dengue fever.
Surgical: He has no history of hospitalization and operations done other than septic
knee operation as mentioned before.
Health maintenance: The patient did not received vaccines for tetanus, pertussis,
diphtheria, polio, measles, rubella, mumps, influenza and varicella and hepatitis B virus.
Allergies: He has no known allergy to drugs and food.

Family Medical History:

The patient has no heredo-familial history of cancer, hypertension, diabetes,
hepatitis, and tuberculosis. His mother is suffering from asthma; and it was inherited by
the patient. His father died last year due to pneumonia. Among his siblings, he is the
only one who inherited asthma from their mother.

Personal and Psychosocial History:

Patient C. A. was born and raised in Pasil, Kalinga. Due to lack of financial
assistance, he did not attend school. He is the 2 nd child among eleven (11) siblings. At a
young age, he started working as a farmer in their family-owned fields. His sister
described him as timid person, but easy to get along as time goes by.
He is not a smoker; he drinks alcohol with his co-workers during their free time as
their way of relieving stress. He eats all kinds of food and doesn’t have any special diet
but prefer consuming vegetables. He doesn’t have any exercise routine, but considers
farm works as his way of maintaining his shape.
He haven’t tried to get a girlfriend, so, he haven’t experienced engaging to any
sexual activities with same or opposite sex. He has a good relationship with all of his co-
workers as well as with his relatives and neighbors. The patient has maintained a positive
attitude and outlook in life despite the recent events. The patient remains hopeful and
he strives to get better to help his mother and his younger siblings.

CABAUATAN | DELA CRUZ | MENDOZA | PAGDILAO | QUIRIMIT | ROLLON | TUBBAN MD 2A

CASE STUDY NO. 7 Page |3

Review of Systems (as verbalized by SO)

General  “nabawasan siya ng timbang simula nung nagkasakit na”

(+) weight loss
 “nanghihina siya” (+) weakness
 “nahihirapan din siya matulog” (+) sleep disturbance
Pulmonary  “inuubo siya at may konting plema” (+) cough, (+)
phlegm production
Cardiac  “mabilis siyang hingalin lalo na „pag mabigat yung
binubuhat” (+) easy fatigability
 “nafefeel niya rin yung pag-tibok na mabilis ng puso niya
lalo na pag sinasaksak yung mga gamot nya” (+)
palpitation
Gastrointestinal  “di naman siya nahihirapan tumae” (-) constipation
Genito-urinary  “okay naman yung pag-ihi niya kasi tama lang daw yung
dami ng ihi niya” (-) oliguria, polyuria
Musculoskeletal  “sumasakit din yung kasu-kasuan niya minsan” (+) joint
stiffness
Neurologic  “nakakausap naman naming siya ng maayos at walang
di siya maalala” (-) memory disturbance, (-) mental
damage

CABAUATAN | DELA CRUZ | MENDOZA | PAGDILAO | QUIRIMIT | ROLLON | TUBBAN MD 2A

CASE STUDY NO. 7 Page |4

Physical Examination
Vital Signs:
Body Temperature: 36.8˚C
Pulse Rate: 82 beats/min
sPO2: 98%
Respiratory Rate: 21 breaths/min
Blood Pressure: 140/100 mmHg

General  Difficulty of breathing specially after taking antibiotics

Eyes  No yellowing of sclera
 Extra ocular muscles intact
 Pupils equal, round, and reactive to light
 Pink palpebral conjunctiva
Nose  No nasal congestion
Mouth  Dry lips
 Teeth are complete
 N tongue discoloration
Neck  No palpable swelling around cervical lymph node area
Lymph Nodes  Palpable swelling at the inguinal lymph node
Cardiovascular  No jugular venous distention
 No carotid bruits
Lungs  Noticeable asymmetric chest expansion
 Crackles at the left lung
Skin, Hair, and Nails  Normal capillary refill time in nails
 Dry hair
Abdomen  Normal bowel sounds
 Abdomen soft and non-tender
Genito-Urinary  Genital exam not performed since complaints were not
related
Rectal  Rectal exam not performed.
Extremities  Swelling and redness at the left lower limb
Neurological  Senses are intact (CN I-XII)
 Test for reflexes were not performed.

CABAUATAN | DELA CRUZ | MENDOZA | PAGDILAO | QUIRIMIT | ROLLON | TUBBAN MD 2A