QUIRINO MEMORIAL MEDICAL CENTER

Katipunan Road corner J.P. Rizal Street

Project 4, Quezon City, Metro Manila 1109

Name of patient: A.N. Informant: Husband and Son

Age/Sex: 67/ Female Reliability: 90%
Address: 2 J. Perez St., Project 4, Quezon City, Metro Manila Historian: BONILLA, JENELYN U.
Date: December 23, 2019

I. General Data

This is a case of patient A.N., 67 years old, female, married, unemployed, Filipino, Roman
Catholic, born on October 21, 1952 in Aklan, currently residing at 2 J. Perez St., Project 4, Quezon
City, Metro Manila, admitted for the first time in Quirino Memorial Medical Center on December 23,
2019.

II. Chief Complaint

Decreased Sensorium

III. History of Present Illness

Patient is a known case of Lung Cancer with Brain Metastasis diagnosed last October 2019
in Fe Del MUndo Hospital.
3 months prior to admission, patient became a bedridden with maintenance medications of
Dexamethasone 4 mg/cap, Omeprazole 40 mg/cap OD, Levetiracetam 500 mg/tab and Caltrate
tab.
Few hours prior to admission, patient had feverr, Tmax of 38.5 ℃ hence given Paracetamol
500mg/tab, 1 tab which afforded temporary relief.
One hour prior to admission, patient’s relative gave the next dose of Paracetamol but the
Patient was unable to swallow and noted to have decreased sensorium hence rushed to ER
Department QMMC and was subsequently admitted.

IV. Past Medical History

Patient has unrecalled childhood immunizations. She had measles, mumps and chicken pox during
her childhood. Patient is a known case of Lung Cancer with Brain Metastasis diagnosed last October 2019 in
Fe Del Mundo Hospital. No known history of food and drug allergy. No known history of hypertension,
diabetes, tuberculosis, stroke, asthma, blood disease, kidney disease, thyroid disease and psychiatric illness.

BONILLA, JENELYN U.
Department of Internal Medicine
Junior Intern- OLFU

1
 V. Family History

Patient’s parents are both deceased due to unrecalled illnesses. Patient has five siblings.
There current health status where unknown by the informant. No heredofamilial diseases noted
such as hypertension, diabetes, cancer, asthma, diabetes, blood disease, seizure disorder, kidney
disease and psychiatric illness.

VI. Personal and Social History

Patient is a college graduate and a housewife. She is a non-smoker and non-alcoholic

beverage drinker. Patient claimed to have no history of illegal drugs used like marijuana or shabu.
She usually have 8 hours sleep daily but with interrupted sleeping pattern. She eats three times a
day with no food preference. She consumes about 1 liter of water per day. Patient is bedridden
since three months ago.
She lives in a one-story concrete type of house, with three rooms, six windows and two own
comfort rooms. Garbage is segregated and collected twice a week (Wed and Saturday). Source of
drinking water is Mineral while non-drinking water is NAWASA.

VII. OBGYN History

Menarche occurred at 15 y/o. Menses was regular, lasts for 3-5 days, consumes 3-4 moderately
soaked pads per day, with no dysmenorrheal symptoms. Menopause occurred at 52 y/o. No history of
contraceptive use. No history of sexually transmitted disease.
OBSTETRIC SCORE: G4P2 (2-0-2-2)
G1 1979; Miscarriage ; Completion Curettage
G2 1981; Miscarriage; Completion Curettage
G3 1983; boy; Full term; Normal Spontaneous Delivery; No materno-fetal Complication; Alive
G4 1988; boy; Full term; Normal Spontaneous Delivery; No materno-fetal Complication; Alive

VIII. Review of Systems

General
[-] weight gain [-] loss of appetite [-] diaphoresis
[-] weight loss [-] increased appetite

Integumentary
[-] pigmentation [-] lumps [-] sores [-] cyanosis
[-] pruritus [-] change in hair & nails [-] dryness [-] jaundice

Head
[-] light headedness [-] dizziness

Eyes
[-] eye redness [-] eye itching [-] eye pain [-] photophobia
[-] excessive tearing [-] glasses [-] double vision

BONILLA,Ears JENELYN U.
Department [-]ofvertigo [-] hearing
Internal Medicine [-] tinnitus [-] ear discharge
Junior Intern- OLFU

2
 Nose
[-] nose discharge [-] nosebleed [-] itching [-] colds
[-] sinus problem [-] sneezing [-] obstruction

Throat
[-] sore throat [-] dry mouth [-] hoarseness [-] bleeding gums
[-] dentures [-] dental carries

Respiratory
[-] sputum [-] back pain

Cardiovascular
[-] easy fatigability [-] palpitation

Gastro-intestinal
[-] melena [-] dysphagia [-] steatorrhea
[-] constipation [-] hematochezia [-] vomiting
[-] abdominal pain [-] abdominal mass

Musculo-skeletal / Extremities
[-] intermittent claudification [-] bone deformity [-] numbness
[-] atrophy [-] stiffness [-] joint pain
[-] muscle pain

Genito-urinary
[-] polyuria [-] flank pain [-] hematuria
[-] dysuria [-] discharge [-] catheter
[-] suprapubic pain [-] frequency [-] dribbling
[-] oliguria

Neurologic
[-] hallucination [-] tremors [-] syncope [-] slurring of speech
[-] loss of memory [-] focal weakness [-] numbness [-] seizure
[-] delirium [-] speech difficulty

Endocrine
[-] heat/cold intolerance [-] polyuria [-] polyphagia
[-] polydipsia

Hematologic
[-] easy bruisability [-] pallor [-] easy fatigability

Psychiatric
[-] sleep disturbance [-] depression [-] hallucination

PHYSICAL EXAMINATION

IX.
BONILLA, General
JENELYN Survey:
U.
The Medicine
Department of Internal patient is drowsy and confused, calm, tidy in appearance, well groomed, endomorph,
Junior Intern-
wellOLFU
developed muscle, no gross deformity, non-ambulatory, in cardiorespiratory distress.

3
 X. Vital signs
Temperature: 36.5 C (right axilla)
Pulse Rate: 106 beats/min (right radial artery)
Respiratory Rate: 28 cycles/min
Blood Pressure: 90/50 mmHg(right arm)
Oxygen Saturation: 89 % RA

XI. Integumentary:

Skin is light brown in color, smooth, cold clammy, dry, mobile, with good elasticity and
turgor, no lesion. Skin hair is black, fine and evenly distributed. Nails are pale in color with capillary
refill of more than 2 seconds, no clubbing or swelling of nail beds.

XII. HEENT:

Hair:
Hair is black, smooth, abundant and well-distributed. Scalp is slightly mobile along the cranium,
no mass, no lesions, no tenderness and no parasites. Cranium is normocephalic, symmetrical, no bony
deformities. The temporal arteries are not visible but palpable with strong pulsation.

Face:
Skin is light brown in color, round, symmetrical, no lesion, no involuntary movements.

Eyes:
Eyebrows are symmetrical, black and evenly distributed. Eyelids have no lesion, no edema, no
ptosis or retractions. Negative for lid lag test, no exopthalmos, no enopthalmos and no periorbital
edema. Eyelashes are black, present in both upper and lower lid of both eyes. Conjunctiva is pale in
color, no edema, and no discharge. No swelling, no tenderness and no hematoma noted on both
periorbital area. Both sclera is anicteric, no visible blood vessels and no lesions. The cornea is
transparent, and has no ulcer, foreign body, opacity or lesion. Iris are both round and dark brown.
Pupils are 4mm in diameter, equally round and 2mm upon constriction, reactive to both direct and
consensual light and accommodation reflex. Visual acuity on both eyes cannot be assessed during
examination. Both lenses are transparent, no opacities.

Ear:
The external ears are both semicircular, upper helix at the level of eyes’ lateral canthus,
symmetrical, no deformities, no lesions noted. No tenderness over auricular and mastoid area. External
auditory canal on both ear is patent, no congestion, no foreign body, no redness, no discharge.
Tympanic membrane is intact with no perforations. Patient can hear soft spoken voice on both ears.

Nose:
Nose is symmetrical, no redness or swelling, no flaring of alae nasi. Patent vestibule with short
vibrissae. Mucosa is pinkish in color, no swelling, no lesions, no secretions, no bleeding. Nasal septum
is in JENELYN
BONILLA, the midline,
U. no perforations. No tenderness and clouding of paranasal sinuses upon palpation and
upon of
Department transillumination
Internal Medicinetest, respectively.
Junior Intern- OLFU

4
 Mouth and Throat:
Lips are pale, symmetrical, dry, no lesions. Buccal mucosa is pink in color, moist and no lesions.
Tongue is in the midline, pinkish, no deviation on protrusion and retraction. Gingiva is pinkish, no
gingival recession, no bleeding, no hypertrophy or atrophy. Uvula is at the midline. Tonsils are not
enlarge, no exudates.

Neck:
Skin brown in color, symmetrical, no tenderness, able to do range of motion, trapezius and
sternocleidomastoid muscles are well-developed. Trachea is in the midline and the thyroid gland is not
palpable, no enlargement and no tenderness. No palpable periauricular, posterior auricular, occipital,
submental, submandibular, superior cervical, deep cervical and supraclavicular lymphadenopathy.

XIII. Chest and Lungs:

Skin is light brown, no subcutaneous blood vessels, no gross deformities. Chest is elliptical in
shape. AP diameter is 1/3 of transverse diameter. No bony deformities with thin muscle
development. Expiration is longer than inspiration. There is no chest lagging upon inspection. No
intercostal retractions or bulging, no narrowing or widening of ICS. The RR is 28 cpm, rapid and
shallow rhythm. No signs of distress or use of accessory muscles and respiration. Symmetrical
chest expansion. Equal tactile fremitus on both lung fields. Resonant on all lung fields. Vesicular
breath sound on all lung fields.

XIV. Cardiovascular:

Skin is light brown in color, no scars, no lesions, no bulging nor depression, no visible pulsation
upon tangential lightning in supine position. Carotid pulsation is visible, palpable and strong, no
bruits. No jugular vein distention. Precordium is adynamic, and the apex beat is best appreciated at
6th ICS MCL. Without heaves noted. No lifts and thrills with normal rhythm and rate, 106 bpm. S1 is
louder than S2 at the apex and S2 is louder than S1 at the base, with S3 noted. Pulses of brachial,
radial, popliteal fossa, posterior tibialis and dorsalis pedis are both strong and equal, with grade of
+2.

XV. Abdomen:

Patient’s abdominal circumference is 36 inches at the level of umbilicus. Abdomen is flabby,

symmetrical, no bulging, no mass and no lesion. There is no superficial vein or striae upon
inspection. Umbilicus is inverted. No visible pulsation or peristalsis noted. Upon auscultation on the
right lower quadrant, normoactive bowel sounds of 14 cpm. No bruits were heard over the area of
aorta, right and left renal artery. Upon light palpation, the abdomen is soft and no direct tenderness
or muscle guarding noted. Upon manual palpation, liver, spleen and kidneys are not palpable.
General tympanism is noted on all four quadrants. Spleen dullness is absent at traube’s space.
Liver span measures 10 cm along MCL. Negative result for murphy’s sign, psoas, obturator,
BONILLA,markel’s,
JENELYNrovsing,
U. fluid wave and shifting dullness, no ascites and no costovertebral angle
Department of Internal Medicine
tenderness noted.
Junior Intern- OLFU

5
 XVI. Spine and Extremities

Temporomandibular joint:
No swelling, no redness, no mal-alignment, no deformities, no crepitus on patient’s TMJ.
There is a free range of motion observed on the patient’s TMJ.

Cervical Spine and Back:

No lesions, no palpable mass, and no gross deformities, palpable C7, paravertebral
muscles, and spinous processes. No scoliosis, kyphosis or lordosis noted. Noted full range of
motion as to flexion, lateral bending and rotation on both sides.

Hands and wrist:

Nail beds are symmetrical on both right and left, no brittle nails. Has no ulnar and radial
deviation of wrists; no swelling, enlargement, nodes or tenderness of interphalangeal and
metacarpophalangeal joints upon palpation of both hands. No atrophy of muscles. Noted full range
of motion as to flexion, extension, abduction and adduction of fingers, and apposition of thumbs on
both sides. Negative for tinel’s sign and phalen’s test.

Forearm and Elbow:

No swelling, no redness, no tenderness, no palpable mass, no gross deformities and with
lesion on elbow noted. Palpable olecranon process, medial epicondyle, and lateral epicondyle.
Measurements above right and left elbow are 12 inches and below right and left elbow are 10
inches. Palpable ulna and radius. Noted full range of motion as to flexion, extension, pronation and
supination on both sides.

Upper arm and shoulder:

No swelling, no redness, no tenderness, no palpable mass, no gross deformities and with
lesions noted on shoulder area. No atrophy of muscles. Palpable coracoid process, greater
tuberosity, clavicle, and acromion process. Noted full range of motion as to abduction, adduction,
external and internal rotation on both sides.

Hip:
No lesions, no swelling, no redness, no tenderness, no palpable mass, and no gross
deformities noted. No atrophy of muscles. Noted full range of motion as to flexion, extension and
lateral bending on both sides. Negative for Straight Leg Raising test, Thomas test, Patrick’s test and
Gaenslen’s test.

Knees:
No swelling, no redness, no tenderness, no palpable mass, no gross deformities and no
lesions noted. No atrophy of muscles. Palpable patella, tibia and fibula. Measurements above right
and left knee are 17 inches while the measurements below the right and left knee are 15 inches.
Noted full range of motion as to flexion and extension on both sides.

Ankle and Foot:

BONILLA, JENELYN No U.lesions, no redness, no tenderness, no palpable mass, and no gross deformities, no
Department edema. No Medicine
of Internal atrophy of muscles. Lateral malleolus and medial malleolus are palpable bilaterally.
Noted
Junior Intern- OLFUfull range of motion as to flexion, extension, dorsiflexion, plantar flexion, inversion, and

6
 eversion of foot and toe on both sides.
XVII. Neurologic Examination

a. Cerebrum
Patient is drowsy, confused, easily arousable to name calling, oriented to time, place and
person, cooperative, able to follow simple and complex command, can name object and can repeat
sentence without difficulty. Patient has intact immediate, recent and remote memory, can do simple
math calculation, do abstract thinking, has knowledge of general information, has appropriate moral
judgment, can repeat sentences, and no aphasia.

b. Cerebellum
Patient has no intentional tremors and able to perform finger-to-nose test smoothly, negative
for dysmetria on both upper and lower extremities. No dysdiadochokinesia and is able to perform
alternating pronation and supination.

c. Cranial Nerves

CN I (Olfactory): able to detect and identify the smell on both nostrils; intact.
CN II (Optic): all visual fields intact; visual acuity cannot be assessed
CN II & III (Optic and Oculomotor): Pupils are equally round and responds to direct and indirect
light stimuli
CN III, IV & VI (Oculomotor, Trochlear, Abducens): normal extraocular muscle movement upon
checking six cardinal fields of gaze
CN V (Trigeminal): can feel pinprick / brushing sensation on her face; muscle tension upon teeth-
clenching symmetrical and equal; muscle mastication shows absence of atrophy and fasciculation;
intact
CN VII (Facial): (+) facial asymmetry
CN VIII (Acoustic): can hear and relay whispered words on both ears; air conduction is longer than
bone conduction on both ears upon performing Rinne’s test; no lateralization upon Weber’s Test
CN IX & X (Glossopharyngeal, Vagus): uvula is in the midline; pharyngeal walls rise
symmetrically upon phonation and stimulation of the gag reflex; no hoarseness noted or vocal
anomalies; intact
CN XI (Spinal Accessories): able to shrug both shoulders against resistance; able to rotate and
bow head against resistance
CN XII (Hypoglossal): tongue is in the midline; no apparent deviation upon protrusion; no
fasciculation or atrophy noted; intact

Motor Exam: Muscles are symmetrical in both upper and lower extremities, normotonic, without
atrophy or fasciculations. Muscle strength index of 4/5 on right upper and lower extremities and 5/5
on left upper extremity and lower extremities.

DeepTendon Reflex: DTR are normal. Biceps, triceps, knee and ankle are 2+. Patient is negative
for babinski and chaddock reflex.

Sensory Exam: Intact sensation for pain, crude touch and position sensation on upper and lower
extremities, both sides. Stereognosis and graphesthesia are present and normal.

Meningeal signs: Patient is negative for kernig’s and brudzinski’s sign. No nuchal rigidity
BONILLA, JENELYN U.
XVIII. Assessment
Department of Internal Medicine
Junior Intern- OLFU

7
 Lung Cancer with Brain Metastasis

BONILLA, JENELYN U.
Department of Internal Medicine
Junior Intern- OLFU