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FEU DR.

. NICANOR REYES MEDICAL FOUNDATION MEDICAL CENTER Regalado Avenue, corner Dahlia Street West Fairview, Quezon City 1118* Tel. No.: 427-0213

430 A CLINICAL HISTORY

March 6, 2011

Informant: Patient %Reliability: 90%

IDENTIFYING DATA: Medaldine Libante, 40 years old, female, Filipino, Catholic, housewife , presently residing at Fairview Quezon City, born on September 1970, in Cebu, admitted for the 2nd time at FEU-NRMF Medical Center on March 6, 2011. CHIEF COMPLAINT: numbness and rigidity of both hands HISTORY OF PRESENT ILLNESS: The history of present illness started 4 days prior to admission when the patient felt numbness and rigidity of both hands accompanied by shallow breathing. She went to the E.R of our institution to sought consult and was advised to relax and rest. After few hours she was sent home. No medications were given. 3 days prior to admission, with the above symptoms, she again decided to seek consult at the ER where she was advised to rest and was sent home. No medications were given. Few hours prior to admission, same with the above symptoms, she sought consult at the PTR where ionized calcium was requested which revealed decreased result (0.99). She was then advised for admission, hence, admitted. PAST MEDICAL HISTORY February 2, 2011 s/p thyroidectomy Patient is non-hypertensive, non-diabetic and non-asthmatic. She denies previous history of trauma, accident and blood transfusion. FAMILY HEALTH HISTORY: He denies history of heredofamilial diseases such as hypertension, diabetes, heart, kidney, liver, lung diseases. PERSONAL AND SOCIAL HISTORY: Patient is a housewife. He currently lives with her son and husband who were both apparently well. He is a non-smoker and non-alcoholic beverage drinker. He lives in a well-lit, well-ventilated house. Garbage is collected once a week. REVIEW OF SYSTEMS: Constitutional : (-) weight loss , (-) generalized body weakness, (-) loss of appetite Skin: (-) itchiness, (-) excessive drying and sweating, (-) cyanosis, (-) jaundice

Head: Eyes: Ears: Nose and sinuses: Mouth and throat: Neck: Respiratory: Cardiovascular: Gastrointestinal: Genitourinary: Extremities:

(-) numbness, (-) vertigo, (-) lesions (-) blurring of vision, (-) photophobia, (-) eyeglasses (-) difficulty of hearing, (-) earache, (-) tinnitus, (-) ear discharge (-) change is smell, (-) nasal obstruction, (-) watery nasal discharge, (-) pain around paranasal discharges (-) numbness of the tongue, (-) slurred speech, (-) toothache, (-) gum bleeding, (-) disturbance in taste, (-) sore throat, (-) pain, (-) limitation in movement, (-) mass (+) shallow breathing (-) dyspnea, (-)chest pain, (-) cough, (-) hemoptysis, (-) wheezing (-) chest pain, (-) palpitations, (-) orthopnea, (-) paroxysmal nocturnal dyspnea, (-) edema, (-) cyanosis, (-) syncope, (-) easy fatigability (-) abdominal pain, (-) nausea, (-) dysphagia, (-) diarrhea, (-) constipation, (-) hematemesis, (-) melena, (-) hematochezia (-) dysuria, (-) polyuria, (-) anuria, (-) hematuria, (-) genital discharge, (-) urethral discharge (+) numbness and rigidity of both hands (-) swelling of joints, (-) tenderness of left arm , (-) limitation of movement of left arm

PHYSICAL EXAMINATION: General Survey: Patient is conscious, coherent, afebrile, not in cardiorespiratory distress Vital Signs: BP: 100/60 mmHg CR: 85 bpm RR: 20 cpm Temp: 37.2C SKIN: fair, mobile, with no superficial blood vessels seen and no lesions. Body hair is short, fine, scanty, and evenly distributed. Nails are pink, clean, smooth, no lesions and with normal nail folds. HEAD: Thick, black hair, evenly distributed, normocephalic, no deformity, temporal arteries are not visible but palpable, with strong equal pulses. With scarred wound on the left eyebrow and chin. FACE: fair skin, no masses or lesions, no tenderness. No facial asymmetry. EYES: Thin, black eyebrows, evenly distributed. Palpebral fissures are normal and symmetrical. Eyelashes are thin, with outward direction of growth, no matting, pink palpebral conjunctivae, anicteric sclerae, transparent cornea, lens are clear, black iris with regular contours, pupils are 2-3 mm equally reactive to light and with accommodation. No exophthalmos or enophthalmos. NOSE AND PARANASAL SINUSES: Symmetrical, with distinct borders, no tenderness, patent vestibules, mucosa is pink, septum midline and intact, turbinates are not congested, no nasal discharge, no tenderness over the frontal and maxillary sinuses. EARS: Auricles are symmetrical, no tenderness, the auditory canals are patent, tympanic membranes are pearly white, intact, normal contour, visible cone of light.

ORAL CAVITY: Lips are pink and dry. Buccal mucosa and gums are pink, smooth, no signs of swelling, Tongue is normal in size, located midline, and symmetrical. Hard and soft palate are pink, no lesions; uvula is in the midline, tonsils are not enlarged; pharyngeal wall is pink with no exudates. NECK: Neck is normal in size, supple, symmetrical, neck vein not distended, no mass, normal muscle development and tone, trachea in the midline, soft, no palpable lymph nodes, thyroid gland not palpable, with sutured wound on the anterior neck. CHEST/LUNGS: Skin is fair, no lesions, no dilated blood vessels, no tenderness and with normal muscle development. Bony thorax is elliptical in shape, symmetrical chest expansion, no intercostal retractions, no lagging. There were no masses or tender areas. Vesicular breath sounds. HEART: Adynamic precordium, normal rate, regular rhythm with no precordial bulging, no thrills nor heaves. The apex beat is at the left 5th intercostals space left midclavicular line. Jugular vein is not visible and not distended. ABDOMEN: flat, no lesion or scar, no bulging flanks, no dilated blood vessels, no visible peristalsis and mass, normoactive bowel sound, no bruit over the epigastric area. No fluid wave and shifting dullness. Soft and non-tender all over the 4 quadrants. Negative for direct and rebound tenderness. EXTREMITIES: no gross deformities, full and equal pulses, no edema, SKIN: no active skin dermatoses NEUROLOGIC EXAMINATION: Cerebral Function: conscious, coherent, not in cardiorespiratory distress Cerebellum: No nystagmus, Cranial Nerves: CN I - not assessed CN II- 2-3 mm pupils both constrict briskly reactive to light both direct and indirect and accommodation CV III, IV, VI - can move eyes in 6 cardinal directions of gaze CN V - can clench teeth CN VII - no facial asymmetry CN VIII - can hear CN IX, X - (+) gag reflex, uvula midline CN XI - can shrug both shoulder CN XII - tongue at the midline

R 5/5 5/5

Motor 5/5 5/5

R 100% 100%

Sensory 80% 90%

R ++ ++

DTR ++ ++

Pathologic Reflexes: (-) Babinski sign Signs of meningeal irritation:(-) Kernigs sign, (-) Brudzinski, no nuchal rigidity

ASSESSMENT: Hypocalcemia PLAN: For referral to IM- Endocrinology service

JIIC Inocencio, Richard B.