INTERNAL MEDICINE

PLENARY
Elardo, Salvatore
Gulla, Cloyd
Magnaye, Rechelle
Mambucon, Joeffrey
I. GENERAL DATA

MC, a 50 years old female born on 8/12/1967 in Imus:

● Filipino
● Married
● Catholic
● Currently residing in Bacoor, Cavite
● Right handed
● Admitted at DLSUMC on October 01, 2018

I. CHIEF COMPLAINT: Palpitations

II. HISTORY OF PRESENT ILLNESS
● 2 weeks PTA: cough, colds, fever
○ Phlegm: thick and viscous, yellow in color
○ Allergic Rhinitis
■ Acetaminophen (biogesic)
■ Sodium chloride nasal spray (sniff)
■ Ciclesonide nasal spray (Omnaris)
■ Levocetirizine (Zykast)
● 5 Days PTA
○ Bilateral Non-Pitting Edema
● During Consultation
○ Palpitation
○ Difficulty of breathing
○ Chest pain
● Admission
IV. PAST MEDICAL HISTORY
a. Hypertension (2004)
- prescribed with:
- Metoprolol (Neobloc)
- Perindopril arginine + Amlodipine (Coveram) changed to Amlodipine (Amvasc)
a. Gallstone (2006)
- unrecalled medication
- noted to take Hyoscine butylbromide (Buscopan) for months for RUQ pain relief
- Patient also noted that she took unrecalled herbal medicine that she claims dissolved the
gallstone
a. Chronic Kidney Disease (February, 2018)
- prescribed medicine were ketorels,Febuxostat (Urinorm), B-complex-Vitamin C-Folic Acid
(Renal-vite), Trestor
V. PERSONAL AND SOCIAL HISTORY
❏ Education: College; Course: BS Computer Engineer
❏ Occupation: Businesswoman (Pest-control operator)
❏ Hours of work per day: 6-8 hours
❏ Usual daily activities: Since the patient works from home, she spends the
whole day at home doing house chores.
❏ # Of household members: 6
❏ Housing: Concrete
❏ Diet: Low fat, low cholesterol diet. Mostly fish and vegetables
❏ Water supply: NAWASA
❏ Drinking water: purified
❏ Garbage disposal: once a week
VI. FAMILY HISTORY
❏ HPN: (+) Maternal Side
❏ TB: (+) sister (+) brother
❏ Cardiac dse: (+) 2 siblings
❏ Cancer: (+) 2 Siblings
❏ DM: (-) both sides Asthma: (-) Both sides

VII. OB HISTORY
❏ menarche at 11 years old and had menopause at 49 years old
❏ OB score is G5P4 (4014)
❏ She has regular menstrual period that usually last for 3 days.
❏ Cesarean delivery three times
❏ With history of eclampsia
VII. REVIEW OF SYSTEMS

A. General: (-) weight loss (+) weakness (-) loss of appetite

(+) easy fatigability (-) fever
B. Integument: (-) wound (-) rash (-) erythema (-) pallor (-) clubbing of
nails (-) hyper/hypopigmentation (-) mass at the lateral side
of right arm
C. Head and Neck: (+) headache(-) sore throat (-) distention of vein,
(-) mass (-) dizziness (-) swelling
D. Eyes: (-) corrective lenses (-) pain (-) redness (-) discharge
(-) icteric sclerae
E. Ears:(+) difficulty in hearing (R) ear (-) otalgia (-) vertigo (-) tinnitus
F. Nose and Sinuses: (+) watery discharge (+) epistaxis
(-) obstruction (-) difficulty smelling
G. Mouth & Throat: (-) toothache (-) hoarseness (-) dysphagia (-) ulcers
(-) tongue fasciculation (-) sore throat
H. Respiratory: (+) dyspnea(+) cough(-) hemoptysis (+) tachypnea
(-) pleuritic chest pain
I. Cardiovascular: (-) palpitations (-) angina (-) dyspnea
(-) orthopnea
J. GIT: (-) anorexia (+) nausea (-) vomiting (-) diarrhea (-) abdominal
distention (-) abdominal pain (-) constipation (-) intolerance
K. GUT: (+) nocturia(+) polyuria (-) oliguria (-) anuria (-) dysuria (-)
hematuria (-) flank pain (-) mass
L. Vascular : (-) claudication (-) varicose veins (-) ulcers
L. Hematologic: (+) easy bruising (-) easy bleeding (-) pallor
M. Endocrine: (-) cold intolerance (+) polyuria (-) polyphagia
(-) polydipsia (-) diaphoresis
N. Emotional/Behavioral: (-) mood changes
O. Musculoskeletal/Extremities: (-) muscle pain (-) fractures
(-) joint swelling (-) back pains (-) hyporeflexia
P. Neurologic: (-) seizure (-) syncope (-) tremors (-) one- sided
weakness(-) slurred (-) sensory loss
VII. REVIEW OF SYSTEMS

Pertinent:

Head and Neck: (+) headache, (+) nausea

Ears:(+) difficulty in hearing (R) ear
Nose and Sinuses: (+) watery discharge, (+) epistaxis
Respiratory: (+) dyspnea, (+) cough, (+) tachypnea
GUT: (+) nocturia, (+) polyuria
Hematologic: (+) easy bruising
Endocrine: (+) polyuria, (+) intolerance to cold
PHYSICAL EXAM

GENERAL SURVEY:

The patient is well developed and well nourished. She is

conscious, coherent, and oriented to time, place and person.
She is in mild respiratory distress, weak but ambulatory, and
appears his stated chronological age of 50. Patient has IV
line on the right dorsum of the hand.
PHYSICAL EXAM: VITAL SIGNS

BP: 140/90 mmHg, Sitting right

*CR: 102 beats/min
*PR:88 beats/min
RR: 16 cycles/min
Temp: 37.2℃
PHYSICAL EXAM
SKIN – unremarkable
- No pallor, jaundice, erythema, edema and wound;
- not febrile or cold to touch, has good skin turgor, normal degree of moisture, soft and resilient

HEAD AND NECK – Unremarkable: Patient has black hair. She has symmetrical skull and facial
symmetry

EYES – Unremarkable: Symmetrical, no redness.

EARS
- Patient has no masses, swelling or ulceration
- (+) cerumen/impaction on the right ear
- Tuning Fork test: Weber Test: (+) on the contralateral part of the affected ear

MOUTH AND THROAT – Unremarkable : Lips is symmetrical, no mass; Teeth is complete

HEART
- (-) heaves and thrills
- On auscultation: irregular rate, (-) cardiac murmur
PHYSICAL EXAM
CHEST AND LUNGS
- (-) chest deformity, masses
- Tactile fremitus is equal
- Normal breath sounds (vesicular on almost all parts of the lungs
- On auscultation: (+) coarse crackles - at the basal part of the lungs

ABDOMEN
- Globular, symmetrical; (+) surgical scar on the midline, hypogastric area, below the
umbilicus; (-) masses
- *succussion splash: (+); CVA tenderness: (-)

EXTREMITIES
- (-) Masses, Lesions, Cyanosis, Clubbing, Bipedal edema
- (-) Joint pains
- Pulses not palpated

MENTAL STATUS EXAMINATION

- The patient was awake, fairly groomed, and dressed appropriately. His speech was spontaneous and he was
cooperative with the examiner. His mood is calm with an appropriate affect. He is well oriented to time, place
and person.
 CASE ASSESSMENT
ASSESSMENT/PRIMARY IMPRESSION/ADMITTING DIAGNOSIS

1. COMMUNITY ACQUIRED PNEUMONIA, MODERATE RISK

- Salient Features: patient presents with productive cough and colds, fever, edema, tachycardia,
palpitations, dyspnea, orthopnea, (+) coarse crackles on both lungs (basal part), all are consistent
with the signs and symptoms of pneumonia

2. UNCONTROLLED HYPERTENSION

- Diagnosed since 2004, patient has persistent hypertension despite treatment.

3. STAGE 3 CHRONIC KIDNEY DISEASE

- Because no lab tests were given, we can just correlate the patient’s symptoms with the
manifestation of the different stages, in this case our patient/stage 3 CKD patients can manifest with
fatigue, fluid retention, swelling (edema) and shortness of breath
Differential Diagnosis Rule in Rule out

CONGESTIVE HEART (+) Cough (-) Paroxysmal Nocturnal

FAILURE (+) Palpitations Dyspnea
(+) Dyspnea (-) Ascites
(+) Orthopnea (-) Lethargy/Confusion
(+) Crackles
(+) Tachycardia Cannot Totally Rule out
(+) Family history of heart dse
(+) Age

ISCHEMIC HEART (+) Chest Pain (-) Referred pain

DISEASE (+) Palpitations (-) Diaphoresis
(+) Dyspnea (-) Nausea
(+) Tachycardia (-) Fatigue
(+) Hypertension
(+) Family history of heart dse
(+) Age
Differential Diagnosis Rule In Rule out

AORTIC DISSECTION (+) Dyspnea (-)Acute Severe chest pain

(+) Hypertension (Ripping or Tearing in character)
(+) Tachycardia (-) Interscapular Pain
(+) Chest Pain (-) Syncope
(-) Left/Right BP differential
(-) Pulse Differential/Deficit
(-) Altered Mental status
(-) Hemiparesis/Paresthesia
(-)Limb pain/Pallor

PULMONARY TB (+) Cough (-) Poor appetite

(+) Fever (-) Night Sweats
(+) Palpitations (-) Weight Loss
(+) Dyspnea (-) Hemoptysis
(+) Orthopnea (-) Weakness
(+) Crackles
(+) Tachycardia
CASE DISCUSSION: CAP
- Pneumonia results from the proliferation of microbial pathogens at the alveolar level
and the host’s response to those pathogens.
- It is a lower respiratory tract infection acquired in the community within 24 hrs to <2
weeks
- Signs and symptoms are acute cough, tachypnea, tachycardia, fever, abnormal chest
findings (rhonchi, crackles, wheezes), dyspnea, pleuritic chest pain and hemoptysis

- Patient (+) fever, respiratory tract infection. She also has a chronic disease with
uncontrolled comorbidities (hypertension). Patient maybe immunocompromised
resulting to higher risk of contiguous extension of infection to lower airways
causing pneumonia. Her work as a businesswomen is also a risk factor because
it requires a lot of communication/exposure with other people.
MANAGEMENT: PNEUMONIA

Diagnostics: Treatment:

a. Chest Radiograph
- Essential in the diagnosis of CAP,
assessing severity, differentiating
pneumonia from other condition, and
in prognostication
- a new parenchymal infiltrate remains
the reference diagnostic standard of
pneumonia
a. Microbiologic studies
- Low risk CAP: optional
- Moderate and high risk CAP: blood
culture and GSCS with antibiotic
sensitivity tests or respiratory
specimens should be done
CASE DISCUSSION: HYPERTENSION
- 2 or more elevated readings on at least 2 clinical visits over a period of one to
several weeks
- Classification:
MANAGEMENT: UNCONTROLLED HYPERTENSION
NON-PHARMACOLOGIC MANAGEMENT: LIFESTYLE MANAGEMENT
a. Weight reduction: attain and maintain BMI <25kg/m2
b. Dietary salt reduction: <6g NaCl/day
c. Adapt DASH-type Dietary Plan: diet rich in vegetables and low fat dairy; reduced content of
of saturated and total fat
d. Physical activity: regular aerobic activity

PHARMACOLOGIC

a. Diuretics
b. B-blockers
c. ACE Inhibitors
CASE DISCUSSION: CKD
- spectrum of different pathophysiologic processes associated with abnormal
kidney function and a progressive decline in GFR
- Defined by KDOQI as kidney damage for >/= 3months, as defined by
structural or functional abnormalities of the kidney, with ow without decreased
GFR by either of the following or GFR <60ml/min/1.73m2 for 3 months with or
without kidney damage
- Most of the time ckd stages 1 and 2 are asymptomatic. Typically its not until stages
3-5 that significant metabolic disarrangement causing disturbance in water and
electrolyte balance causing clinical manifestations. Stage 5 CKD needs dialysis.
Clinical Manifestations (Stage 3 CKD)

- Peripheral Edema
- Pulmonary Edema
- Proteinuria
- Polyuria or Oliguria
- Muscle Cramps
- Fatigue
CASE DISCUSSION: CKD
MANAGEMENT: CKD