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FINAL

COURSE
REPORT
1
COURSE OUTLINE
I. Community Project Proposal
II. Community Clinic
III. Community Activities
IV. Zumba
V. Family Home Visits
COMMUNITY PROJECT
BRGY ESCOPA III

BLOCK 6
January – February 2019
COMMUNITY
CLINIC
Residents-in-Charge:
• Dr. Doris Joan Dela Cruz
• Dr. Ma. Angelica Cielo Exconde
Dates of Clinic
• January 07, 2019 • January 21, 2019
• January 09, 2019 • January 23, 2019
• January 11, 2019 • January 25, 2019
• January 14, 2019 • January 28, 2019
• January 30, 2019
• January 16, 2019
• January 18, 2019
Dates of Clinic
• February 1, 2019 • February 13, 2019
• February 4, 2019 • February 15, 2019
• February 6, 2019 • February 18, 2019
• February 8, 2019 • February 20, 2019
• February 11, 2019 • February 22, 2019
CENSUS
Patients Seen January February

Pedia 232 151

Adult 106 106

Geria 61 96

Total Patients Seen: 399 353


Top 5 Cases - PEDIATRIC
Rank Diagnosis No. Of Cases

1 URTI 164

2 PCAP A 63

3 ATP 26

4 UTI 12

5 AGE S DHN 11
Top 5 Cases - ADULT
Rank Diagnosis No. Of Cases

1 URTI 37

2 HYPERTENSION 26

3 PTB, PRESUMPTIVE 17

4 TYPE 2 DM 11

5 BANIAE 7
Top 5 Cases - GERIATRIC
Rank Diagnosis No. Of Cases
1 HYPERTENSION 79
2 TYPE II DM 41
3 URTI 17
4 PRESUMPTIBE TB 7
5 DYSLIPIDEMIA 6
COMMUNITY ACTIVITIES
Mother’s Class
Parenting Styles
OBJECTIVES:
• To increase awareness on their parenting styles
• To introduce and demonstrate different parenting styles
they can use
• To teach the advantages and disadvantages of the
different parenting styles
Mother’s Class
Parenting Styles
Mother’s Class
Parenting Styles
Mother’s Class
Parenting Styles
OUTCOME:
• The mothers became aware of the different parenting
styles
• The mothers were able to reflect on their parenting
style
• The mothers were able to understand why their
children behave in a certain way
Mother’s Class
Parenting Styles
Mother’s Class
Top 5 Behavioral Management Strategies
OBJECTIVES:
• To increase awareness on their management
strategies
• To introduce and demonstrate different management
strategies they can use
Mother’s Class
Top 5 Behavioral Management Strategies
OUTCOME:
• The mothers became aware of their behavioral
management strategies
• The mothers were able to have an idea on future
behavioral management strategies
COMMUNITY ACTIVITIES
(Day Care, January 2019)
Road Safety Rules for Kids:
Choo-Choo Train

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TOPIC: Basic Traffic Rules

VENUE: Daycare, Escopa III

TIME AND DATE: 01/10/19 , 8:00-9:00am

EXPECTED PARTICIPANT: 10

GENERAL OBJECTIVES:
At the end of the activity, the participants must be able to follow basic traffic rules correctly.

SPECIFIC OBJECTIVES:
At the end of the activity, the participants must be able to:
1. Identify basic traffic rules properly; and
2. Demonstrate basic traffic rules appropriately.
OUTCOME

TIME AND DATE: 01/10/19 , 8:00-9:00

PARTICIPANTS: 10

OBJECTIVES MET:
General:
At the end of the activity, the participants were able to follow basic traffic rules correctly.
Specific:
At the end of the activity, the participants were able to:
1. Identify basic traffic rules properly; and
2. Demonstrate basic traffic rules appropriately.
COMMUNITY ACTIVITIES
(Day Care, February 2019)
Zum-babies

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TOPIC: Zum-babies

VENUE: Daycare, Escopa III

TIME AND DATE: 02/19/19 , 9:00-10:00am

EXPECTED PARTICIPANT: 20

GENERAL OBJECTIVES:
At the end of the activity, the participants must be able to appreciate the importance of physical
exercise even at a young age

SPECIFIC OBJECTIVES:
At the end of the activity, the participants must be able to:
• Explain the importance of physical exercise
• Demonstrate the proper way of exercise
OUTCOME
TIME AND DATE: 02/19/19 , 9:00-10:00 am

PARTICIPANTS: 20

OBJECTIVES MET:
General:
At the end of the activity, the participants must be able to appreciate the importance of
physical exercise even at a young age

Specific:
At the end of the activity, the participants were able to:
• Explain the importance of physical exercise
• Demonstrate the proper way of exercise
Senior Citizen’s Class
TEAM C: Tagisan ng Talino
TAGISAN NG TALINO
“In a review of several studies, researchers found that seniors with memory loss who
worked on puzzles for 45 minutes two times a week had improved scores on memory
tests. These improvements accounted for approximately six to nine months delay in
symptoms or decline.”
-- Benefits of Jigsaw Puzzles for Seniors with Alzheimer’s, Clarity Pointe
General Objective
• To raise awareness about the importance of keeping the mind alert,
especially among the elderly
Specific Objectives
• To lecture about dementia and Alzheimer’s disease
• To perform mind exercises through crossword puzzle games
• To encourage activeness and teamwork among the participants
SENIOR CITIZEN’S CLASS
• Dementia and Alzheimer’s Disease lecture
OUTCOME
• Most of the participants gave positive feedbacks about the activity.
• Challenging but fun at the same time.
• Interactive
• It was really an opportunity to exercise and stimulate the mind.
• They enjoyed the refreshments.
TRIAGE
LAY LECTURES
Oral Hygiene
Oral Hygiene
This was conducted last February 1
and 22, 2019 at the QMMC - OPD.
This lecture was done to reiterate
the importance of oral hygiene.
There were approximately 40 adult
individuals who participated in the
lecture.
Oral Hygiene
PhilHealth
This was conducted last February 6,
2019 at the QMMC-OPD. This
lecture was done to encourage
patients to enroll in PhilHealth. They
also discussed the PhilHealth
requirements for applications and its
benefits. There were approximately
30 adults who participated in the
lecture.
Common Adult Cancers
in the Philippines
This was conducted last February
11, 2019 at the QMMC-OPD. This
lecture was done in order to inform
the patients of the common adult
cancers in the Philippines, its risk
factors, symptoms and preventive
measures.
TRIAGE LAY LECTURES
(January 2019)

59
Self-medication and Antibiotic
Resistance
The activity was held at the OPD waiting area, with 25 participants
composed mainly of adults. We conducted the lay lecture at 1:00 pm
and ended at 1:45 pm. The participants were all attentive to the lecture.
They asked questions, especially regarding the problems that antibiotic
resistance can cause. Overall, the lecture was brief and easily
understood by the participants. They were able to participate in the
recap done at the end of the lecture.
TRIAGE LAY LECTURES
(February 2019)

62
Acute Gastroenteritis
The activity was held at the OPD waiting area, with 30 participants
composed mainly of adults. We conducted the lay lecture at 1:00 pm and
ended at 1:15 pm. The participants were all attentive to the lecture. They
asked questions, especially regarding the symptoms, since their
children/grandchildren had been diagnosed with AGE at some point.
Overall, the lecture was brief and easily understood by the participants.
They were able to participate in the recap done at the end of the lecture.
Acute Gastroenteritis
Smoking Cessation
The activity was held at QMMC- OPD where two interns gave a
one hour lecture about Smoking Cessation with the contents shown below.
We were able to gather approximately 30 participants waiting at the OPD
to listen to the lecture. To aid our discussion and for easier understanding
of the participants, we provided them leaflets with contents the same as
the lecture. After the lecture we welcomed the participants to ask
questions regarding the topic and we were able to answer these
questions.
Smoking Cessation
“ Yosi, Yosi, May Baga Ka pa Ba?”

January 23, 2019 Lay Lecture


Chronic Pulmonary Diseases and
Smoking Cessation
Held at the QMMC OPD Triage with discussion on Chronic
pulmonary diseases focusing on Chronic Bronchitis and Emphysema. It’s
objective was to include the etiology and pathophysiology of the diseases in
correlation with encouraging smoking cessation and benefits of early
cessation.
TEAM B LAY LECTURE JANUARY 30, 2019
of
DESCRIPTION:
Recently conducted at QMMC-OPD in efforts to educate patients about the effects
of self-medication to illness, health and medical expenses. About 30 individuals
participated the interactive lecture where concerns and queries were raised and
answered.
TEAM C LAY LECTURE
February 08, 2019
A brief overview on Mental Retardation, currently referred to as Intellectual Disability
was conducted at the QMMC - OPD with an audience of about 30 persons.

Some of it's objectives included raising awareness on the new terminology, enhancing
their knowledge about ID and fostering open mindedness towards persons with
intellectual disability.
Lay Lecture: Down
Syndrome
February 8, 2019
Down Syndrome

• A brief and meaningful discussion about


Down syndrome - its signs and symptoms,
diagnosis and management
Zumba
FAMILY
HOME VISIT

80
Team A
Daduya· De Villa· Dela Cruz· Fajarito·
Faustino· Guevara. Jaime

81
Angsuanco
76/M
Diagnosis: Medications:
● COPD ● Doxofylline 400 mg OD
● PTB Cat. I - completed treatement Montelukast 10 mg OD
(Jan. 2019) ● Atorvastatin 20 mg OD
● r/o Pulmonary Neoplasm ● Aspirin 80 mg OD
● s/p BKA, Left (1956) ● Amlodipine 10 mg OD
● s/p Cataract Surgery, OS (2011) ● Salbutamol neb PRN for DOB
● s/p CVD Infarct (2012) ● Salmeterol 50 mcg + Fluticasone
100 mcg MDI PRN for DOB
Angsuanco
76/M
BIOMEDICAL
S O A P
1. Chronic cough Occasional DOB O2 Sat: 93% COPD r/o Pulmonary Medications:
Occasional SOB Neoplasm Doxofylline 400 mg OD
Long-standing cough Decreased breath Montelukast 10 mg OD
sounds Salmeterol +
Fluticasone MDI prn for
DOB
Salbutamol neb prn for
DOB

Given pneumococcal
vaccine
For Chest CT Scan
Breathing exercises
Pulmo service follow-up
Angsuanco
76/M
BIOMEDICAL
S O A P
2. Hypertension Usual BP: 120-130/80- BP: 120/90 Hypertension Stage II - Medications:
90 controlled Atorvastatin 20 mg OD
Amlodipine 10 mg OD

Low salt, low fat diet


Daily exercise as
tolerated by the patient

3. s/p CVD infarct No weakness Motor strength: 5/5 on s/p CVD infarct Medications:
bilateral upper Aspirin 80 mg/tab OD
extremities and right
lower extremity Referred to rehab
service
Due for Neuro service
consult
Angsuanco
76/M
PSYCHOSOCIAL
S O A P
1. Family relationship Less interaction within the No signs and symptoms Encourage to have a
family members of depression and family meeting
suicidal tendencies Encourage family
members to bond as
much as possible
2. Dependence Needs help in using the Katz Index of ADL: 3 Encourage to have a
toilet, and in bathing (moderately dependent) family meeting
Lawton-Brody IADL: 2 Ensure the patient that he
(high level of is not a burden to other
dependence) family members

3. Depression Prefers to stay at home Geriatric Depression Further counseling about


most of the time Scale: 7 (suggests depression
Spends most of his time depression) Reassure patient of his
watching TV worth
Feels helpless at imes
Diaz
62/F
Diagnosis: Medications:
● Hypertension Stage II - ● Amlodipine 10 mg OD
uncontrolled ● Aspirin 80 mg OD
● Breast Mass, Right ● Vitamin B Complex tab OD
● Gabapentin 300 mg PRN for pain
Diaz
62/F
BIOMEDICAL
S O A P

1. Elevated BP (+) occasional BP: 100/70 Hypertension Stage II Diet counseling: Low salt,
episodes of chest pain: low fat diet
HR: 72 - controlled Diagnostics:
heavy and non- AP, NRRR, murmur Repeat laboratory work-up
radiating in character, after 3 months; still for 2D-
not appreciated
with an unrecalled pain Echo with doppler studies
scale, lasting for < 10 Cont. Amlodipine 10mg/tab
mins, relieved by rest OD and Aspirin 80 mg/tab
OD
and deep breathing Encourage continuity of
exercises compliance to medications
(-) difficulty of For referral to IM-Cardio
breathing consult once with 2D-Echo
(-) palpitation with doppler result
Daily light to moderate
(-) nape pain physical activities
(-) headache Daily BP monitoring and
recording
Diaz
62/F
BIOMEDICAL
S O A P

2. Breast Mass (-) breast pain ~2x2 cm firm, Breast Mass, Right Monthly breast self-
(-) breast discharge movable, non-tender examination to check
(-) skin dimpling mass on the right lower for any physical
outer quadrant of right changes in both
breast (-) skin breasts
discoloration and
changes Awaiting
histopathology result
(Jan. 2019) s/p CNAD,
right breast (Dec.
2018)

For Surgery follow-up


once with
histopathology result
Diaz
62/F
BIOMEDICAL
S O A P

3. Neuropathic pain (+) numbness of weak pulses Neuropathic pain Cont. Vitamin B
bilateral legs (-) edema complex tab OD
(-) pins and needle Gabapentin 300mg/tab
sensation 100% 100% TID PRN for pain
Encourage continuity
80% 80% of compliance to
medications

For possible laboratory


work-up (FBS, HbA1c)

Encourage light to
moderate physical
activities only
Diaz
62/F
PSYCHOSOCIAL
S O A P

1. Economic Status Lack of fund for SCREEM Maximize the


diagnostic procedures privilege given by the
Economic : government to senior
Family’s income is citizens such as
inadequate for their medical assistance
needs
The family is not
able not allocate fund
for savings
Osuna
55/M
Diagnosis: Medications:
● Hypertension Stage II - controlled ● Losartan 50 mg OD
● s/p Acute Intracranial ● Amlodipine 5 mg OD
Hemorrhage, Right Lentiform ● Simvastatin 40 mg BID
Nucleus (2017) ● Aspirin 80 mg OD
● s/p Explore Laparotomy for Stab
Wound (1985)
Osuna
55/M
BIOMEDICAL
S O A P
1. Hypertension Usual BP: 120-140/80- BP: 130/90 Hypertension Stage II - Medications:
90 controlled Losartan 50 mg OD
Amlodipine 5 mg OD
(-) nape pain Simvastatin 40 mg BID
(-) dizziness
Low salt, low fat diet
(-) chest pain
Daily BP monitoring
For blood chem on Feb.
2018
Ecxercise as tolerated by
the patient
2. s/p Acute Weakness of the left Motor: s/p Acute Intracranial Medications:
Intracranial side of the body Right UE and LE: 5/5 Hemorrhage, Right Aspirin 80 mg OD
Hemorrhage, Right Left UE and LE: 0/5 Lentiform Nucleus
Lentiform Nucleus For Neuro follow-up
Advised to take Vitamin
B complex
Osuna
55/M
PSYCHOSOCIAL
S O A P
1. Financial Medications takes a big Monthly income: Advise patient to seek
constraint chunk in household 12,000 for other organizations
budget that can help on his
Financially dependent Monthly budget: 10,000 medicines
on his wife and children Encourage family
meeting
Suggest a livelihood
program for stroke
patients
2. Unproductivity Not fit to work Katz Index of ADL: 6 Suggest a livelihood
(independent) program for stroke
patients
Quilates
21/F
Diagnosis: Medications:
● Schizophrenia ● Olanzapine (Olavex) 10 mg
ODHS
● Quetiapine (Victus) 25 mg ODHS
● Divalproex Sodium (Divalgen) 500
mg BID
Quilates
21/F
BIOMEDICAL
S O A P
1. Schizo- (+) Difficulty initiating (+) Disoriented to time, Schizophrenia, Medications:
phrenia and maintaining sleep person, place multiple episodes Olanzapine (Olavex) 10mg/tab 1 tab
(+) Episodes of poor (+) Occasional auditory ODHS
impulse control and hallucinations Quetiapine (Victus) 25mg/tab 1 tab
ODHS
agitation (+) Mumbling episodes
Divalproex Na (Divalgen) 500mg/tab
(-) Depersonalization
OD 1 tab OD in AM, 1 tab in PM
(-) Grandiosity
Encourage and educate regarding
the importance of compliance to
medications and follow-up to
Psychiatry Department.

Avoid chocolates, tea, coffee, soft


drinks, energy drinks, alcoholic
beverages
Quilates
21/F
PSYCHOSOCIAL
S O A P
1. Financial Financially dependent Monthly income: Advise patient to follow up
constraint on his father 20,000 and ask to be able to be
given a more accessible
Monthly budget: 10,000 cheaper medicine
Encourage family meeting
2. Unproductivity Not fit to work Encourage active
participation in pro-health
activities in the community
and nearby hospital (free
medications, community
clinics, lectures on mental
health) to lessen
discrimination and increase
awareness regarding mental
disorders.
Ragos
67/M
Diagnosis: Medications:
● PTB Cat. I - completed treatment ● Losartan 50 mg OD
(Jan. 2019)
● DM Type II
● Hypertensive Suspect
Ragos
67/M
BIOMEDICAL
S O A P
1. Hypertension Usual BP: 130-140/80- BP: 130/90 mmhg Hypertension For Hypertensive Work-up
Suspect 90 HR: 88bpm Suspect Low salt, low fat diet
RR: 18 cpm Daily BP monitoring
(-) nape pain T: 36.7
(-) dizziness O2: 98%
(-) chest pain
(-)blurring of vision
2. DM Type II No Subjective BP: 130/90 mmhg DM type 2 Follow-up repeat laboratory
complaint HR: 88bpm work up to determine sugar
(-) blurring of vision RR: 18 cpm control (FBS, HbA1c)
(-)numbness T: 36.7 Diet counselling (DM diet)
O2: 98% Daily blood sugar monitoring
Non-compliant for and recording
Medication (Metformin) Follow up at IM-DM Clinic at
the OPD
Ragos
67/M
PROBLEM LIST
BIOMEDICAL
S O A P
3. PTB – completed No Subjective BP: 130/90 mmhg For repeat Chest Xray
treatment (Jan. 2019) Complaint HR: 88bpm For repeat Sputum AFB
RR: 18 cpm x2
T: 36.7 Follow-up at TB DOTS
O2: 98% Center with results

4. Wheelchair bound Lower body weakness Atrophy of lower Still for Ortho
(27 years duration) extremities Consultation
Ragos
67/M
PSYCHOSOCIAL
S O A P
1. Financial Non-compliant to Moderatly Advise patient to seek for
constraint medications and Dysfunctional APGAR other organizations that can
laboratory work-ups help on his medicines
Encourage family meeting
Suggest a livelihood program
for PWD patients
Salazar
55/M
Diagnosis: Medications:
● Atherosclerosis ● Digoxin 0.25 mg OD at noon
● CAD ● Losartan 50 mg OD in AM
● CHF NYHA III-C ● ISMN 60 mg, ½ tab BID
● Hypertension Stage II - controlled ● Aspirin 80 mg OD at noon
● s/p CVD Infarct (2015, 2017, ● NAC 600 mg ODHS
2018)
Salazar
55/M
PROBLEM LIST
BIOMEDICAL
S O A P
1. Congestive Heart (+) dyspnea RR : 24cpm Congestive Heart Still for cardio consult
Failure (+) Shortness of breath 02 sat : 95% in room air Failure III-C Complete blood
(+) Bibasal crackles chemistry workup
(-) neck vein Check patient’s
engorgement compliance to
(-) edema medication
Daily Blood pressure
monitoring and record
Limit oral fluid intake
Salazar
55/M
BIOMEDICAL
S O A P
2. Risk for CVD (+) Known history of BP : 110/70 mmHg S/P CVD (2018) Referral to neuro
CVD Temp : 36.2 C Complete blood
(2018) HR : 68 chemistry workup
RR : 24cpm Check patient’s
02 sat : 95% in room air compliance to
(+) left sided weakness medication
MOTOR on Left side : Daily Blood pressure
3/5 (both upper and monitoring and record
lower extremities Diet counseling : low
(+) use of cane salt, low fat diet
(-) slurring of speech
Salazar
55/M
BIOMEDICAL
S O A P
3. Hypertension (+) known hypertensive BP : 110/70 mmHg Hypertension Stage 2, Still for referral to cardio
(2018) Temp : 36.2 C controlled Complete blood
(-) chest pain HR : 68 chemistry workup
(-) headache RR : 24cpm Urinalysis
(-) nape pain 02 sat : 95% in room air Check patient’s
(-) blurring of vision (+) left sided weakness compliance to
MOTOR on Left side medication
:3/5 (both upper and Daily Blood pressure
lower extremities monitoring and record
MO (+) use of cane Diet counseling : low
salt, low fat diet
Team B Home Visit
Cuntapay-Del Rosario-Diche-Domingo-Hernandez-Janoras

105
Heramia 50/M
• Diagnosis: Major Depressive disorder with psychotic features

• Medications:
o Escitalopram 10 mg/tab OD
o Colchicine 500 mcg/tab BID
o Febuxostat 40 mg/tab OD

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PROBLEM LIST

A. Biomedical

S O A P

JANUARY 2019 Pain after eating (+) Tenderness and Gouty arthritis Avoid purine rich
#1 Pain at right beans and drinking slight swelling on the foods, sweetened
ankle alcohol right ankle drinks, and alcoholic
(+) Non-erythematous beverages
(+) No limitation of
movement For BUA monitoring
every 3 months

Celecoxib 200
mg/cap BID prn for
pain

Continue Colchicine
and Febuxostat
PROBLEM LIST

A. Biomedical

S O A P

Patient not seen Currently at work Major Depressive Continue Colchicine


FEBRUARY 14, 2019 Disorder with 500 mcg/tab BID and
Psychotic features, Febuxostat 40 mg/tab
Attention Seeking OD
behavior with
substance abuse and
Alcoholic Liver Disease
FEBRUARY 21, 2019 Patient was seen No complaints Major Depressive Continue present
Disorder with management
Psychotic features,
Attention Seeking
behavior with
substance abuse and
Alcoholic Liver Disease
B. PSYCHOSOCIAL

S O A P

#1 Prevention of No specific stressor No signs and Major Depressive Continue pursuing


future relapse of during the time of symptoms of Disorder with hobbies in order to
MDD, suicidal examination depression and psychotic features, in deal with stressful
tendencies or suicidal tendencies remission situations (financial,
hallucinations family support,
personal issues)
effectively

Maintain close family


relationship and open
communication,
especially regarding
patient’s condition
Dela Fuente, 92/F
• Diagnosis: Hypertension St. II, Uncontrolled; Mature Senile
Cataract, OU; Verruca Vulgaris; Steatocystoma multiplex

• Medications:
o Amlodipine 5mg/tab OD
o Losartan 100mg/tab OD
o Vitamin B Complex OD

110
PROBLEM LIST

A. Biomedical

S O A P

JANUARY 16, 2019 No subjective BP = 140/80 mmHg Hypertension St. II, Daily BP monitoring
#1 Hypertension complaints Uncontrolled
Cont meds:
Amlodipine 5mg OD,
Losartan 100mg OD
For hypertensive work
up on February 2019

#2 Cataract Blurring of vision Counting fingers at 3 Mature Senile Advised cataract


ft Cataract, OU surgery but relatives
refused
#3 Verruca Vulgaris Pruritus Involvement of chest Verruca Vulgaris For electrodessication
and all extremities,
lesions consisting of
multiple well defined
skin colored rough
surfaced papules

#5 Back pain Lower back pain (-) LROM Musculoskeletal Hot compress as
Kyphosis Strain needed for pain
Vitamin B complex
tablet OD
PROBLEM LIST

A. Biomedical

S O A P

FEBRUARY 6, 2019 5 days prior to home Clear breath sounds, Otitis Externa, Resolving Avoid manipulation of
visit, the patient had otologic exam revealed the ears; educated on
sudden ear pain after no tragal tenderness, proper ear hygiene;
cleaning her ears with slightly hyperemic ear increase oral fluid
cotton buds. No reports canal, minimal cerumen, intake; assured that
of ear discharge, cough, intact tympanic ears will get better
colds or fever membrane without any medications
B. PSYCHOSOCIAL

S O A P

#1 Economic Saving for her own APGAR = 6 Family conferences


anticipated health (Moderately Encourage quality
emergencies dysfunctional) time with family
GDS = 5 (Normal or members
no depression)
Sumayao, 48/M
• Diagnosis: Hypertension stage I - uncontrolled, s/p CVD infarct (2014,
2016)

• Medications:
o Amlodipine 10 mg/tab ODHS
o Vitamin B complex tab OD
o Vitamin C tab - 2 tablets OD
o Calcium tab (Caltrate plus) OD
o Piracetam tab OD - dose unrecalled

115
PROBLEM LIST

A. Biomedical

S O A P

JANUARY 2019 No subjective BP = 140/100 Hypertension stage I - Daily BP monitoring


#1 Hypertension complaints No edema uncontrolled Hypertensive workup
Clear breath sounds Start Losartan 50
mg/tab ODAM
Continue Amlodipine
10 mg/tab ODHS
DASH diet
Hypertensive workup
Watch out for edema

#2 Loss of Inability to move and Passive range of s/p CVD infarct (2014, Referral to rehab for
movement, right loss of sensation, motion, right arm July 2016) daily exercise
arm right arm Limited active range Low salt, low fat diet
of motion, right leg
Weakness on the Weakness and MMT = 0/5 (right
right leg decreased sensation, arm); ⅗ (right leg)
right leg Sensation = 0% (right
arm); 20% (right leg)
PROBLEM LIST

A. Biomedical

S O A P

FEBRUARY 2019 No subjective BP = 140/90 Hypertension stage I - Daily BP monitoring


#1 Hypertension complaints No edema uncontrolled Still for hypertensive
Clear breath sounds workup
Continue Losartan 50
mg/tab ODAM
Continue Amlodipine
10 mg/tab ODHS
LSLF diet
Watch out for edema
#2 Neck pain Pain on the lateral (+) erythema T/C muscle strain Frequent bed turning
aspect of the neck (+) tenderness upon Advised alternating hot
(L>R) upon touching palpation and cold compress
and upon movement
(+) tenderness upon Advised intake of
movement, full ROM Paracetamol
500mg/tab every 6
hours as needed for
pain
PROBLEM LIST

A. Biomedical

S O A P

Inability to move and Passive range of s/p CVD infarct (2014, Referral to rehab for
#3 Loss of loss of sensation, right motion, right arm July 2016) daily exercise
movement, right arm arm Limited active range of Low salt, low fat diet
motion, right leg
Weakness on the Weakness and MMT = 0/5 (right arm); ⅗
right leg decreased sensation, (right leg)
right leg Sensation = 0% (right
arm); 20% (right leg)
B. PSYCHOSOCIAL

S O A P

JANUARY 2019 Patient was Re-establish


#1 No support from abandoned by family communication and
the patient’s parents Loss of discuss patient’s
and siblings communication with condition, including
family members complications and
prognosis
Encourage family to
offer additional
support (financial,
emotional,
psychological)

#2 Caregiver The wife expresses Modified Caregiver Caregiver strain Encourage children to
fatigue being tired from Strain Index = 28 offer more help in doing
taking care of the (Tendency to strain) household chores
Advice about stress
patient and children
management (simple
The wife is the
exercises, self-care)
breadwinner of the
family
B. PSYCHOSOCIAL

S O A P

FEBRUARY 2019 The wife expresses Modified Caregiver Caregiver strain Encourage more active
#1 Caregiver fatigue being tired from taking Strain Index = 28 caregiver participation
care of the patient and (Tendency to strain) from the children
children
Advised about stress
The wife is the management (simple
breadwinner of the exercises, more
family personal time)

The wife complains of


frequent upper back
pain
Pablo, 62/F
• Diagnosis: CHF NYHA IV; Hypertension stage I – Uncontrolled;
Obesity Class II; COPD

• Medications:
o Losartan + HcTZ
o Atorvastatin 80mg/tab OD

121
PROBLEM LIST

A. Biomedical

S O A P

JANUARY 2019 (+) pruritus Visible lice scattered Pediculosis Permethrin


#1 Lice infestation all over the head Manual removal

#2 COPD Difficulty of breathing O2 Sat: 92% COPD Avoid exposure to


Decreased breath cigarette smoke and
sound on left lower dust
lung field Salmeterol +
Hgb: 123 Fluticasone inhaler
Hct: 0.42 Advised oxygen
therapy

122
PROBLEM LIST

A. Biomedical

S O A P

#3 Elevated blood Dizziness BP: 150/110 mmHg Hypertension stage II Hypertensive work up
pressure FBS: 4.90 mmol/L uncontrolled BP monitoring
Total Cholesterol: 4.02 Lifestyle modification
mmol/L

#4 Back Pain Lower back pain Difficulty standing up Obesity class II Lifestyle modification
Total Cholesterol: 4.02 Celecoxib 200 mg/cap
mmol/L BID prn for pain
Blood Uric Acid: 562 Vitamin B complex
umol/L tablet 1 tab OD
UA Hyaline Cast:
3/LPF
BMI = 64.6(obese)

123
PROBLEM LIST

A. Biomedical

S O A P

FEBRUARY 2019 (+) pruritus on scalp Visible lice scattered Pediculosis Permethrin shampoo –
#1 Lice Infestation all over the head leave for 10 minutes
then rinse
Manual removal using
fine-toothed comb
B. PSYCHOSOCIAL

S O A P

#1: Support System Lack of communication SCREEM Lack of adequate Family Conference
about disease (Educational) – level of education Simplified discussion of
prognosis and education hinders disease prognosis
complications comprehension of and complications
most challenging
circumstances

#2: Unproductivity Boredom (as Geriatric Depression Lack of recreational Encourage more quality
verbalized by the Scale = 4 (No activities time with immediate
patient) depression) family
Katz Index of ADL = 6 Offer other activities
(Independent) (board games,
puzzles, reading
pocket books etc)
Unay, 60/F
• Diagnosis: Hypertension St. II – uncontrolled; T2DM – uncontrolled;
Hypoalbuminemia secondary to Hypertensive nephropathy vs DM
nephropathy

• Medications:
o Metformin 500mg/tab, TID
o Losartan 50mg/tab BID
o Atorvastatin 40mg/tab OD
o Clonidine 75mcg/tab for BP ≥ 160/100 mmHg

126
PROBLEM LIST

A. Biomedical

S O A P

JANUARY 2019 Dizziness BP = 160/100 Hypertension stage II Daily BP monitoring


#1 Hypertension - uncontrolled Hypertensive workup
DASH diet

#2 Bilateral leg Swelling of both legs (+) Bilateral pitting T/C CHF R/O PAOD For AV doppler, both
swelling Difficulty of breathing edema, grade 3 legs
Easy fatigability (+) Crackles For chest Xray
Discolorations on For 2D echo
both legs Start Furosemide 40
mg/tab OD

#3 Elevated blood Frequent urination at FBS (Aug. 2018) = Type 2 DM - For FBS, HbA1c,
sugar night 7.10 (elevated) uncontrolled BUN, Creatinine
HbA1c (Aug. 2018) =
6.80% (elevated)
PROBLEM LIST

A. Biomedical

S O A P

FEBRUARY 2019 Swelling of both legs (+) Bilateral pitting T/C CHF R/O PAOD Still for AV doppler,
#1 Bilateral leg Difficulty of breathing edema, grade 3 both legs
swelling Easy fatigability (+) Crackles Still for chest Xray
Discolorations on Still for 2D echo
both legs Furosemide 40
mg/tab OD

#2 Elevated blood Frequent urination at FBS (Aug. 2018) = Type 2 DM - Still for FBS, HbA1c,
sugar night 7.10 (elevated) uncontrolled BUN, Creatinine
HbA1c (Aug. 2018) =
6.80% (elevated)
B. PSYCHOSOCIAL

S O A P

#1 Dependence on Relies on husband for Katz Index of ADL = 2 Dependence Allow patient to
husband/family activities of daily (Dependent) perform small,
living personal tasks

#2 Caregiver Husband often talks Modified Caregiver Caregiver stress Advice family to
agitation with an angry voice Strain Index = 17 provide, if possible,
and cuts off patient (Normal) another caregiver to
while talking help the husband
Stress management
(exercise)
Melegrito, 85/M
• Diagnosis: Chronic Obstructive Pulmonary Disease

• Medications:
o Montelukast 10mg tablet

130
PROBLEM LIST

A. Biomedical

S O A P

FEBRUARY 2019 No subjective BP: 120/90, PR: 88, O2 Chronic Obstructive Continue present
complaints sat: 98% Pulmonary Disease management
B. PSYCHOSOCIAL

S O A P

FEBRUARY 2019 His daughter Caregiver strain Encourage more active


#1 Caregiver fatigue expresses tiredness caregiver participation
from taking care of the from the children
patient especially he
needs assistance in Advised about stress
his every action. management (simple
exercises, more
personal time)
Torres, 72/M
• Diagnosis: Chronic Kidney Disease Stage 3, Hypertension Stage II,
uncontrolled; Diabetes Mellitus Type 2; CVD Infarct (2016)

• Medications:
o Clopidogrel 75 mg/ tab, 1 tab OD
o Linagliptin 5 mg/tab, 1 tab OD
o Atorvastatin 20 mg/ tab, 1 tab OD
o Enalapril 10 mg/ tab, 1 tab OD
o Amlodipine 10 mg, 1 tab OD

133
PROBLEM LIST

A. Biomedical

S O A P

JANUARY 2019 Few hours to home visit, V/S: Hypertension St. II – Continue medications:
patient experienced BP: 140/80mmHg Uncontrolled  Clopidogrel
headache, precipitated HR: 84 bpm 75mg/tab, 1 tab
by argument with his RR: 20 cpm OD
son, throbbing in O2 Sat: 98%  Linagliptin 5
character, intermittent, Temp: 36.7o mg/tab, 1 tab OD
 Atorvastatin
and radiating to the
20mg/tab, 1 tab
nape area, with a PS of
OD
7/10. A sudden rise in
 Enalapril
BP also prompted 10mg/tab, 1 tab
relative to bring the OD
patient in for medical  Amlodipine
consult 10mg/tab, 1 tab
OD
Daily BP monitoring
DASH DIET
PROBLEM LIST

A. Biomedical

S O A P

FEBRUARY 2019 No subjective V/S: Hypertension St. II – Continue medications


complaints BP: 140/80mmHg Uncontrolled maintenance
HR: 89 bpm medications
RR: 18 cpm
O2 Sat: 98% Daily BP monitoring
Temp: 36.5o DASH DIET
B. PSYCHOSOCIAL

S O A P

#1 Possible “parusa sa akin ng GDS = 13 Family conferences


Depression diyos itong sakit ko” (sugggestive of Encourage quality
depression) time with family
members
Catharsis
Formulate recreational
activities for bed
bound or wheelchair
bound patients
TEAM C Home Visit
Dy· Eke· Feliciano· Feliciano· Fitero· Gardoce

137
Mamauag Family

• This is a case of RM, 53/M, Previously seen at QMMC


since Sept 2018 and managed as a case of HTN St. II,
controlled, Polycythemia Vera, S/p Intracranial
Hemorrhage, Right, Thalamocapsular Area.
PROBLEM LIST
BIOCHEMICAL
Subjective Objective Assessment Plan

Number 1 Left-sided Weakness BP 140/80, Hr 98, RR 19, T 36.7, O2 98% S/P intracranial Hemorrhage, Right, • Have baseline Laboratories: Na, K, CL, Mg, Ca
(+) left sided facial weakness Thalamocapsular area (2018) • For Update of Rehab, noted funds were already
(+) left tongue deviation secured starting 28 session at QMMC at
(+) slurring of speech 01/21/19.
Oriented to time, Place, Person • Plan for speech therapy techniques that can be
(+)weak shoulder Shrug on Left shoulder done at home.
Motor 5/5 RE, 3/5 LUE, 0/5 LLE • Plan for repeated neurologic examinations
Sensory: 100% Right side, 0% Left side including CN and MMSE every home visits.
(+) dysarthria, • Avoidance of hypotension or hypertension (MAP
(+) slurring of speech = 70-130 mm Hg)
(-) babinski • Continue current medication: Irbesartan
150mg/tab OD, Amlodipine 10mg/tab OD
Subjective Objective Assessment Plan

Number 2 No Subjective complain BP 140/80, Hr 98, RR 19, T 36.7, O2 98% HTN St. II • Retrieve previous Lab results
(-) sudden blurring of vision AS, PPC, (-) olyguria, (-) flank pain • Have baseline Laboratories: TLP, Cholesterol,
(-) olyguria BUN, Crea, SGOT, SGPT
(-) flank pain • Advised to have a list of BP monitoring and
(-) nape pain record
(-) dizziness • Avoidance of hypotension or hypertension (MAP
(-) DOB = 70-130 mm Hg)
• Continue current medication:Irbesartan
150mg/tab OD, Amlodipine 10mg/tab OD
• Advised for a Low salt, Low fat diet
• Encourage Daily exercise such a walking outside
or doing laps around the house,

Number 3 No Subjective complain BP 140/80, Hr 98, RR 19, T 36.7, O2 98% Polycythemia Vera • Retrieve previous Lab results
(-) sudden blurring of vision AS, PPC, (-) olyguria, (-) flank pain • Have baseline Laboratories: CBC w/PC
(-) olyguria (-) organomegaly • Advised to have a list of BP monitoring and
(-) flank pain (-) spleenomegaly record
(-) nape pain • Avoidance of hypotension or hypertension (MAP
(-) dizziness = 70-130 mm Hg)
(-) DOB • Continue current medication:Hydroxyurea
500mg/tab TID
• Advised precaution against bleeding events
PROBLEM LIST

PSYCHOSOCIAL

Subjective Objective Assessment Plan

Number 1 Verbalized occasional episodes BP 140/80, Hr 98, RR 19, T 36.7, O2 98% T/C Depressive Disorder Due to • Encourage increased Verbal communication
worthlessness, Hopelessness, (+) left sided facial weakness Another Medical Condition among family members for them to be self aware
Prefers to stay at home, rather (+) left tongue deviation (DSM-5) of the emotional needs of other family members.
than going out to talk to others (+) slurring of speech • Get in a routine, to enable the patient to have
and stays at bed most of the Oriented to time, Place, Person short, easy, attainable goals within each day
time. (+)weak shoulder Shrug on Left shoulder for confidence boost.
Motor 5/5 RE, 3/5 LUE, 0/5 LLE • Encourage daily exercise as the body releases
Sensory: 100% Right side, 0% Left side chemicals that helps make the mind and body
(+) dysarthria, at ease and have a sense of accomplishment
(+) slurring of speech • For further evaluation.
COMPLETE BLOOD COUNT

PARAMETER RESULT RESULT REFERENCE RANGE


(Dec. 3, 2018) (JAN. 7, 2019)

RBC 3.48 3.01 4.2 - 5.4 (X10^12/L)

Hemoglobin 103 101 120 - 160 (G/L)

Hematocrit 0.32 0.28 0.36 - 0.47 (VOL %)

Platelet Count 231 204 150 - 450 (X10^9/L)

WBC 9.5 5.7 5.0 - 10.0 (X10^9/L)

Neutrophil 0.67 0.58 0.50 - 0.70

Lymphocytes 0.27 0.37 0.2 - 0.5

Eosinophils 0.06 0.04 0.0 - 0.06

Monocytes 0.00 0.01 0.02 - 0.09

Basophils 0.00 0.00 0.0 - 0.02


Cranial CT-Scan

Sept. 12, 2018 • Acute intracranial hemorrhage, right posterior putamen,


posterior limb of right internal capsule, and thalamus (4.9) with
mild impression on the third ventricle
• Chronic lacunar infarcts or prominent periventricular spaces,
left thalamus.
• Cerebro-cerebellar atrophic changes
• Atherosclerotic bilateral internal carotid and vertebral arteries.
Chest-PA/AP

Sept. 12, 2018 • Suspicious, right upper lung. Suggest apicolordotic view for
verification
• Magnified cardiac silhouette.

Sept. 17, 2018 • Unchanged chest findings,


• Previously noted suspicious opacities in the right upper lung
remain unchanged, apicolordotic view suggested
• Cardiac silhouette is again magnified due to supine positioning

Sept. 22, 2018 • Suspicious opacities in the right upper lung for which for which
an apicolordotic study is suggested.
• The rest of lungs is clear
• Cardiac silhouette is still magnified
• The rest is normal findings
KUB

Sept. 18, 2018 • Normal sized kidneys with diffuse parenchymal disease based
on echogenicity
• Exophytic renal cyst, right
• Simple renal cortical cyst, left
• Renal parenchymal calcification, left.

Carotid-Doppler

Sept. 24, 2018 • Atherosclerotic, both common carotid arteries


• Type 4 plaque in the right carotid bulb producing 37.9% area
stenosis
• Unremarkable color and spectral Doppler imaging of the
bilateral neck arteries with no evidence of hemodynamically
significantly stenosis.

Apicolordotic view

Oct. 21, 2018 Incorrelation with the previous chest radiograph done on the
same day 09/22/2018, present apicolordotic study confirms the
presence of interstitionodular opacities in the right upper lung.
Consider PTB of undetermined activity.
No other significant findings.
DE LEON, ROGER 79/M
• Diagnosis: T/C Senile Dementia; HTN St I, controlled; T/C
Hypertensive Nephrosclerosis; Dyslipidemia

• Medications:
o None

145
HOME VISIT
• JANUARY 24, 2019
DE LEON, ROGER (Index Patient)
BIOMEDICAL
PROBLEM LIST S O A P
1. Non compliant to • Known case of • VS: 120/80mmHg; • T/C Senile • Cont LSLF diet
maintenance Hypertension 62bpm; 20cpm; dementia • Cont familiarization
meds Stage I 36.5C; 96% • Hypertension exercises
2. Sleep difficulty • Awake at night • Unremarkable PE Stage I, controlled • For laboratory
3. Outdated • No other • Dyslipidemia work-up
laboratories subjective • T/C Hypertensive
complaints Nephrosclerosis
DE LEON, ROGER (Index Patient)
PSYCHOSOCIAL
PROBLEM LIST S O A P
1. Severe degree of • MMSE done MMSE score: 4 Severe cognitive For 24-hour
impairment in impairment supervision and
MMSE assistance with ADL
HOME VISIT
• JANUARY 29, 2019
DE LEON, ROGER (Index Patient)
BIOMEDICAL
PROBLEM LIST S O A P
1. Non compliant to • Known case of • VS: 120/90mmHg; • T/C Senile • Cont LSLF diet
maintenance Hypertension 65bpm; 18cpm; dementia • Cont familiarization
meds Stage I 36.7C; 98% • Hypertension exercises
2. Sleep difficulty • Awake at night • Unremarkable PE Stage I, controlled • Cont
3. At risk of • No other • MNA score: 11 • Dyslipidemia Ketoanalogue OD
malnutrition by subjective • T/C Hypertensive
MNA complaints Nephrosclerosis
• Elevated
Creatinine @
148.50 umol/L
DE LEON, ROGER (Index Patient)
PSYCHOSOCIAL
PROBLEM LIST S O A P
1. Severe degree of • Katz Index of ADL • Katz index of ADL • Senile Dementia • For 24-hour
impairment in done score: 2 • Severe cognitive supervision and
MMSE impairment assistance with
2. Patient is ADL
relatively
dependent by
Katz Index
DE LEON, ROSITA
BIOMEDICAL
PROBLEM LIST S O A P
1. Hypertension • Known case of • VS: 130/90mmHg; • Hypertension • Cont LSLF diet
Hypertension 66bpm; 20cpm; Stage I, controlled • Cont maintenance
maintained with 36.4C; 98% • Dyslipidemia medications
Losartan 50mg OD • Unremarkable PE
• Known case of
Dyslipidemia
maintained with
Atorvastatin 40mg
OD
• No other
subjective
complaints
DE LEON, ROSITA
PSYCHOSOCIAL
PROBLEM LIST S O A P
1. She is the only • Caregiver AMA Caregiver Self- Caregiver strain • For MCSI
caregiver to the assessment Assessment
index patient survey done Questionnaire: 2
points

Question #17: 7 (may


indicate high degree
of distress)
DE LEON, RONALDO
BIOMEDICAL
PROBLEM LIST S O A P
1. Throat pain • 1wk PTC, (+) fever, • VS: 120/80mmHg; • ATP resolving • Cont prescribed
2. Joint pains undocumented, (+) 89bpm; 20cpm; meds
throat pain, (+) joint
37.0C; 98% • Increase oral fluid
pains, (-) cough, (-)
colds • Hyperemic intake
• 2 days PTC, pharyngeal walls
symptoms increase in • Swollen upper lip
severity hence consult • (-) CLADs
at QMMC ER and • CBS
was diagnosed with
• (-) Abdominal pain
ATP, exudative; given
with Co-Amoxiclav upon palpation
625mg TID x 7d, • The rest of the PE
Paracetamol 500mg was unremarkable
q4 PRN,
Chlorhexidine oral
solution
GONZALES FAMILY
M.G, 64/F, is the index patient with a diagnosis of
Amyotrophic Lateral Sclerosis (2016).
PROBLEM LIST
A. BIOMEDICAL
S O A P
1. (+) difficulty standing up or Vitals: Amyotrophic Lateral -encourage ambulation every
walking BP- 110/60 mmHg Sclerosis; Borderline 2-3 hours
PR- 90 bpm Hyperlipedemia
(+) numbness, lower RR- 20 cpm -avoid prolonged sitting or lying
extremities > upper T- 36.9 C down in one position
extremities O2- 99%
-advise consult for
Extremities: rehabilitation or alternatively,
(+) atrophy, left leg suggest proper fine and gross
(+) muscle spasms, right and left hands motor exercises

Motor: -suggest to do total lipid profile


3/5 5/5
-diet modification: eat more
5/5 5/5 fruits and vegetables, whole
grains, poultry; cut back on
Sensory: fried and fatty food
100% 100%
-suggest to repeat urinalysis
90% 90%

-unable to walk

-other PE findings essentially normal


CBC: January 28, 2019
Test Name Result Reference Range
RBC 4.2 4.2-5.4
Hemoglobin 117 120-160
Hematocrit 0.37 0.36-0.47
Platelet count 294 150-450
WBC 6.3 5.0-10.0
Neutrophil 0.55 0.50-0.70
Lymphocytes 0.37 0.2-0.5
Eosinophil 0.03 0.0-0.06
Monocytes 0.05 0.02-0.09
Basophil 0.00 0.0-0.02
Chemistry: January 28, 2019

Test Name Result Reference Range

Glucose, FBS 4.09 3.89

Total Cholesterol 5.75 0.517

Creatinine 29 49-90

Blood Uric Acid 375 150-350


Urinalysis: January 25, 2019

Color yellow WBC 2/hpf


Transparency clear RBC 4/hpf
Reaction 5.5 Epithelial Cells many
Specific Gravity 1.014 Bacteria occasional
Albumin negative Mucous Threads rare
Sugar negative Yeast Cells none
Ketones negative Crystals none
Nitrite 0.01 mg/dL + Casts none
Urobilinogen 2.0 mg/dL +
Bilirubin negative
CXR-PA: August 24, 2017

●Suspicious opacities, left upper lung. Suggest APL view.


●Left-sided minimal pleural effusion vs. thickening
●Tortuous aorta
●Degenerative osseous changes of the thoracic spine
2. (+) lower back pain Extremities: T/C muscle spasm -encourage ambulation
(+) atrophy, left leg of the lower back every 2-3 hours
(+) muscle spasms, right secondary to
and left hands prolonged sitting -avoid prolonged sitting or
lying down in one position
Motor:
3/5 5/5 -suggest to start analgesics
PRN
5/5 5/5

Sensory:
100% 100%

90% 90%

-unable to walk

-other PE findings
essentially normal
3. (+) joint pain, upper (-) joint deformities Hyperuricemia -diet modification: eat more
extremities > lower (-) joint swelling, fruits, vegetables, whole grains,
extremities redness low-fat dairy, lean meat and
-full range of motion on poultry; cut back on saturated
active movement of fats, sweet fruit juices, high-fat
both upper and lower dairy products, seafood, beans;
extremities low-purine diet

Laboratory result: -increase oral fluid intake


1/28/19
Serum uric acid: 375
umol/L (N: 150-350
umol/L)
2. (+) weight loss Wt: 50 > 45 kgs At risk for -monthly weight monitoring
malnutrition
(+) appetite BMI: 18.1- underweight -review/construct proper
nutritional or diet plan focusing
Nutritional Assessment on high protein for muscle gain
(MNA) score of 17.5
suggestive of at risk for
malnutrition
PROBLEM LIST
A. PSYCHOSOCIAL
S O A P
1. (+) unproductivity Geriatric Depression T/C depressive -start writing exercises
Scale (GDS) score of disorder
-noted more hours on 6 suggestive of secondary to -start psychosocial positive
wheelchair, chair, or depression chronic disease reinforcement therapy
bed
-encourage socialization
outside the home, reconnect
with friends
Paris, 73/M
• Diagnosis: HTN St II, DM II, PTB resolved (2016), S/P CVD bleed (2016)

• Medications:
o None

165
Home Visits Activities

January 15, 2019 - Introduction as new family doctors for Jan – Feb 2019 & Establishment of rapport
- History & PE
- Mini Mental Status examination done

January 22, 2019 - Vital signs & Physical examination done - Complete Geriatric Assessment

January 25, 2019 - Collection of blood and urine sample - The following tests were done: CBC, FBS,
Total cholesterol, Creatinine, Blood uric acid, Urinalysis

January 30, 2019 - Feedback on laboratory results


- Mini Nutritional Assessment done
- Education of caregiver on the diet of the patient
PROBLEM LIST

A. BIOMEDICAL

S O A P

#1 Hypercholesterolemia (-) chest pain BP 110/80 mmHg T/C Dyslipidemia Diet rich in fruits,
(-) headache HR 75 bpm vegetables & whole grains,
(-) dizziness RR 20 cpm poultry, nuts & beans. Low
T 36.6’C fat dairy foods
O2 97% Limit intake of sugar –
sweetened foods &
(+) Elevated total beverages
cholesterol - 5.59mmol/L For total lipid profile
(215mg/dL)
#2 Asymptomatic No subjective complaints (-) joint tenderness Asymptomatic Low purine diet
Hyperuricemia Hyperuricemia - Avoid vegetables such as
(-) redness over joints (+) Elevated blood uric acid cauliflower, mushroom,
(-) swelling of joints - 456umol/L (7.6mg/dL) spinach
(-) joint pain - Avoid sardines, patis,
dilis, bagoong
Avoidance of heavy meals
and excessive intake of
meat and seafood
Increase oral fluid intake
(atleast 8 glasses of water
per day)
167
#3 Anemia (+) weakness (+) fatigue Pale palpebral conjunctiva Anemia secondary to Iron For PBS w/ reticulocyte
Deficiency count
Hgb 102 G/L Resume Ferrous sulphate
Hct 0.33 vol% + Folic acid
supplementation, 1 tab
once a day

#4 Hypertension Stage II (+) fatigue BP 110/80 HTN St II – controlled Diet rich in fruits,
(-) chest pain vegetables & whole grains,
(-) difficulty of breathing poultry, nuts & beans. Low
(-) headache fat dairy foods
Limit intake of sugar –
sweetened foods &
beverages. (Salt restriction
of <6g NaCl /day)
Attain and maintain BMI
<25kg/m2
Close follow-up

#5 DM type II (+) increase in appetite FBS 4.69mmol/L DM Type II – diet controlled Limit intake of sugar –
(+) polyuria (84.42mg/dL) sweetened foods &
beverages. (Salt restriction
of <6g NaCl /day)
For Hemoglobin A1C
Attain and maintain BMI
<25kg/m2
Close follow-up
#6 Moderate cognitive (+) forgetfulness MMSE score of 17 T/C dementia Advise follow-up w/
impairment (+) repeats questions neurology service every 6
several times months to 1 year
(+) restricted vocabulary Advised games like
crossword puzzle or Sudoku
to improve memory
Family supervision &
assistance of activities of
daily living

#7 Malnourished (+) fatigue Cachectic T/C Malnutrition Decrease intake of juices


(+) loss of muscle mass (+) thin, dry, pale skin secondary to inadequate Increase caloric intake
Calf circumference less caloric intake Attain and maintain BMI
than 31 <25kg/m2
Malnutrition indicator score Refer to nutritionist for
of 14 nutrition counseling

#8 Left Hemiplegia (+) inability to move, left (+) muscle atrophy, left S/P CVD bleed (2016) Daily rehab exercises
upper & lower extremities lower extremity - Passive range of motion
(+) weakness, left upper & (+) contracture, left lower exercises such as inner arm
lower extremities extremity stretch, wrist stretch, straight
push movement, circle
movement
- Passive exercises like hip
flexion with hold
5 – 10mins daily of mental
practice (motor imagery)
Ulcer prohylaxis – bed
turning every 2 hours
B. PSYCHOSOCIAL

S O A P
#1 Depression (+) depressed mood GDS score of 13/15 Post-Stroke Depression Supportive
(+) diminished interest / psychotherapy
pleasure in activities
(+) increase in appetite Regular home visits
nearly everyday
(+) feelings of Encourage to leave the
worthlessness house in an assisted
device (wheelchair) at
least once a month
WELLNESS PLAN
1. Can have rice, meat, milk, fruits. Salt restriction of <6g NaCl /day
2. To achieve LDL-C of at least < 130mg/dL
3. Maintain BP at < 130 / 90
4. Advise prostate examination to include a digital rectal exam and/or a PSA if
necessary.
5. Screen for cancer: annual colonoscopy
6. Get vaccinated – Herpes Zoster Vaccine, Pneumococcal Conjugated Vaccine
and Influenza (annually)
9. Advise follow-up w/ neurology service every 6 months to 1 year
10. Advise consistency to rehab exercises daily
11. Regular home visits
12. Close follow-up
COMPLETE BLOOD COUNT (January 25, 2019)

PARAMETER RESULT REFERENCE RANGE

RBC 4.97 4.7 – 6.1 (X10^12/L)

Hemoglobin 102 140 - 180 (G/L)

Hematocrit 0.33 0.40 - 0.54 (VOL %)

Platelet Count 179 150 - 450 (X10^9/L)

WBC 7.1 5.0 - 10.0 (X10^9/L)

Neutrophil 0.41 0.50 - 0.70

Lymphocytes 0.51 0.2 - 0.5

Eosinophils 0.06 0.0 - 0.06

Monocytes 0.00 0.02 - 0.09

Basophils 0.02 0.0 - 0.02


CLINICAL CHEMISTRY (January 25, 2019)
PARAMETER RESULT REFERENCE
RANGE
FBS 4.69 3.89 - 5.50 (mmol/L)
Total Cholesterol 5.59 0 - 5.17 (mmol/L)
Creatinine 77.20 64 - 104 (umol/L)
Blood Uric Acid 456.00 210 - 420 (umol/L)
URINALYSIS (January 25, 2019) URINALYSIS (January 25, 2019)

Physical Examination Microscopic Examination

WBC: None Bacteria: None


Color: Light Yellow Reaction: 6
RBC: None Mucous Threads:
Transparency: Clear Specific Gravity: 1.013 Rare

Epithelial cells: Occasional Hyaline Cast: None


Chemical Examination

Albumin: Negative Nitrite: Negative

Sugar: Negative Urobilinogen: 2.0mg/dl

Ketones: Negative Bilirubin: Negative


Aguilar, 15/M
• Diagnosis: down Syndrome, VSD Chronic Venous Insufficiency

• Medications:
o None

175
PROBLEM LIST

A. BIOMEDICAL

S O A P

#1 Edema, Pitting, Grade (-) chest pain BP 110/80 mmHg -Chronic Venous Low salt diet.
2, left leg (-) headache HR 65bpm Insufficiency
(-) dizziness RR 16 cpm -use minimal amount of
T 36.7’C salt, patis and other
O2 97% seasonings such as oyster
sauce, barbecue sauce
AS, PPC, (-)TPC (-) NAD (- and liquid seasoning in
) CLAD cooking. An additional
amount of salt or
SCE, CBS seasoning in the table per
se in dining is not allowed.
AP, NRRR (-)MURMURS
-Allowed condiments are
NABS any seasoning that adds
5mg or less sodium per
(+) EDEMA, PITTING, serving
GRADE 2, (+) FEP
-Referral to Pedia Cardio

176
PROBLEM LIST

PSYCHOSOCIAL

Subjective Objective Assessment Plan

Number 1 -patient isnt really able to BP 110/80 mmHg • Encourage increased Verbal communication
verbalize very well his emotions among family members for them to be self aware
rather it is almost always shown HR 65bpm of the emotional needs of other family members.
in actions like he will hug or cry. RR 16 cpm • Get in a routine, to enable the patient to have
T 36.7’C short, easy, attainable goals within each day
for confidence boost.
O2 97% • Encourage daily exercise as the body releases
chemicals that helps make the mind and body
at ease and have a sense of accomplishment
AS, PPC, (-)TPC (-) NAD (-) • For further evaluation.
CLAD

SCE, CBS

AP, NRRR (-)MURMURS

NABS

(+) EDEMA, PITTING, GRADE 2,


(+) FEP
Aguilar,I 50/M
• Diagnosis: DM Type 2

• Medications:
o Metformin 500 mg/tab, twice a day.

178
PROBLEM LIST

A. BIOMEDICAL

S O A P

#1 T2DM (-) polydypsia BP 120/80 mmHg T2DM 1) Diet Modification


(-) polyphagia HR 71bpm -reduce intake of high-
(-) polyuria RR 16 cpm sugar foods.
T 36.76C
O2 97% -sugar, hard candies, jams,
jellies, syrup,honey, ice
AS, PPC, (-)TPC (-) NAD (- cream and sherbets should
) CLAD only be used occasionally.

SCE, CBS 2) Increase Physical


Activity
AP, NRRR (-)MURMURS
2) or diabetic work-up
NABS -FBS, CBC, BUN, Crea
UA, HbA1c
(-) Edema (+) FEP -Start Atorvastatin
40mg/tab, once a day
before bedtime

-Follow-up for the results

179
PROBLEM LIST

A. BIOMEDICAL

S O A P

#2 Obesity Weight gain Wt: 71 kgs Obese Class 1 1) Encourage Diet


Ht: 5 ft modification
BMI: 30.7 -Low carbohydrate
low fat diet with high fiber
intake.

-limit meat and


poultry with visible fat, fried
or cooked with fat, fish
canned in oil, cream,
butter, oil. Mayonnaise &
other salad dressings.

2) Exercise daily at least 30


minutes of brisk walking..

180
PSYCHOSOCIAL
PROBLEM LIST S O A P

1. She is the primary • Caregiver Modified Caregiver Interpretation-Normal Encourage increased Verbal
communication among family
caregiver to the assessment Strain Index (MCSI) members for them to be self
aware of the emotional needs of
index patient survey done other family members.
• Get in a routine, to enable the
Score: 22 patient to have short, easy,
attainable goals within each day
for confidence boost.
Tabayoyong,B 76/F
• Diagnosis:
S/P removal of mass, left arm
HPN Stage 2, uncontrolled
Osteoarthritis
Obesity

• Medications:
o Losartan 100mg/ tab
o Clonidine 75mcg

182
A. BIOMEDICAL

S O A P

#1 HPN Stage 2, uncontrolled (-) dizziness BP 190/110 mmHg HPN Stage 2, uncontrolled Shifted Losartan 100mg to
with BP elevetions of up to (-) headache HR 68 bpm Losartan 100mg+HCTZ 12.5mg
200/110 (-) chest pain/heaviness RR 16 cpm tablet, once a day (AM)
(-) nape pain T 36.5C
UBP: 140/90 (-) blurring of vision O2 97% Amlodipine 5mg/tab, q tablet
(-) nausea & vomiting once a day
AS, PPC, (-)TPC (-) NAD (-)
CLAD Clonidine 75mcg/tab SL if BP is
more than 160/100
SCE, CBS
-Patient is advised to do BP
AP, NRRR (-)MURMURS monitoring with her Digital BP
app for better home monitoring.
NABS
-strongly advised to seek consult
(-) Edema (+) FEP immediately at the ER if with
episodes of sudden dizziness,
nape pain, chest pain or
heaviness and difficulty of
breating

-low salt, low fat diet

-still for 2d Echo,


UA, CBC, BUN, Crea, FBS

183
A. BIOMEDICAL

S O A P

#2 Osteoarthritis (+) Joint pains. BP 190/110 mmHg Osteoarthritis -Paracetamol 500mg/tab


HR 68 bpm every 6 hours for pain
RR 16 cpm
T 36.5C -Diclofenac 50mg/tab BID PS:
O2 97% 5/10

AS, PPC, (-)TPC (-) NAD (-) Glucosamine Sulphate


CLAD 250mg/tab. 2 capsules BID for 4
weeks taken 15mins before
SCE, CBS meals.

AP, NRRR (-)MURMURS

NABS

(-) Edema (+) FEP (-)


inflammation on the joints

184
A. BIOMEDICAL

S O A P

#3 Obesity No subjective complains BP 190/110 mmHg Obese Class 1 Weight Loss


HR 68 bpm
RR 16 cpm Fall Risk Precautions:
T 36.5C 1 Install handle/guide bars in the
O2 97% bathroom. Adivse to use rubber
mats on bathroom flooring
Wt: 77
Ht: 152cms 2 advise use of cane or long
BMI: 33 umbrella as support especially
when walking outside.
AS, PPC, (-)TPC (-) NAD (-)
CLAD 3. Reiterate the importance of
maintaning the area near the
SCE, CBS stairs clear of any toys

AP, NRRR (-)MURMURS Exercises- ideally with


supervision on up to 3 sessions
NABS or until patient can do it on her
own
(-) Edema (+) FEP (-)
inflammation on the joints 1 sitting and standing eercises
to be done initially at least a
week to improve muscle
strenght balance and
coordination
2 Standing exercises also to
improve balance

-For Lipid Profile


185
Tandoc, 33/M
• Index patient is E.T. 33/M, with a diagnosis of CHF
secondary to substance - induced cardiomyopathy,
NYHA Class III; PTB cat. I, Treatment Completed
(January 2019)

186
A. BIOMEDICAL

January, 2019 S O A P
#1 Congestion Difficulty of In mild respiratory CHF secondary to • Diet: Low salt, low fat
distress with the ff VS: substance - induced diet.
breathing • Limit oral fluid intake
B/P: 100/60 T: 36.6C P: cardiomyopathy,
78 bpm to 1L per day.
R: 26 cpm O2:80% NYHA Class III; • Diagnostics:
PTB cat. I, Treatment For repeat chest X-
• (+)crackles, both Completed (January ray, sputum AFB
mid to base area 2019) For retrieval of 2D
• Globular abdomen, echo, Chest CT scan
NABS, dull on results
percussion, • Maintain on O2 support
nontender especially at night at
• (+) Bipedal edema, bedtime via NS at 2-3
grade II LPM
• Avoid strenuous
activities.
• Continue current
medications
• For IM-Cardio follow-up
as OPD basis.
• For TB-DOTS follow-up
as OPD basis.
Chest Radiograph
Done last January 23, 2019

Result:
● Bilateral PTB with bronchiectatic changes in the
right upper lobe
● Cardiomegaly
● Bilateral pleurodiaphragmatic adhesions
A. BIOMEDICAL

February, 2019 S O A P

Difficulty of In mild respiratory CHF secondary to • Diet: Low salt, low fat
distress with the ff VS: substance - induced diet.
breathing • Limit oral fluid intake
B/P: 100/60 T: 36.6C P: cardiomyopathy,
78 bpm to 1L per day.
R: 26 cpm O2:80% NYHA Class III; • Diagnostics:
PTB cat. I, Treatment For repeat chest X-
• (+)crackles, both Completed (January ray, sputum AFB
mid to base area 2019)
• Globular abdomen, • Maintain on O2 support
NABS, dull on especially at night at
percussion, bedtime via NS at 2-3
nontender LPM
• (+) Bipedal edema, • Avoid strenuous
grade II activities.
• Continue current
medications
• For IM-Cardio follow-up
as OPD basis.
• For TB-DOTS follow-up
as OPD basis.
THANK YOU!