IDENTIFYING DATA

• XY
• 38 years old
• Male
• Separated
• Account Executive of Henry’s Restaurant and Catering Services
• Filipino
• Christian
• Born on May 21, 1977 in Quezon Province
• Presently residing at San Jose,Rodriguez Bulacan
• Admitted for first time in FEU-NRMF Medical Center
• Admitted on April 12, 2016
CHIEF COMPLAINT
Coughing with blood
 HISTORY OF PRESENT ILLNESS
15 mins prior to admission
• Patient experienced coughing out of fresh blood while driving approximately ½
teaspoon in amount
• Not associated with difficulty of breathing, chest pain, back pain, fever, sore throat,
sore throat and cough and colds
• No medication taken
• Patient immediately rushed to the Emergency Department
• Admitted
PAST MEDICAL HISTORY
• Hypertensive for 2 years uncontrolled
• No maintenance drug
2011- Had right nasal polypectomy

• History of childhood disease such as measles, mumps, chickenpox

• No allergies to food, dust or drugs
• Denies history of asthma, PTB, cancer, liver diseases, kidney diseases,
thyroid disease
• No previous history of cerebrovascular accident or myocardial infarction
• No history of previous accidents, and blood transfusions
FAMILY HISTORY
• Father: deceased, 74 years old, unrecalled cause of death
• Mother: Deceased, 63 years old, heart attack
• Patient is the 4th among 7 siblings:
• 1st sibling, Deceased, Stroke
• 2nd sibling, Hypertension
• 3rd sibling, Hypertension
• 5th sibling, hypertension
• 6th sibling, hypertension
• 7th sibling, apparently well
• Patient has 4 children, all apparently well
• Family history of stroke, heart attack, and leukemia on maternal side
• Denies any heredofamilial history of asthma, lung, liver, kidney and thyroid diseases
PERSONAL AND SOCIAL HISTORY
• Patient is a college graduate (Bachelor of Science in Commerce)
• Bank employee
• Married for 41 years with her husband, who is a 40 year old former OFW
• Lives with her spouse, her 2 children in a well-lit, well-ventilated 2 storey
concrete house
• Non smoker
• Non alcoholic
• No preference in food, consumes 3 cup of coffee every other day, drinks 8
glasses of water per day
REVIEW OF SYSTEMS
• Constitutional: (-) weight loss or gain, (-) dizziness, (-) loss of consciousness
• HEENT: (-) diplopia, (+) use of reading glasses (-)anosmia, (-) epistaxis, (-) nasal obstruction, (-)
ear pain, (-) ear discharges, (-) tinnitus, (-) deafness (-) sore throat, (-) hoarseness of voice, (-)
gum bleeding (-) neck pain on movement
• Skin: (-) diaphoresis, (-) rashes, (-) cyanosis
• Respiratory: (-) DOB, (-) pleuritic chest pain, (-) cough, (-) hemoptysis, (-) wheezes
• Cardiovascular: (-) palpitations, (-) substernal pain, (-) syncope, (-) orthopnea,
• GIT: (-) diarrhea, (-) constipation, (-) regurgitation (-) dysphagia,
• GUT: (-) nocturia, (-) incontinence
• Nervous: (-) vertigo, (-) amnesia, (-) confusion
• Extremities: (-) deformities
• Hematologic: (-) bleeding tendencies, (-) easy bruising
• Endocrine: (-) intolerance to heat/cold, (-) polyuria, (-) polydipsia, (-) polyphagia
PHYSICAL EXAMINATION
General Survey: Patient is conscious, coherent, oriented to time, place and
person, cooperative, well groomed, with no signs of distress, with the
following vital signs:

BP= 140/80 mmHg CR= 96 bpm RR= 20 cpm T= 36.8 ̊C

PHYSICAL EXAMINATION
• Skin: Skin is brown, moist, with normal mobility and turgor.
No lesions. No hypo and hyperpigmentation. Hair is black,
fine, scanty and evenly distributed. Nails are pink, smooth
with normal folds.
• Head: Normocephalic, without deformities and swelling, no
tenderness, no masses, no lesions. Has short, thin black hair,
evenly distributed, no dandruff and no lesions on the scalp.
Temporal arteries are not visible but palpable with strong equal
pulsations. Face is round, symmetrical, no masses, normal
facie, no lesions and no involuntary movements.
PHYSICAL EXAMINATION
Eyes: Eyebrows are black, fairly abundant, normally distributed and smooth in
texture. No lid edema, ptosis and tremors; negative lidlag. Palpebral fissures are
symmetrical measuring 2cm. Eyelashes are thin, with normal outward growth,
without matting. Eyeballs are normally set. Palpebral conjunctivae are pink,
without lesions. Sclera is white without lesions. Lens are transparent without
lesions. Corneas are transparent without lesions. Iris is black with normal contour.
Pupils are equal in size and shape, symmetrical, positive for direct and indirect
pupillary light reflexes and accommodation. Lens are transparent.
Ears: External ears are symmetrical, without deformities, lesions and tenderness.
No mastoid tenderness. External canal is patent, without discharge and lesions;
tympanic membrane is pearly white with positive cone of light.
PHYSICAL EXAMINATION
Nose and Paranasal Sinuses: Nose is symmetrical, no tenderness. Nasal
septum has pink mucosa, without lesions; located at the midline without
perforations. Nasal cavity is patent with pink mucosa, no discharges and
normal turbinates. Frontal and maxillary sinuses are positive for
transillumination test and no tenderness upon palpation.

Mouth and Pharynx: Lips are pink,moist, symmetrical, without lesions, no

deformities. Buccal Mucosa is pink, no lesions and gingivae are pink
smooth, moist without lesions. Tongue is pink, with rough surface, moist,
symmetrical, no lesions, no tremors. Hard and soft palate are pink, no
deformities lesions nor masses. Uvula at midline, tonsils are not enlarged,
pharynx is pink no lesions and no exudates.
PHYSICAL EXAMINATION
• Neck: Neck normal in size, symmetrical, with well-developed muscles.
No tenderness with full range of motion. Trachea in midline no
palpable lymph nodes. Thyroid is not visible nor palpable.

• Thorax and Lungs: Skin is fair, no lesions, no visible dilated blood

vessel. Chest is symmetrical, normal muscle development, no
deformity, with no effort in breathing, inspiration longer than
expiration. No tenderness nor palpable masses. No abnormal rhythm.
Symmetrical chest expansion on lateral, anterior and posterior, no
lagging, equal tactile fremitus. Vesicular breath sounds. (-)
Bronchopony, (-) egophony, (-) whispered pectoriloquy.
PHYSICAL EXAMINATION
• Heart: Precordium is not bulging, apex beat is located at 5th ICS, LMCL. No thrills, heaves.
Adynamic precordium. S1 louder on the apex and S2 louder on the base, no S3, no S4, no
murmurs. Carotid arteries have equal strong pulsations. Jugular veins are not distended.

• Abdomen: Flabby, symmetrical, fair, no lesions, no localized bulging and swelling, no

superficial blood vessel, no visible peristalsis and pulsation.4cm horizontal linear surgical
scar on the right upper quadrant. Normoactive bowel sounds. No bruit heard on the
epigastric area and periumbilical areas. Abdomen is tympanitic all over. Negative for
fluid wave and shifting dullness. Liver span measured at 7cm. The abdomen is soft upon
light palpation, no superficial masses and tenderness. On deep palpation, there are no
masses palpated, liver edges are not palpable, spleen and kidneys are not palpable.
 PHYSICAL EXAMINATION
• Extremities : Mixture of multiple erythematous fluid filled (bullae and
vesicles) with the largest measuring 3.5 x 6 x 2.5 cm on the antero-
lateral right foot and right posterior leg with hyperpigmentation and
crusting.
• Full and equal pulses, no cyanosis, no edema, CRT <2sec.
PHYSICAL EXAMINATION
Neurologic Examination:

GCS 15: (E4V5M6)

Cerebrum: Patient is conscious, coherent, cooperative, well groomed,

no mannerism, oriented to time place and person, intact immediate,
recent and remote memory, can follow commands, can do calculation,
can do abstract thinking, no emotional lability
PHYSICAL EXAMINATION
Cranial Nerves:
• CN I: can identify the smell of coffee, both nostrils
• CN II: 20/20 J1+ on Jaeger chart, (+) ROR, no visual field defects, pupils are 2-3mm equally reactive to
light with accommodation
• CN II & III: both pupils constrict briskly reactive to both direct and indirect light
• CN III, IV, VI: Adduction of both eyes and constriction of both pupils on accommodation test. Equal and
complete opening of both eyes. Can move eyes in 6 cardinal directions
• CN V: can feel light touch and pain stimulus on both sides of the face, (+) corneal blink reflex, can clench
teeth, protrude jaw and move side to side, (-) jaw jerk
• CN VII: can identify taste of sugar and salt solution on both sides of tongue, can frown, raise eyebrows,
close both eyes shut
• CN VIII: intact gross hearing, no lateralization on Weber test, no nystagmus
• CN IX, X: no dysphonia, uvula at the midline, (+) gag reflex
• CN XI: can turn head from side to side against resistance, can elevate both shoulders against resistance
• CN XII: no atrophy nor fasciculation, no tremor, no tongue deviation, moves tongue from side to side
PHYSICAL EXAMINATION
Cerebellum: can do finger to nose test, heel to shin test. Negative
Romberg test.

Motor: No atrophy nor fasciculation, good muscle tone, no involuntary

movements, muscle strength 5/5 in both upper and lower extremities.

Sensory: can feel light touch and pain equally, can sense position and
vibration equally, able to differentiate warm and cold temperature
equally.
PHYSICAL EXAMINATION
Reflexes:
1. Superficial reflexes: abdominal reflexes: present
2. Deep Tendon Reflex: ++ biceps, ++ triceps, ++ brachioradialis,
++ patellar, ++ ankle
3. Pathologic reflexes: Negative for Babinski

Signs of meningeal irritation: no nuchal rigidity, (-) Brudzinki sign,

(-)Kernig sign
Salient Features:
• XX
• 65 years old
• Female
• Diabetic, S/P open cholecystectomy 2014
• Non smoker and Non alcoholic beverage drinker
• Chief complain: Increase number and size of skin lesion at right leg.
• Multiple erythematous small elevated fluid filled lesions, non tender, non pruritic.
• Physical examination:Mixture of multiple erythematous fluid filled (bullae and
vesicles) with the largest measuring 3.5 x 6 x 2.5 cm on the antero-lateral right foot
and right posterior leg with hyperpigmentation and crusting.
Assessment:
Infected Bullae, Right leg
Plan:
• Diet: Diabetic Diet
• IVF: PNSS x 100cc/hr
• Laboratories: CBC, Na, K, Creatinine.
• Therapeutics:
• Ampicillin Sulbactam 1.5mg now then 750 mg Q8 ANST ( )
• Metformin 500mg/tab 1 tab BID
• Linagliptin 5mg 1 tab OD
• Rosuvastatin 10mg/tab ODHS
• Refer to Dermatologist