MARTIN FEDERIC M.

PALCO
Medicine II PRECEPTORIAL
Dr. Lois Sortigosa

This is the case of Mr EP, newly admitted for epigastric pain, 69, Male,
Filipino, Roman Catholic, Single of Passi City, Iloilo.

HISTORY OF PRESENT ILLNESS
7 months prior to admission, patient experienced pain located at
epigastric area radiating to the chest area; with gradual onset, rated as 8 in
a 0-10 numeric pain scale; intermittent; aggravated by swallowing and is
relieved by intake of water. No medical consultation made as claimed.
Symptoms persisted.
6 months prior to admission, patient decided to undergo medical
consultation with Dr Villalobos because of the persistence of symptoms and
claimed that the pain is now unrelieved even with intake of water. Patient
was then advised to undergo a series of laboratory examination and
ultrasound of the abdomen with no significant findings noted. He was then
advised to take unrecalled medications with no relief.
Same discomfort persisted with the intensity of pain gradually
increasing, still aggravated with food intake but is not alleviated by any
measure. There has also been a change in the sleeping pattern because of
the discomfort as claimed, with patient have difficulty to sleep.
One month prior to admission, persistence of the same symptom
associated with difficulty in swallowing, loss of appetite and gradual loss of
weight prompted patient to undergo medical consultation with a
Gastroenterologist. He was advised to undergo CT Scan of the abdomen,
urinalysis and Fasting Blood Sugar, with no significant findings noted. He
was then advised to undergo endoscopy. Endoscopic examination revealed a
tumor in the esophageal area extending to the cardia with sporadic
appearance in the stomach up to the antral-pyloric area. He was thus
advised to undergo chemotherapy session. PEG was also performed to
promote nutrition.
Same symptom persisted up to the day of admission.



PAST MEDICAL HISTORY
No incidence of childhood illness as claimed. No immunization as
recalled. Currently on maintenance medication, Norvasc (Amlodipine) 10
mg/tab for Hypertension started on December, 2014. Diagnosed with
Pulmonary Tuberculosis on April 2014 and currently undergoes multidrug
directly observed treatment shortcourse (Rifamipicin and Isoniazid) for the
said illness. Does not take any herbal supplement as claimed. Diet include
meat and pork at least thrice a week. Patient has 100 pack years history of
smoking and is also a chronic drinker of Pale Pilsen everyday. Ended
smoking and alcohol intake when symptoms in the history started. On
osterized tube feeding via PEG every 4 hours started on June 21, 2014.
Considers walking as his form of exercise. Walks approximately 3-4 hours
per day prior to admission.
FAMILY HISTORY
Mother and Father died at the age of 85 and 90 years old respectively.
Elder brother, EP died of unrecalled cause. Patient is the second among
siblings. RP, his younger brother died at the age of 63 of cancer in colon on
March 22, 2014. DP, the 4
th
among the siblings is generally healthy as
claimed. Aged 61, is also a chronic smoker of unknown pack years. MP and
PP the 5
th
and 6
th
among them respectively are generally health at the age
of 56 and 52. RP, the 7
th
among the siblings died at the age of 18 after been
fallen at the coconut tree. AP, the 8
th
among the siblings is described as
generally healthy at the age of 44.

PSYCHOSOCIAL HISTORY

Patient is single, an Automotive graduate; works as a farmer in their
owned sugar cane and farm; claims, nail maubos na akon kwarta sa pagpa-
ayo ko di sa akon sakit. is self-supported financially.


SEXUAL AND REPRODUCTIVE
Inactive sexual lifestyle as claimed.

REVIEW OF SYSTEMS

General: (-) fever, (+) weight loss
Skin: (-) skin itchiness
Head: no significant findings
Eyes: use of reading glass
Ears: no significant findings
Nose: No significant findings
Throat: (+) cough to a yellowish, purulent sputum (+) difficulty of
swallowing
Chest, heart and Lungs: No significant findings
Abdomen: Urinary frequency
Extremities: Ambulatory, good posture and gait




PHYSICAL ASSESSMENT

General Survey: Received this client, male, accompanied by significant
others, in sidelying position, asleep, not in cardio-respiratory distress. With
IVF attached at left arm, patent and infusing well.
Vital signs: Height of 167.6 cm and Weight of 51 kg; With temperature of
37.7 degrees Celsius per left axilla, afebrile; Blood pressure of 90/60 mmHg
per right leg; Respiratory rate of 26/ min, unlabored, with no use of
accessory muscles in breathing; cardiac rate of 86/min at apical area,
regular in rate and rhythm and is synchronous with the pulse.
Skin: good skin turgor; no lesions noted; brown complex; no scars noted
Head: not palpable lymph nodes; no deformities
Eyes: use of reading glasses; good visual acuity; Pupils equally round and
reactive to light and accommodation
Ears: good hearing acuity; good ear recoil;
Neck: cervical lymph nodes not palpable; trachea is at midline
Posterior Thorax and lungs: decreased breath sounds heard on left lower
lung lobe
Anterior thorax: good vocal fremitus
Cardiovascular system: normal heart sound
Lower extremities: good gait and posture
Nervous System: coherent, no slurring of speech, oriented to time, place
and person; no neurological deficits noted