cineMedicinecineMedicineci

neMedicinecineMedicinecin
eMedicinecineMedicinecine
MedicinecineMedicinecineM
edicinecineMedicinecineMe
dicinecineMedicinecineMedi
cinecineMedicinecineMedici
necineMedicinecineMedicin
ecineMedicinecineMedicine
cineMedicinecineMedicineci
neMedicinecineMedicinecin
eMedicinecineMedicinecine
MedicinecineMedicinecineM
edicinecineMedicinecineMe
dicinecineMedicinecineMedi
cinecineMedicinecineMedici
necineMedicinecineMedicin
MEDICINE - I
History Taking & Physical
Examination
September !" #$!
%&&IET%" &'stan C(
)*ENTES" Da+ne C(
,E&EN%" -atrina ,(
,." -yle Dominic -(
*MI/" Caress Domini0'e %(
Date and time of interview: September !" #$! at #1 pm
Source of referral1 None
Source of history1 Patient an2 common la3 3i+e
Reliability1 $4
Identifying data1 Mr( Ernesto %biertas" !5 years ol2" male" common la3" &oman
Catholic" 'nemploye2" c'rrently resi2ing along Calanipa3an &oa2 Tacloban City "
3as a2mitte2 +or the 6rst time in Eastern 7isayas &egional Me2ical Center 8E7&MC9
at aro'n2 $1 am on %'g'st #:" #$!(
Chief complaint1 Heart enlargement" e2ema o+ the arms an2 legs(
History of present illness1
; months PT%" patient notice2 2epen2ent" non-pitting" painless s3elling on
both +eet 'pon rising in the morning( It 3as not relie<e2 by raising the +eet +or more
than 5 2egrees angle an2 e<en a+ter taking prescribe2 me2ications( Patient can
'rinate ! to ; times per 2ay o+ $"; ml yello3ish 'rine( .ral intake 3as not
restricte2 3ith a minim'm o+ = to $ glasses per 2ay( Prescribe2 maintenance
me2ications o+ /asix an2 %l2actone 3ere taken b't not religio'sly an2 e2ema 2i2
not s'bsi2e( Patient sleeps 3ith ; pillo3s at night( Patient also experience2
intermittent >galloping? palpitations an2 prescribe2 me2ications o+ Neobloc $;mg
P." %spilet an2 Cor2arone 3ere taken as maintenance b't still the palpitations
persiste2( .rthopnea an2 Dyspnea +or more than t3enty steps 3as note2( There
3as also rec'rring pro2'cti<e co'gh an2 col2s 3ith $-# ml o+ 3hitish expectorate(
No me2ications 3ere taken +or co'gh( % noticeable 2ecrease in m'scle mass 3as
also note2" 3hich starte2 gra2'ally since .ctober #=( No +e<er an2 no chest
pains" no cons'ltation 2one(
! months PT%" progressi<e" ascen2ing" pitting e2ema 'p to the thigh area"
an2 a moist" re22ish in appearance" tolerable pain+'l s3elling in the scrot'm 3as
also note2( The sai2 con2ition prompte2 him to stop 3orking( Symptoms o+
2yspnea" orthopnea" palpitations" co'gh an2 col2s 3ere still present 3ith the same
characteristics 3ith the prescribe2 me2ications still taken( No cons'lt 2one(
# months PT%" persistence o+ abo<e symptoms no3 3ith progressi<e pitting
e2ema note2 'p to the ab2omen" an2 both arms( Dyspnea at rest no3 note2(
Patient can no longer 3alk 3itho't assistance( Prescribe2 me2ications 3ere still
taken b't not religio'sly( )re0'ency an2 <ol'me o+ 'rination also noticeably
2iminishe2" aro'n2 +o'r times per 2ay 3ith an acc'm'late2 <ol'me o+ @;ml per
2ay( No cons'lt 2one(
$ month PT%" patient 3as con6ne2 to be2 2'e to se<erity o+ symptoms an2
easy +atigability( %bo<e symptoms o+ 'pper an2 lo3er extremities s3elling" scrotal
an2 ab2ominal s3elling" 2yspnea at rest" orthopnea" palpitations" co'gh an2 col2s"
3ith the same characteristics still persiste2( Prescribe2 me2ications still taken b't
still no relie+ on the abo<e symptoms( *rine o'tp't signi6cantly 2ecrease2 to
aro'n2 $ml per 2ay" 3ith a +re0'ency o+ 'p to three times only(
% 2ay prior to a2mission the patient cannot 'rinate anymore( The symptoms
o+ 'pper an2 lo3er extremities s3elling" scrotal an2 ab2ominal s3elling" an2
2yspnea at rest" orthopnea" palpitations" an2 scrotal pain noticeably aggra<ate2(
)e3 ho'rs PT%" persistence o+ 'pper an2 lo3er extremities s3elling" scrotal
an2 ab2ominal s3elling" an2 2yspnea at rest" orthopnea" palpitations" an2 scrotal
pain persiste2 an2 still no 'rine o'tp't( Patient 6nally 2eci2e2 to seek cons'lt in
E7&MC on %'g'st #:" #$!" hence a2mission(
Past Medical History:
Childhood illness: Has one episo2e o+ asthma attack as a chil2( No measles" no
r'bella" no m'mps" no 3hooping co'gh" no chicken pox" no rhe'matic +e<er(
.ccasional co'gh an2 col2s 3ere treate2 3ith herbal me2ication an2 .TCs(
dult illness:
Medical1 Hypertensi<e since #=" 3ith heart 2isease" mil2 stroke last .ctober
#=" No DM" No TA" No" Pne'monia" No C.PD" No" -i2ney 2isease" No cancer or
any malignant illness(
Past Hospitali!ation:
B%2mitte2 in C'eDon City ,eneral Hospital last .ctober #= 2'e to mil2
stroke an2 3as conc'rrently 2iagnose2 3ith enlargement o+ the heart( Prescribe2
me2ications o+ Hypace ;mg 8Enalapril Maleate9" Esentiale" Moriamen
8m'lti<itamins9" /osartan Potassi'm" Neobloc $;mg 8Metoprolol9 an2 %spilet 3ere
gi<en(
BCheck 'p in C'eDon City ,eneral Hospital 2'e to e2ema o+ the lo3er
extremities last )ebr'ary #E( Prescribe2 me2ications gi<en are /asix 8+'rosemi2e9
an2 %l2actone 8Spinorolactaone9(
BCheck 'p on March #$5 +or e2ema on lo3er extremities" same me2ications
contin'e2(
B /ast check-'p on .ctober #$5 +or e2ema o+ lo3er extremities an2 scrotal
area" same me2ications contin'e2 pl's Cor2aron 8amio2arone9 3ith Sylimarin an2
7it( A complex s'pplement(
Surgical: Di2nFt ha<e any s'rgical operations yet(
Psychiatric: Gith History o+ 2epression last .ctober #= 2'e to 3ork relate2
stress( No cons'lt on 2epression con2'cte2(
Health maintenance:
Imm'niDations1 *nrecalle2 chil2hoo2 imm'niDations
Screening Tests1 #D Echo an2 H-&ay last .ctober #=" 6n2ings o+ enlarge2
heart(
"ife Style Issues:
%llergies1 None
Smoking1 .ccasional smoker" starting high school" 's'ally 2'ring 2rinking
sessions(
%lcohol1 .ccasional 2rinker" can cons'me 5 to ; glasses o+ alcoholic
be<erages per session
Dr'g *se1 Gith history o+ 2r'g 'se +or both MariI'ana an2 Shab'
8metamphetamine9 +or the year $EE@ to #5(
#amily History:
)ather1 Die2 at ;: years ol2 2'e to Hypertension
Mother1 Still ali<e b't hypertensi<e
,ran2parents1 2ie2 o+ ol2 age
)o'r Siblings1 )irst sibling 2iagnose2 3ith J'i2 in the l'ngs" others siblings
apparently 3ell an2 all li<ing abroa2(
Personal and Social History:
Patient 3as born an2 raise2 in Calanipa3an" Tacloban City( He li<es 3ith his
common la3 3i+e an2 they ha<e # chil2ren" : an2 # years ol2( He only reache2 $
st

year college( He ha2 many 2iKerent Iobs be+ore( He 3orke2 in Coca Cola as a
pro2'ction staK in the year $EE@ +or : months only" 3here he 2rank coke anytime
he 3ante2( He also 3orke2 as a sec'rity g'ar2 in &ock3ell Mall( It 3as 2'ring this
time that he starte2 'sing 2r'gs e<ery 2ay" be+ore an2 a+ter 3ork" s'ch as
mariI'ana an2 shab'( He stoppe2 'sing 2r'gs in the year #5(
He 'se2 to play basketball in his yo'nger years( He also 'se2 to 3ork as a
liaison oLcer in a constr'ction site( It 3as 2'ring this time that he experience2
2epression 3hen his boss acc'se2 him o+ losing the companyFs check( He also
experience2 mil2 stroke on = years ago 2'e to 3ork-relate2 stress(
He 'se2 to sleep at aro'n2 =pm an2 3akes 'p at ; am( &ecently" 2'e to his
con2ition" he ha2 2iLc'lty sleeping( He 3o'l2 'se ; pillo3s at night to be able to
sleep com+ortably( He 3o'l2 also position himsel+ in a si2e lying position to a<oi2
2yspnea( He 3o'l2 sometimes 3ake 'p at night a+ter $-# ho'rs a+ter retiring 2'e to
a s'22en +eeling o+ 2iLc'lty in breathing 3hich 3as 2escribe2 as a >2ro3ning?
+eeling(
He 'se2 to take his maintenance me2ications religio'sly" b't 2'e to 6nancial
constraints" he only prioritiDes his antihypertensi<e me2ications( His taking o+
2i'retics 3o'l2 2epen2 on their b'2get an2 3o'l2 sometimes take it only 3hen he
experiences e2ema(
%s o+ no3" he claims that his illness has signi6cantly change2 his li+e( He
canFt per+orm his past acti<ities anymore s'ch as playing basketball or other
acti<ities o+ 2aily li<ing s'ch as carrying hea<y obIects( He can no longer participate
in any social gatherings 2'e to his con2ition(
He is anxio's abo't his illness an2 3o'l2 sometimes be 2escribe2 as
>irritable? by his 3i+e( He is not a religio's person b't he is a &oman Catholic( %s o+
no3" his only s'pport system is his +amily(
Review of systems:
$eneral survey: Progressi<e 3eight loss o+ greater than ;4 since #= 'p to the
present(
S%in:
Hair1 No hair loss
Skin1 3ith skin 2ryness" no rashes" no l'mps" no itchiness" no sores(
Nails1 changes o+ color(
H&&'(
Hea21 No history o+ hea2 inI'ry" no light hea2e2ness" no hea2ache" no +e<er(
Eyes1 Al'rre2 <ision" no eye glasses 3orn" no contact lens" no eye pain" no
excessi<e tearing" no pre<io's eye exam" no specs" no spots" an2 no Jashing lights(
Ears1 .ccasional Tinnit's" No hearing problems" no <ertigo" no pain" no
in+ection" no 2ischarges" no 'se o+ hearing ai2s
Nose an2 sin'ses1 recent col2s last a'g'st 3ith 3hite 2ischarge" no nasal
st'Lness" no noseblee2s" an2 no sin's tro'ble
Throat or mo'th or pharynx1 no blee2ing g'ms" no 2ent'res" no sore tong'e"
no 2ry mo'th" no +re0'ent sore throats" an2 no hoarseness(
'ec%: no s3ollen glan2s" no l'mps" no pain" no stiKness
)reasts: no l'mps" no pain" no 2iscom+orts" no nipple 2ischarges
Respiratory: recent co'gh on %'g'st
Cardiovascular: hypertensi<e" 2yspnea at rest" easy +atigability" orthopnea" ha2
#D echo on #= 3ith 6n2ings o+ enlarge2 heart" 3ith occasional palpitations" 3ith
s'22en +eeling o+ 2iLc'lty breathing $ to # ho'rs a+ter retiring
$astrointestinal: s3elling o+ the ab2omen last %'g'st" no excessi<e belching b't
3ith pain 'pon belching" no 2iLc'lty an2 pain 3ith s3allo3ing" no change in bo3el
habits" reg'lar bo3el mo<ements once per 2ay o+ yello3ish stool" no loss o+
appetite" no na'sea" no <omiting" no 2iarrhea" no constipation" no ab2ominal pain
Peripheral vascular: 2iLc'lty 3alking 2'e to e2ema on both thighs # months PT%"
3ith ten2er s3elling on both 'pper an2 lo3er extremities" no color changes in
6ngertips or toes 2'ring col2 3eather
*rinary: no 'rine o'tp't 2ays PT%" no s'prap'bic pain" no Jank pain
$enital: ten2er s3elling o+ scrot'm 3ith re2ness" no 2ischarges" no history o+
sex'ally transmitte2 in+ections
Musculos%eletal: no m'scle pains" 3ith Ioint pains 2'ring col2 3eather" limitation
o+ motion or acti<ities 2'e to present con2ition" no neck or lo3 back pain
Psychiatric: 3ith history o+ 2epression last #= 3ith no note2 a2mission
'eurologic: irritable 2'e to recent con2ition" problems in long term memory" no
2iDDiness" no hea2ache" no <ertigo" no +ainting" no 2iDDiness" 3o'l2 ten2 to get
2isoriente2 to place" 3o'l2 sometimes experience tingling sensations on 2istal
extremities" no tremors" no seiD'res
Hematologic: no easy br'ising or blee2ing" no history o+ past trans+'sions
&ndocrine: no heat or col2 intolerance" no excessi<e s3eating
PH+SIC" &,MI'(I-':
$eneral Survey:
Mr( %biertas is abo't ;F$$ tall" 3ith 3eight loss o+ more than ;4 starting .ctober
#=" participati<e 3ith slo3 response" poorly groome2" 3ith poor hygiene(
7IT%/ SI,NS1
Aloo2 Press're1 EM@ mm Hg
P'lse Press're1 :# beats per min'te
&espiratory &ate1 $= cycles per min'te
Temperat're1 5;(; 2egrees Celsi's
S%in. Hair. and 'ails
S-IN1 bro3n in colorN 3ith =cm" open" yello3ish" irreg'larly-shape2 3o'n2
locate2 at inner right
lo3er legN smooth an2 6rmN 2ry an2 slightly cool to to'chN goo2 skin
t'rgor
H%I&1 black in colorN e<enly 2istrib'te2N no presence o+ parasitesN o+ a<erage
text'reN resilient
N%I/S1 ro'n2" har2" pink nailbe2N smooth" 6rm" immobile
H&&'(
HE%D1 normocephalic 3ith symmetrical scalp 3itho't lesionsN har2 an2
smooth
)%CE1 3ith # to 5 mm" ele<ate2" bro3nish mole at right 'pper lip 8at
<ermillion bor2er9" an2 at
right chin $ to # mm an2 is non-ele<ate2(
EOES1
Eyelids and lashes: li2 margins moist an2 paleN lashes short" e<enly
space2" an2 c'rle2
slightly o't3ar2N blinking symmetrical an2 <ol'ntary(
Conjunctiva and sclera: icteric scleraN pale b'lbar an2 palpebral
conI'ncti<a(
Pupils: e0'ally ro'n2 an2 reacti<e to light an2 accommo2ation(
Peripheral vision: 'nable to recogniDe lo3er right portion o+ the :
car2inal gaDes
Visual acuity: can see +ar obIects 3ith 2iLc'lty seeing in a 2istance o+
less than a +oot(
E%&S1 e0'al in siDe on both si2esN color same as +aceN 3ith yello3ish
2ischarge insi2e the ear
canalN non ten2er 'pon palpation
N.SE1 color same as +aceN symmetrical appearanceN 2ry 3ith no cr'stingN
sept'm mi2line
smooth consistencyN internal m'cosa moist 3ith no lesionsN no
ten2erness or pain
TH&.%T 8.& M.*TH %ND PH%&ONH91 pale lipsN pale oral m'cosaN pale an2
non-blee2ing g'msN
$! teeth8right 'pper1 $
st
an2 #
n2
molars" $ canine" $ central an2 lateral
incisorsN le+t 'pper1 $ central an2 lateral incisors" $ canine" $ #
n2
molarN right
lo3er1 #
n2
molar" $ canineN le+t lo3er1 $ canine" $ lateral incisor" $ #
n2
molar9N
no tong'e 2e<iation" no inJame2 tonsils" '<'la at mi2line" no lesions an2
inJammations on pharynx(
'&C/: extra skin Jap on the posterior neck abo't $cmN no lesionsN no
massesN lymph no2es not enlarge2N no 'n's'al p'lsationsN s'pple neck"
smooth controlle2 mo<ementsN trachea at mi2lineN thyroi2 isthm's barely
palpableN lobes not +eltN smooth" 6rm an2 non-ten2er thyroi2
'(&RI-R CH&S(: bro3n in colorN symmetrical l'ng expansionN pigeon
chestN <isible intercostal spacesN mi2line stern'mN no gynecomastiaN no pain
an2 ten2erness o<er thoraxN 2ecrease2 tactile +remit'sN resonance on 'pper
an2 mi22le l'ng 6el2s bilateralN 2'llness on lo3er l'ng 6el2s bilateralN
2ecrease2 breath so'n2s on all l'ng 6el2sN coarse crackles on lo3er l'ng
6el2s bilateral
P-S(&RI-R CH&S(: bro3n in colorN symmetrical l'ng expansionN no pain
an2 ten2erness o<er thoraxN 2ecrease2 tactile +remit'sN resonance on 'pper
an2 mi22le l'ng 6el2s bilateralN 2'llness on lo3er l'ng 6el2s bilateralN
2ecrease2 breath so'n2s on all l'ng 6el2sN coarse crackles on lo3er l'ng
6el2s bilateral