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Central Philippine University


COLLEGE OF MEDICINE
School Year:
First Semester

ADULT PATIENT HISTORY & PHYSICAL ASSESSEMENT
by:
Name: Lizlin Noemi C. Bajada
DATE AND TIME OF ASSESSMENT
Date of Interview: July 27, 2014
Time of Interview: 10:30 P.M
I.General Data

Name : TME ( Teresa )
Sex : Female
Age : 20 years old
Birthdate : February 17, 1994
Civil Status : Single
Educational Attainment : 3
rd
year College Level (BS Accountancy)
Nationality : Filipino
Occupation : Student
Height : 5 2
Weight : 45 kg.
Religion : Roman Catholic
Place of Residence : Barosong, Tigbauan, Iloilo
Source of Data : Mother
Reliability : 98% respectively
Date of Admission : July 23, 2014
Room Number : F1

II. CHIEF COMPLAINT: Schedule for Chemotherapy last dose
III. HISTORY OF PRESENT ILLNESS
The patient was diagnosed with non-Hodgkins lymphoma on October 2012. She went to
the hospital together with her mother for compliance of 6 cycle regimen of chemotherapy in
relation to her condition apparently well and without any associated signs and symptoms. The
patient was advised for admission, thus admitted.
IV. PAST MEDICAL HISTORY
Childhood Illnesses: Chickenpox. No Scarlet Fever or Mumps.
Adult Illness:
Surgical


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August to September 2012.
The patient experienced fever, backaches, persistent barking cough, and a growing lump
initially on her left neck. The patient sought consultation and undergone X-ray result presented
mediastinal mass. Dr. Gargalicana and undergone Surgical Biopsy of her Neck Mass. Before the
procedure. Myrin P Forte was prescribed and given with unrecalled dosage and timing as
treatment to consider Tuberculosis (r/t Lymphadenopathy).

October 20, 2012.
The patient had undergone Thoracocentesis. Her Lungs collapsed after the operation and
was transferred to the ICU for further monitoring.

Previous Hospitalizations

October 13-30, 2012.
The patient was admitted at Iloilo Mission Hospital due to Dyspnea and a choking
sensation related to the enlarging neck mass. Admitted for 17 days. Biopsy results came in and
resulted to the diagnosis of Non-Hodgkin Lymphoma Stage III. Lymphatic nodular enlargement
was palpated in her axilla upon physical examination.
The X-ray results revealed with Pneumonia with pleural effusion with approximated 1.6
liters. CT scan results revealed multiple lumps within the entire Lung and metastasis to the
Stomach. The patient was discharge on Oct.30 with improved condition. The patient was advised
for chemotherapy and home medications were given.

November 6, 2012.
The patient was admitted at Iloilo Mission Hospital to begin her course of Chemotherapy.
Her first cycle of chemotherapeutic drugs was given and she was discharged after 1 week
(November 11, 2012).

November 16, 2012.
She developed seizures, mouth ulcers, abdominal pain, and dysphagia after her first
cycle, which made her being admitted in the ICU (1 week). Follow-up chemotherapeutic drug,
Vincristine, which was supposedly given, was deferred due to the condition. On the third day of
admission, the patient experienced Left Hemiparesis.The patient was admitted for 2 weeks and
was discharged thereafter in an improved condition.

December 2012.
The course of chemotherapy was continued for a total of 6 cycles every 21 days and
experienced typical side effects of chemotherapy such as alopecia, nausea, and vomiting.
No other untoward signs and symptoms were noted throughout the entire course. The patients
chemotherapy courses were finished on April 2013.

April 2013.
First courses of chemotherapy was finished.



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March 25, 2014.
The patient was admitted at Iloilo Mission Hospital for a new session for chemotherapy
after the discovery of a new lump on her left neck accompanied with difficulty of swallowing
and dyspnea. Consultation was done prior to admission, where routine laboratories were once
again done and X-Ray and CT Scan revealed another mediastinal mass, but was not as severe as
the previous one.

May 6, 2014.
The patient was admitted at Iloilo Mission Hospital for a cycle of her Chemotherapy and
was closely monitored after the discovery of an increase in her left neck mass. The patient was
also treated with Pneumonia and Pleural Effusion.The patient was maintained on her
chemotherapy and the mass was found out to be decreasing in size, discharging her on May 22,
2014. She was discharge and continued her chemotherapy for 6 cycles every 21 days.
Surgery: none
Obstetric/Gynecological: Menach- 14 y.o
Regular menstrual flow
2 packs of napkin/month

Psychiatric: None
Allergies: none
Immunizations: Complete DOH-recommended
Screening Tests:
V. FAMILY HISTORY
Father is currently well, a retired army, and was diagnosed with Diabetes Mellitus and
Hypertension. Mother is also well, Dept.Ed teacher, diagnosed with Diabetes Mellitus,
Hypertension and positive of Tuberculosis otherwise well. Patient is the 2
nd
child among three
siblings. Her elder sister, 23 y.o, nurse well and healthy. Her younger brother, 18 y.o, well,
studying marine engr.
On the other hand, there were no familial lung disease, liver disease, kidney disease,
seizure disorder, hematologic disorders, and mental disorder on both sides of the family.
VI. PERSONAL AND SOCIAL HISTORY

Patient is a resident of Barosong, Tigbuan, Iloilo a B.S in accountancy student. Rarely
goes out in their home because of her condition. Their house is along the road made of concrete
with 5 rooms and 1 comfort room and utilizes a pour-flush type. Water source for cooking,
bathing, washing, and cleaning is taken from a well. They bought sterilized water for drinking.
Garbage is disposed by burning.

Patient diet are more on fish and vegetables and a cup of rice every meal. She drinks milo
and 4 glasses of water/day. She often take MX3, Usana, Polynerve, Iberet, Amino vita as her
food supplement.

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The patients stays at home most of the time due to her condition. She had limited
activities.Her hobbies are surfing the internet, playing games in the computer and texting. The
patient had a good academic performance. She is religious and usually goes to mass every
Sunday but because of her condition, she rather stays at home. Her sleeping schedule usually 6-7
hours per day. No history of tobacco and alcohol.

VII. REVIEW OF SYSTEMS

General:
(+) weight loss
(+) weakness
(+) fatigue
(-) loss of appetite

Skin:
(-) rashes
(+) lumps
(-) itching
(-) dryness
(-) change in skin color
(-) change in nail color
(+) change in hair /loss
(-) change in size or shape of mole

HEENT

Head:
(+) headache
(+) dizziness
(-) lightheadedness
(-) head injury

Eyes:
(-) pain
(-) redness
(-) excessive tearing
(-) blurred vision


Ears:
(-) hearing loss
(-) vertigo
(+) ear ache
(-) discharges (white)
(+) tinnitus

Nose:
(-) nasal stuffiness
(-) frequent colds
(-) discharges
(-) itching
(-) nasal flaring noted
(-) nosebleed


Throat:
(-) gum bleeding
(-) dentures
(+) sore tongue
(+) dry mouth
(-) hoarseness
(-) frequent sore throat

Neck:
(+) pain
(+) swollen glands
(+) neck stiffness
(+)lumps


Breast:
(-) lumps
(-) pain
(-) nipple discharge

Respiratory:
(+) cough
(+) sputum (whitish)
(+) dyspnea
(-) wheezing

Cardiovascular:
(-) heart murmur
(-) chest pain
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(-) palpitation
(-) edema
(+)shortness of breath with activity

Gastrointestinal:
(+) swallowing difficulty
(-) heartburn
(+) loss of appetite
(+) vomiting
(-) pain during defecation
(-) bleeding
(-) abdominal pain
(-) food intolerance
(-) jaundice

Peripheral vascular:
(-) leg cramps
(-) swelling of leg or foot
(-) redness
(-) tenderness

Urinary:
(-) polyuria
(-) bedwetting
(-) burning sensation during urination
(-) hematuria
(-) suprapubic pain

Genitalia:
(-) lesions
(-) itching
(-) pain
(-) discharges
(-) menarche

Musculoskeletal:
(-) muscle pain
(-) joint pain
(-) stiffness
(+)back pain

Neurologic:
(+) dizziness
(-) loss of consciousness
(+) seizure
(+) sensory loss
(+) weakness(left sided hemiparesis)

Hematologic:
(+) anemia
(-) easy bruising/bleeding





















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PHYSICAL EXAMINATION

GENERAL SURVEY:

The patient is sitting in bed awake, alert, and well groomed and respond cooperatively. Not
in cardiopulmonary distress, slender, appears according to stated age. Ill looking and wearing
facial mask. Makes eye contact and responsive to questions asked.Conscious, coherent, and not
in cardiopulmonary distress. NSS 1 liter left cephalic


VITAL SIGNS:

Temperature: 36.4 C
Pulse Rate: 98 beats/min
Respiratory Rate: 18 breaths/min
Blood Pressure: 110/70 mmHg

SKIN:
The patient skin is light brown in color. No hypo or hyper pigmented areas. Without swelling,
redness, bruise, cyanosis or pallor. No lesions noted. Normal skin turgor. Warm to touch. Hair is
smooth and evenly distributed. Nails pinkish in color and slightly curved. Capillary refill < 2
seconds. No clubbing of nails.

HEENT:

A. HEAD: Hair is black unevenly distributed hair loss noted. Normocephalic and bilaterally
symmetrical. Scalp is moist and without lesions. No nodules, masses, depressions, or
tenderness noted upon palpation of the scalp and face. No edema or lesions.

B. EYES: Able to see surroundings and moving fingers. Intact Direct and Consensual
Pupillary Reflex. Able to determine color. Eyebrows elevate and lower together at the
same time. Eyelids are symmetrical, closing and meeting freely and together. No
excessive blinking, lesions, and edema. No swelling or lumps on the Lacrimal Gland and
Lacrimal Sac. Conjunctiva is pale and Sclera is Anicteric. No discharges. No opacities in
the Cornea and Lens. Pupils Equally Round and Reactive to Light and Accommodation.
Eye moves in conjugate fashion (CN III, CN IV, CN VI intact). Good blinking reflex
(CN VII intact)

C. EARS: External Ears are symmetrical, normal in shape, and are of the same level. No
cysts, lesions, deformities, nodules, and drainage. The tip of ears is in line with the outer
canthus of the eyes. External canal is clear, with no redness, swelling, or lesions.
Eardrum is pearly grey in color without lesions, perforations, and bleeding. No signs of
hearing difficulties. Sound is equally heard in both ears.

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D. NOSE & SINUSES: The patients nose is normal in shape, position, and size. No
bleeding, swelling, lesions, or masses noted. Nasal Septum is at midline and without
perforations, lesions, swelling, or bleeding. No ulcers or polyps. No swelling around the
nose and eyes. No tenderness upon palpation of the Frontal and Maxillary Sinuses.

E. MOUTH & OROPHARYNX: No Halitosis or Dental Caries. Lips are pinkish and are
moist with no lesions, lumps, cracking, scaliness, or inflammations. Oral mucosa is pink,
moist, smooth, and is free from lesions. Gums are pale red in color and there were no
swelling or bleeding noted. No lose of teeth.

NECK:
Jugular vein not visible/distended. No enlargements, masses, and tenderness noted. No
inflammation or enlargement of the cervical lymph nodes. Thyroid Gland at midline. No
tracheal deviations. No bruits upon auscultation.

LYMPH NODES:
No lymphadenopathy. Lymph nodes are palpable but not enlarged.

THORAX AND LUNGS:
Symmetric with good chest expansion. No intercostal space retraction of bulging. No
contraction of accessory muscles during inspiration. No deformities or asymmetry. No
masses or lesions. No superficial veins. No tenderness upon palpation. Fremitus symmetric
and is felt on all lung fields. Good resonant lung fields upon percussion No adventitious
sound like crackles, rales and wheezes noted. Spontaneous breathing, regular in rate and
rhythm.

CARDIOVASCULAR SYSTEM:
Adynamic precordium (beating and amplitude are normal). Jugular venous pressure is
approximately 5 cm above the sternal angle with head of bed elevated to 30 degrees. No
bounding pulses. No distended neck veins. Point of maximal impulse is diffuse, 8 cm lateral
to the midsternal line in the 5
th
intercostal space. Carotid pulse is palpable and brisk. No
heaves or thrills. No bruits. Heart sound S2 louder tha S1 at apex.

BREAST:
Symmetric and without masses or pain. Nipples without discharge.




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ABDOMEN:
- Inspection: patients abdomen is flat, symmetric, and without masses and exaggerated
pulsations. Umbilicus is depressed with ni signs of inflammation. No lesions and
discolorations.
- Auscultation: Normal bowel sounds. No bruits in all four quadrants.
-Percussion: tympany at the upper left quadrant. Dullness noted over the right upper
quadrant.
- Palpation: Superficial - no tenderness and masses. Liver, Spleen, and Kidney not palpable.
No rebound tenderness

FEMALE GENITALIA:
Not assessed

ANUS AND RECTUM:
Not assessed

PERIPHERAL VASCULAR SYSTEM:
Extremities are warm and without edema. No varisocities or stasis changes. Calves are
supple and nontender. No abdominal bruits. Brachial, radial, popliteal, dorsalis pedias and
posterior tibial pulses are palpable 2+ and symmetric. Capillary refill <2seconds.

MUSCULOSKELETAL:
Good range of motion in all joints. No presence of Heberdens nodes at the distal
interphalangeal joints or Bouchards nodes at proximal interphalangeal joints. No evidence of
swelling or deformity.

NEUROLOGIC:
Mental Status: coherent and cooperative. She is oriented to time, place, person and other
people. With good memory, remote memory and general knowledge. Level of consciousness:
Alert with appropriate behavior and good hygiene. Has clear and spontaneous speech.

Cranial Nerves: I - XII = Intact
Motor System: good muscle bulk and tone
Muscle Strength: 4/5 upper extremities
5/5 lower extremities
Cerebellar : finger-nose intact
Gait with normal base
Romberg test not elicited
No pronator drift
Sensory : Pinprick, light touch, able to distinguish light touch from pain.
Babinski reflex absent
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Reflexes. : 2+ and symmetric with plantar reflexes down-going
BICEPS TRICEPS BRANCH. KNEE
RT 2+ 2+ 2+ 2+
LT 2+ 2+ 2+ 2+

Cranial Nerves
CN 1 - Olfactory. - Sense of smell on each side intact.
CN 2 - Optic. - Visual Activity - able to read newsprint at 12 inches with eyeglasses.
CN 3 - Ocolomotor - Eyes move in conjugate fashion and converge when they
CN 4 - Trochlear - Look at near object; Able to look up and down;
CN 6 - Abducens - Able to look laterally; EOM - intact
CN 5 - Trigemiral - Sensation - with good blinking reflex
Mastication - No difficulty in mastication
CN 7 - Facial Expression - patient is able to smile and frown symmetrically
CN 8 - Vestibulocochlear - Hearing - Able to hear whispered words.
CN 9 - Glossopharyngeal - Swallowing - Able to swallow
CN 10 - Vagus - Gag Reflex - Intact Gag Reflex
CN 11 - Spinal - Neck Motion - Able to rotate the neck, reflexion and Extension, Able to
shrug shoulders.
CN 12 - Hypoglossal - Tongue Protrusion - Able to stick tongue out























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DIFFERENTIAL DIAGNOSIS

Differential Diagnosis Rule In Rule Out

1.Non- Hodgkin Lymphoma -unexplained weight loss
-unexplained fever
-cough
-dyspnea
-back/bone pain
-left lymphnode enlargement
-paplable, painless
lymphadenopathy
-Left lymphadenopathy
enlargement
-(+) Biopsy, Reed
Sternberg cells

2.Hodgkin Lymphoma -unexplained weight loss
-unexplained fever
-cough
-dyspnea
-back/bone pain
-left lymphnode enlargement
-paplable, painless
lymphadenopathy
-Left lymphadenopathy
enlargement
(-) Biopsy, (-)Reed Sternberg
cells
3. Infectious Mononucleosis -unexplained fever
-lymphadenopathy
-pulmonary involvement
-Jaundice
-palatable petechial
-Extreme tonsillar
enlargement
-rash
4. Mediastinal Lymphoma --unexplained weight loss
-unexplained fever
-dysphagia


-bulky anterior mediastinal
mass
-massive mediatinal mass
-breast swelling

5. Small lung Cancer -unexplained weight loss
-unexplained fever
-cough
-dyspnea
-back/bone pain
-pleural effusion

-Hemoptysis
-Stridor



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MANAGEMENT

Chemotheraphy -the most common; usually combination regimens

-Radiation theraphy
-Ritusimab administration
-Bone matrix transplantation: possible role relapsed high-risk disease
-Radioimmunotheraphy
-Transfusion of blood products
-Antibiotics

Pharmacotheraphy
Cytotoxic agents (Chlorambucil, Doxorubicin)- interfere the growth of neoplastic
cells.
Antineoplastic Agents, Histone Deacetylase Inhibitors (Vorinostat)
Monoclonal antibodies-(Rituximab) against the cd20 antigen found in malignant
b lymphocytes
Colony-Stimulating factors- (epoetin alfa, epogen, Procit) Regulates the
production of erythropoietin in the kidney to increase RBC.
Immunomodulators(interferon alfa 2a)- responsible for immune reaction
Cortecosteroids(Dexamehtason, Prednisone)- decrease the inflammatory
response, antii-inflammatory response by inhibiting the recruitement of of
leukocytes and monocytes.

-Ensure that the patient understand their diagnosis, treatment optioins and prognosis and
complication therapy
-Admit the patient if their complication of disease progression like dehydration secondary to
diarrhea, vomiting requiring IV hydration, severe mucositis and fevere with neutropenia.