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GENERAL DATA:

C.L., 64-year old male, Filipino, Roman catholic, retired policeman, born
on June 21, 1950 in San Fernando City, La Union, presently residing in Central
Fairview Baguio City. Informant is the patient with a percentage reliability of
90%.

Chief Complaint: sore throat

History of Present Illness:


Five days prior to consultation, he experienced fever and sore throat after
drinking cold pineapple juice. There was associated dysphagia and throat pain
rated as 8/10 in severity. There was slight and temporary relief with the intake
of vinegar. No medications were taken.
Four days prior to admission, in addition to the sore throat, he started to
have cough. Sputum was characterized to be whitish in color but sparse in
amount.
The above symptoms progressed up to the day of consultation.

Past Medical History:


He had herpes zoster and chicken pox when he was a child. When he was
a 3rd year high school student, he underwent appendectomy. He was
hospitalized in 2011 for benign prostatic hyperplasia. He is on Tamsulosin 400
mg tab OD and Finasteride 5 mg OD. Maintenance medication for
hypertension includes Losartan 50 mg 1 tab OD, but he claims that he only
takes it when he feels palpitations or when his blood pressure would go up. He
is allergic to chicken meat and eggs. He has no allergy to drugs.

Family History:
His mother died at the age of 96 while his father died at the age of 91,
both due to old age. Relatives in both sides of the family have hypertension. No
other heredofamilial diseases such as asthma, diabetes and cancer.

Social and Environmental History:


He does not smoke. He is an occasional alcoholic beverage drinker. He
lives in a bungalow type of house, concrete cement, with 3 rooms and 3
occupants, one communal comfort room. Garbage is segregated and collected
weekly. Drinking water is purchased from a refilling station. No history of travel.
All of the other family members are apparently well.

Review of Systems: (INCLUDE ONLY SYMPTOMS THAT WERE ASKED FROM THE
PATIENT)
General: no weight loss, no fever, no anorexia, no weakness
Skin: no cyanosis, no pallor, no rashes
HEENT: no headache, with eye tearing, no colds, no sneezing, with sore throat,
with dysphagia, with odynophagia, no dryness, no hoarseness of voice, no ear
discharge
Respiratory: with productive cough, no dyspnea
Cardiac: no chest pain, no palpitations, no orthopnea, no paroxysmal nocturnal
dyspnea
GIT: no abdominal pain, no vomiting, no diarrhea, no constipation
GUT: no dysuria, no hematuria, no dribbling, no hesitancy, no incontinence, no
oliguria
Musculoskeletal: no joint pains, no muscle pains

Physical Examination:
General Survey: conscious, coherent, ambulatory, oriented to time, place and
person, not in cardiopulmonary distress
Temperature: 36.1C RR: 20 cpm CR: 120 bpm BP: 140/110 mmHg Weight:
100 kgs
Height: 56 Waist circumference: 40 inches
Skin: fair skin color, acyanotic, warm to touch with good skin turgor; few nevi
on the forearm, no petechiae or maculopapular rashes
HEENT: anicteric sclerae, erythematous palpebral conjunctivae, tearing of the
eyes noted; no ear discharges, intact tympanic membrane; moist and pinkish
nasal mucosa, no nasal discharges, no sinus tenderness, nasal turbinates not
congested; pink and moist lips, wears false teeth; tonsils are enlarged and
inflamed with exudates; anterior cervical lymph nodes are tender and palpable,
about 1x1 cm in diameter; JVP 1 cm above sternal angle; no carotid bruit
Chest and Lungs: symmetrical chest wall expansion, no retractions, resonant,
equal tactile fremiti, vesicular breath sounds, no crackles or wheezes
Heart: PMI at the 5th LICS, MCL, no heaves or thrills, tachycardic with regular
rhythm, S1 louder at the apex, S2 louder at the base, no S3 or S4, no murmurs
Abdomen: globular, everted umbilicus, normoactive bowel sounds, tympanitic,
non-tender, no organomegaly
Extremities: no gross deformities, no joint swelling, no bipedal edema, ++
dorsalis pedis pulses bilaterally
DRE: patient refused
Neurologic Exam: not applicable

PROBLEM LIST:
#1: dysphagia, odynophagia, exudates on tonsils
#2: hypertension
#3: prostatic hyperplasia
#4: allergy to chicken and eggs

PROBLEM NO. 1: dysphagia, odynophagia, exudates on tonsils

Bases for the diagnosis/DDx:


S: 5-day onset of dysphagia and odynophagia; with productive cough; with eye
tearing;
PERTINENT NEGATIVES: NO fever, headache, weakness, colds, sneezing,
hoarseness of voice, ear discharge, chest and abdominal pain

O: Temperature: 38.1C RR: 20 cpm CR: 120 bpm


Skin: warm to touch with good skin turgor; no rashes
HEENT: erythematous palpebral conjunctivae, tearing of the eyes noted; no ear
or nasal discharges, moist and pinkish nasal mucosa, no sinus tenderness,
nasal turbinates not congested; tonsils are enlarged and inflamed with
exudates; anterior cervical lymph nodes are tender and palpable, about 1x1 cm
in diameter
Chest and Lungs: vesicular breath sounds, no crackles or wheezes

A: Acute tonsillitis, bacterial r/o viral


Pathophysiology (as applicable to the patient)
P:
Dxtics:
- CBC to check for leukocytosis and neutrophilia as signs of bacterial
infection
- Throat swab for culture and sensitivity to determine causative
microorganism

Txtics:
a. General Measures:
a. Admit patient to general ward
b. Soft diet
c. Paracetamol to control the fever
d. Hexetidine gargle as pain reliever and anti-inflammatory

b. Specific Measures:
a. Hydration with plain LRS 1 liter to run at 5 cc/kg/hour
b. Coamoxyclav 1.2 grams IV q 8 hours; describe mechanism of action

c. Patient education:

PROBLEM NO. 2: hypertension

S: 64-year old male, hypertensive but does not take Losartan regularly, non-
smoker, occasional alcoholic beverage drinker, with family history of
hypertension, no chest pain, no palpitations, no orthopnea, no paroxysmal
nocturnal dyspnea

O: General Survey: conscious, coherent, ambulatory, oriented to time, place


and person, not in cardiopulmonary distress
CR: 120 bpm BP: 140/110 mmHg Weight: 100 kgs
Height: 56 Waist circumference: 40 inches
JVP 1 cm above sternal angle; no carotid bruit
Chest and Lungs: vesicular breath sounds, no crackles or wheezes
Heart: PMI at the 5th LICS, MCL, no heaves or thrills, tachycardic with regular
rhythm, S1 louder at the apex, S2 louder at the base, no S3 or S4, no murmurs
Abdomen: globular, no organomegaly
Extremities: no bipedal edema, ++ dorsalis pedis pulses bilaterally

A: Hypertension stage 2

P:
Dxtics:
- 12-leads ECG to determine presence of cardiomegaly and ischemic
changes
- CXR-PA to determine presence of cardiomegaly or congestion
- FBS, lipid profile determine risk factors such as DM and dyslipidemia
- Creatinine assess kidney function since patient is hypertensive
- Urinalysis assess kidney function since patient is hypertensive

Txtics:
a. General measures: low fat, low salt diet
b. Specific measures: Losartan 50 mg 1 tab OD; describe mechanism of
action; Amlodipine 10 mg 1 tab OD; describe mechanism of action
c. Patient education: weight loss

PROBLEM NO. 3: prostatic hyperplasia


S: 64 years old, on Tamsulosin and Finasteride for BPH; no dysuria, no
hematuria, no dribbling, no hesitancy, no incontinence, no oliguria

O: refused DRE
A: BPH
P: Dxtics: PSA, ultrasound of prostate
Txtics: continue Tamsulosin and Finasteride; describe mechanisms of action