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Jaymee B.

Quindara Internal Medicine II


Date: August 25, 2017 Time: 10:00 am

General Data
Name: Gavino Fernando Valencia Sex: Male Age: 54 y/o
Address: Barangay Bacsil, Dingras, Ilocos Norte Birthday: February 19, 1963 Civil Status: Married
Occupation: None Religion: Roman Catholic Nationality: Filipino
Informant: Patient and Wife (98% Reliability)

Chief Complaint
“Marigatan nak nga aganges” as verbalized by the patient

History of Present Illness

1 week PTA pt experienced dyspnea whenever pt lies supine or assumes left decubitus position accompanied by
pressure and compressing sensation localized at the left anterior thorax, fatigue and weakness. Symptoms are
relieved by using 3-4 pillows when lying. Symptoms prevented pt from doing some household chores requiring
exertion of too much effort.

Symptoms prompted consult to Karmelli Hospital, Laoag City, Ilocos Note. Pt was diagnosed with pulmonary
congestion secondary to delay in his hemodialysis for the management of uremia and fluid over load. Referred to
MMMH & MC for further management.

Past Medical History

Childhood Illnesses
Reported to experience measles at 6 y/o and varicella at 10 y/o. Patient claimed to receive all immunization but
cannot recall kind of immunization received. BCG scar noted on Left deltoid area. Patient denied any other illnesses
during childhood or other chronic childhood illnesses.

Medical/ Hospitalization
Pt was diagnosed with Diabetes Mellitus Type II in 2007 by Dr. Taylan presenting with the following symptoms of
easy fatigability, polyphagia, polydipsia and polyuria. Was prescribed w/ Regular Insulin 10 IU, Metformin &

Patient experienced uremia and fluid overload/ edema in August 4, 2016. Started on hemodialysis on 2 sessions/
week in November 10, 2016 at MMMH & MC.

Diagnosed with hypertension and hyperlipidemia in November 16, 2016 by Dr. Manuel after consultation for
furunculosis and his blood chemistry checked. Patient was prescribed with simvastatin

Infection of Right brachiocepahic AVfistula in August 19, 2017. Blood culture was done.

Received 2 PRBC in August 19, 2017 for anemia. Patient did not note any adverse reactions.

Received 1 PRBC in August 24, 2017. Patient did not note any adverse reactions.

Currently on hemodialysis via Right IJ catheter 3 sessions/ week. Patient on Regular Insulin 10 IU, Simvastatin,
Digoxin, Allopurinol and Calcium Carbonate.
Surgical removal of benign mixed tumor on Right mastoid area in 2008 at MMMH & MC. Patient did not note any

Amputation of Right 4th and 5th toes due to infected non-healing wound secondary to diabetes mellitus at in 2013 at
St. Camilus Hospital. Patient did not note any complications.

Creation of temporary Right IJ catheter in September 8, 2016 for hemodialysis. Patient experienced chills after 7

Creation of left brachiocephalic AV fistula in November 10, 2016 at MMMH & MC for hemodialysis. Patient
undergone hemodialysis 2x/week.

Incision and Drainage of furunculosis at right thigh in November 16, 2016 at MMMH & MC.

Patient often experience episodes of sadness but no prior diagnosis of depression.

Family History
Patient is the second child of four siblings with two of his brothers also diagnosed with diabetes mellitus. Patient
reported that his father has hypertension while his mother has diabetes. Patient also reported maternal grandmother
had diabetes mellitus. Patient has 3 children but none of them has any illnesses.

Personal and Social History

Patient lives with his family in a three-bedroom, bungalow type house made of concrete near the farm fields of
Bacsil, Dingras, Ilocos Norte. Patient and wife sleep in the same bedroom, while two of his three children sleep in
their own bedrooms. His eldest child lives and works in Manila. They have a communal bathroom with a water-
sealed type latrine. Their water supply for bathing and washing is from a jetmatic hand pump. They use purified
water for cooking and drinking from a water refilling station. Their family owns and manages a sari-sari store
connected to their house.

Patient is a high school graduate. Worked previously at Coca Cola as company security guard from2004-2010.

Patient with 26 pack-year history. He started smoking at 19 y/o, and would consume1 pack of cigarette (20 sticks)
per day. Patient claimed he quitted smoking at 45 y/o.

Patient reported previous alcohol consumption with unrecalled amount of 4x4 gin (700 ml). Patient shared drinking
until he passes out of his consciousness.

He denied any history of illicit drug use.

The patient shared history of consuming around 8 bottles of 237 ml Coca Cola every duty as a security guard of the
same company. Currently, patient is on low salt and low fat diet. Typical meal composed of of 1/2 cup of rice, ½ cup
vegetables and a small slice of lean meat. Typical snack composed of 2-3 slices of wheat bread. Consumes half cup
of black coffee every morning.

Patient reported allergy to eggs, chicken, certain types of fish and unrecalled medications.

Patient reported difficulty performing ADLs independently. Bathes with assistance. Eats with minimal assistance
from wife. Patient receives daily passive range of motion exercises and massage from his wife 30 minutes. Patient
walks with assistance in their compound around 3 minutes or until he is tired and run out of air. Patient watches the
television and movies for recreation. Patient sleeps at around 9:00 pm and wakes around 7:30am.
Review of Systems
General: (+) fatigue, (+) weight loss (previous weight 74 kg, current weight 64 kg, weight loss of 10 kg)
Skin: (+) pruritus, (+) rashes, (+) changes in hair/nails- loss of luster and discoloration of nails
Eyes: (+) visual impairment OD, (+) pruritus, (-) discharge, (-) inflammation, (-) glasses
Ears: (+) hearing loss more prominent on AS, (+) tinnitus, (-) discharge
Nose, Throat, Mouth: (+) abnormal olfaction, (+) dental carries, (+) gingivitis, (-) dysphagia/odynophagia, (-)
tonsillitis, (-) hoarseness
Neck: (+) right IJ catheter, (-) goiter, (-) lymph node enlargement
Respiratory: (+) cough/sputum, (+) difficulty of breathing, (-) pain, (-) respiratory infection, (-) night sweats
Cardiovascular: (+) bilateral pitting edema on the lower extremities, (+) hypertension, (+) mild orthopnea, (-)
palpitations, (-) chest pains, (-) irregular rhythms, patient on simvastatin and digoxin
Gastrointestinal: (+) decreased appetite, (+) constipation, (-) nausea, (-) dysphagia, (-) hemorrhoids
Urinary: (+) polyuria, (+) hesitancy, (+) dribbling, (-) pain, (-) passage of stones
Genitourinary: (+) loss of libido, (+) sexual dysfunction, (-) lesions, (-) discharge
Breast: (+) pain in the left nipple, (-) tenderness, (-) discharge
Extremities: (+) bilateral pitting edema on the right and left lower and upper extremities, (-) pruritus
Hematopoietic system: (+) anemia, (+) history of blood transfusion with no adverse reactions, (-) bleeding/ clotting
Nervous: (+) slowed movement, (-) vertigo, (-) falls, (-) headache, (-) loss of consciousness
Musculoskeletal: (+) muscle weakness, (+) swelling due to edema, (-) wasting/atrophy, (-) pain, (-) fractures, (-)
stiffness, (-) arthritis
Endocrine: (+) DM indicators- polyphagia, polydypsia, polyuria, weigh tloss; (-) goiter, (-) heat/cold intolerance
Psychiatric: (+) depression, (-) sleep disorders, (-) mood swings, (-) hallucinations

Physical Examination

Vital Signs
T: 36.5oC axillary
RR: 21 breaths/ min
HR: 76 bpm
BP: 130/80 mmHg Left Arm

General Survey
Mr. Valencia is a 54yo Right handed man, appears tired but alert and can maintain eye contact. Patient in no
apparent distress, lying on bed with 3 pillows, able to speak in full sentences, conversant. Mesomorph. Weighs 64
kg, Skin appears thin, dry and warm to touch.

Head and Neck

Skull is NC/AT. Scar from pervious surgery noted Right mastoid area. Hair is smooth and oily with normal
distribution. Face is edematous on the right side with symmetric facial expression. Eyes. Periorbital edema
OD>OS. Pale conjunctiva. Icteric sclerae. Ears. Dry cerumen on external ear canal AU. Whisper test (-) AS,
Webber (+) AS, Rinne (+) AU. Nose. Nose at midline, mucosa pink, nasal septum at midline, (-) tenderness over
maxillary and frontal sinuses. Mouth. Lips are dry and black. Oral mucosa pink to red. Gingivitis on upper and
lower teeth. Dental caries on lower incisors and canines. Pink to red pharynx (-) exudates. Limited opening of
mouth. (-) tenderness over TMJ. Neck. (-) palpable lymph nodes. Neck supple, trachea midline, thyroid gland non

Respiratory System
Thorax symmetric, transverse diameter > AP diameter. Skin is taut and shiny in the anterior thorax. Discrete dark-
brown irregular smooth patches (2cm) seen over the entire anterior and posterior thorax. RR: 21 regular, with
normal depth and effort of breathing. Tenderness over Right mid-scapular region level of T2-T5, (-) bruising, (-)
erythema, (-) crepitus over affected area. Decreased lung excursion, bilateral. Pitting edema over anterior thorax
Grade 2. Tactile fremitus present with increased intensity over bilateral upper lung lobes. Dullness over upper and
lower Right lung fields, dullness over upper left lung field. Diaphragmatic excursion of 4 cm. Decreased to absent
breath sound over entire Right lung fields. Left upper lung lobe with muffled breath sound, Left lower lung lobe
with vesicular breath sound.

Cardiovascular System
With Right IJ cath. Carotid pulse with brisk upstroke (-) bruits, (-) thrills. PMI tapping, mid clavicular, 5th ICS (-)
thrills (-) heaves. Distinct S1 and S2, with S2 louder at the base with physiologic splitting of S2 A2>P2 with
widening of split during inspiration. (-) thrills (-) heaves. S1 louder at the apex.

Peripheral Vascular System

Extremities taut and shiny, with thinning of skin over edematous areas of both forearms and both ankles. Skin warm
to touch. Discrete, irregular black-brown smooth patches (2-3cm) over right and left extremities.Brisk capillary
refill, (-) clubbing. Right antecubital area with AV fistula, erythematous with serous discharge. Left antecubital area
with AV fistula scar. Pitting edema at right and left forearms Grade 2+. Pitting edema at right and left ankles Grade
3. Right foot with black discoloration and scar from previous amputation of 4th and 5th digits. Lichenification
between toes and scaling over dorsum. Nails are dry, yellow with slight spooning. Left foot with black-brownish
discoloration, lichenification in between toes, scaling over dorsum. (-) Varicosities in both extremities. Pulses -
Brachial 1+; Radial 0; Popliteal 0; DP 0; PT 0; Femoral (not assessed)

Abdominal wall shows ascites, appearing distended, with bulging flanks. Skin is dry, warm to touch. Hypoactive
bowel sound. Abdominal aorta cannot be detected via palpation or auscultation. Examination limited by ascites. No
mass, no tenderness, no pulsations. Percussion sounds are tympanic in the epigastric region. Dullness over lower
abdomen and over bulging flanks. No CVA tenderness

Patient exhibits no deficits of insight or judgment. Alert and oriented to time, place and person. Thought process is
coherent. No apparent deficits in recent or remote memory. Mood and affect are congruent and appropriate to
environment. Patient often experience episode of feeling down as verbalized “Narigat agsakit, namaymayat lattan
nga mapaltugan nak”.

Neurological/ Musculoskeletal

Ambulation, gait and stance because patient is weak but observed with slowed movements. Patient needs assistance
when changing position on bed.

Weakness on 4 extremities Grade 3.

Spine runs midline without apparent abnormal thoracic kyphosis or lumbar lordosis and no evident masses, lesions,
foreign bodies or other abnormalities.

Cranial Nerves
CN1- can identify the smell
CN2- diminished vision on OD, PERRLA 3 mm, (+) field defect- right superior quandrantinopsia
CN3,4,6- normal ocular muscle movements, (-) nystagmus
CN5- no motor deficits and wasting, symmetric, intact pain, light touch and temperature sensation
CN7- symmetric, no motor deficits, (-) pain
CN8- hearing deficit AS, (-) whisper on AS, (+) Weber on AS, (+) Rinne AU.
CN9,10- can differentiate taste, can swallow and opens mouth wide, (+) gag reflex
CN11- (+) shoulder shrug, able to fight resistance
CN12- can protrude tongue and move side-to-side

Deep Tendon Reflexes

Brachial- unable to assess
Tricep- unable to assess
Patellar- Grade 2+ on both knees
Ankle- unable to assess

Not assessed