Central Philippine University

COLLEGE OF MEDICINE
School Year: 2018-2019
2nd Semester

ADULT PATIENT HISTORY & PHYSICAL ASSESSMENT

DATES & TIME OF ASSESSMENT January 9, 2019, Wednesday (2:10 P.M.)

January 10, 2019, Thursday (5:30 P.M.)
January 11, 2019, Friday (10:30 A.M.)

GENERAL DATA
 Name: M.L., Sr.
 Sex: Male
 Age: 73 years old
 Birthdate: September 20, 1945
 Civil Status: Widower
 Educational Attainment: Elementary Graduate
 Occupation: Previously a Farmer (approximately 40 years)
 Nationality: Filipino
 Religion: Roman Catholic
 Place of Residence: Barangay Agutayan, Dueñas, Iloilo
 Blood Type: AB (+)
 Sources of Data: M.L., Sr.; E.L. (2nd child); M.L., Jr. (7th child)
 Reliability: 90%
 Date of Admission: January 7, 2019 (9 AM)
 Room Number: METC, BED 2
 Handedness Right-Handed

CHIEF COMPLAINT BODY WEAKNESS

HISTORY OF PRESENT ILLNESS

Three (3) weeks prior to admission, there has been a noticeable weight loss which was described as
“daw naggulpi kupos lawas niya”. It was accompanied by a decrease in appetite and change in bowel move-
ment from the usual once a day to every 3 days. In this phase, he was non-compliant to his maintenance
medications which primarily consists of Metformin 500 mg, Gliclazide 30 mg, and an unrecalled antigout med-
ication.
Two (2) weeks prior to admission, specifically on Christmas day, he had a heavy meal which consists
of a high fat and carbohydrate meal with carbonated drinks despite dietary restrictions. He started to experi-
ence body weakness at night. Days after the symptom experience, he started to have dizziness and blurring
of vision. Body weakness still noted at this point. No home management was done and no medications were
taken at this point.
Three (3) days prior to admission, they consulted a private physician at a medical clinic in Passi City
due to body weakness and dizziness. The physician requested laboratory tests which includes Complete Blood
Count, Fasting Blood Sugar, and Blood Chemistry. Betahistine 1 dose was given in the clinic. He was encour-
aged to continue maintenance medications while results are still pending.
Two (2) days prior to admission, he started to have generalized body weakness, decrease appetite
and still with blurring of vision. Results of laboratory tests were not available since the clinic was closed.
One (1) day prior to admission, folks returned to the medical clinic and results of the laboratory tests
revealed the following:
A. Complete Blood Count
 Hemoglobin: ↑ 177 g/L  Neutrophils: ↑ 0.01
 Hematocrit: ↑ 0.52  Segmenters: ↑ 0.87
 WBCs: 8 x 109/L  Lymphocytes: ↑ 0.12

B. Blood Chemistry
 FBS: ↑ 216 mg/dl  Creatinine: ↑ 123.44 U/L
 Uric Acid: ↑ 584 umol/L  Cholesterol: ↑ 8.51 mmol/L
  Triglycerides: ↑ 4.67 mmol/L  LDL: ↑ 5.09 mmol/L
 HDL: ↓ 1.3 mmol/L  SGPT: ↑ 49 IU/L

The following medications were prescribed:

• Viladagliptin+ Metformin 50 mg/500 mg • Atorvastatin 40 mg
• Ketoanalogue • Cefuroxime 500 mg (not given)

On the day of admission, still with body weakness and blurring of vision.

Thus, this admission.