Patient: Hospital No.

Age/Sex: Department: Medicine

Date of Admission: Room No:

CLINICAL HISTORY
Chief Complaint: presence of pus on both feet

History of Present Illness:

Three months prior to consult, patient was exposed to wading in flood water. Both feet resulted to dry, crusting lesions and presence of pinpoint rashes and later
turned to vesicles, described as reddish, itchy, with regular borders. No other accompanying signs and symptoms such as fever, chills, vomiting, skin discoloration, headache,
dizziness, blurring of vision, and abdominal pain. Patient went for consult at a private MD and was advised to do CBC, revealing Cellulitis as its diagnosis. He was given the
following meds: Sultamicillin 650 mg/tab 1 tab BID, Levocetirizine 750 mg/tab BID, Hydroxyzine (Iterax) 1 tab BID, Tramadol + Paracetamol (Dolcet) 1 tab q6 and Mupirocin
ointment. Patient was compliant with said medications and wounds eventually healed and were resolved.
Two weeks PTC, patient noticed some open wound containing pus on the legs and at the feet, described as greenish-yellowish, non-foul smelling, mucoid, still
accompanied with itchiness. Still with no associated symptoms as mentioned above. He self medicated with unrecalled medication which afforded partial relief. No consult
was done.
Few hours prior to consult, due to the increasing severity of symptoms, patient decided to seek consult at our ER.

Past Medical History

Non- Hypertensive
Non-diabetic Family Hx: Personal and Social History:
Non-Asthmatic (-) HPN Nonsmoker
Dyslipidemia (high cholesterol) (-) cancer Occasional alcoholic beverage drinker
maintained Simvastatin 20 mg/tab ½ tab OD (-)DM
No known allergies

Occupation: seaman

ROS:
HEENT: no blurred vision, no hearing, no ear pain, no tinnitus, no dysphagia, no sore throat, no epistaxis, no hoarseness
Respiratory: no hemoptysis, no cough
CVS: no orthopnea, no PND, no palpitations
Genitourinary: no oliguria, no dysuria, no increased frequency, no hesitancy, no tea colored urine
Musculoskeletal: no limitation of movement
Endocrine: (-) polyuria, (-) polydipsia, (-) polyphagia,
Neurologic: No seizure, no paralysis, no tremors, no memory loss

Physical Examination
General Survey Conscious, coherent, Not in cardiopulmonary distress, GCS 15 (E4V5M6)
BP: 120/80 HR: 66 regular RR: 20, 02 sat: 97% T: 36.5 C
Skin and Integumentary No jaundice, no rashes
HEENT Anicteric sclera, pale palpebral conjunctiva, no cervical lymphadenopathy, no tonsillopharyngeal congestion,
Chest and Lungs Symmetrical chest expansion, no retractions, decreased breath sounds on the Left
Adynamic precordium, normal rate, regular rhythm, apex beat at 5th ICS MCL, no murmurs, no heaves, no thrills
Cardiovascular
appreciated
Abdomen Flabby, soft,normoactive bowel sounds, no mass palpated, nontender
Extremities no edema, no cyanosis, pulses full and equal

DRE Examination: No skin tag, good sphincter tone with internal hemorrhoids 1-2 mm mass on 3 o’clock position, no induration, with brownish fecal material on
examination.

NEUROLOGIC EXAMINATION
Mental Status GCS 15
Sensorium Oriented to 3 spheres
Cranial Nerves Intact
Motor Exam 5/5
Pronator drift (-)
Cerebellar Exam NA
Muscle Stretch Reflexes Babinski (-)
Sensory Exam Sensory deficit (-) Romberg’s Test (-)
Meningeal Exam Kernig’s Test (-) Brudzinky’s Test (-)

Present Working Impression

Date Diagnosis/es
External Hemorrhoids grade 1
3/4/2018
t/c dyslipidemia
 2

Dr. /PGI Cruz