IM WARD SECTION 3C - DR.

SAM UY
General Data
Date of Interview: August 29, 2018 Informant: Patient
History taken by: Luna, Ma. Danica Louise M. Patient reliability: 80%

Identifying data
Araceli Gustilo, 67 years old, Female, Single, Filipino, Roman Catholic, born at Negros Occidental at
February 9,1951, currently residing at Phase 9, package 5, block 13A Lot 15 Bagong Silang, Caloocan City, admitted
for the first time in FEU-NRMF Medical Center on August 15, 2018.

Chief Complaint: Non healing wound on the left foot

History of Present Illness:

The present illness started 1 month prior to admission, patient noted a pruritic macule that is brown in color at the
dorsal aspect of her left foot. The patient scratched it which resulted to a wound. The patient put an ointment,
which she could not recall the name, making the wound look wet and a whitish discharge was observed the
following day. There were no associated fever, difficulty in walking and no palpable inguinal lymph nodes. The
patient also said the the wound grew progressively but she didn’t take any medications and no consult was done.

2 weeks prior to admission, the patient noted an increase in the wound’s size now with associated redness,
swelling of the foot and pain in ambulation. However there was still no associated fever and no palpable lymph
nodes. Still no medication was taken and no consult was done.

1 week prior to admission, the patient claims that there was noted increase in the severity of symptoms and the
wound got bigger in size, still having whitish discharge, pain on ambulation and now foul smelling. Her daughter
who is a nurse gave her Cloxacillin 500mg QID.

Few hours prior to admission, the patient was taken to the ER. She was assessed and laboratory tests were
requested. However patient could not recall the tests done and their results, she was diagnosed to have Diabetic
Foot, Left which prompted her admission.

Past Health Illness

● Diabetic for almost 20 years, maintained with Metformin and Gilbenclamide 500/2.5 mg OD
● Had pulmonary tuberculosis, completed treatment
● No known allergies in food and drugs, no history of hypertension, heart diseases, cerebrovascular
accident, and cancer

Family History
● Father is deceased at an unrecalled age
● Mother is deceased at an unrecalled age
● 1 sibling, has no communication anymore
● 1 child, nurse with diabetes
● 1 grandchild, apparently well
● No heredofamilial disease such as cancer and diabetes mellitus
● No other members of the family with similar symptoms
Personal and Social History
The patient is an elementary graduate, a single mother, unemployed, and used to sell processed meat.
Lives in a bungalow, well-lit, well-ventilated. The source of water is Nawasa, and garbage is collected everyday. She
sleeps 8 hours a day, drinks 1 cup of coffee/day. Used to smoke, a 30-pack year smoker, an occasional beverage
drinker, about 2-3 bottles of beer/3 months. Fond of watching television soap operas and walks daily inside her
house as her exercise. No history of illicit drug use.

Menstrual and Gynecological History

Menarche: 15 years old

Menstruation regular with 28-30 days interval, 3-5 days duration, with 3-4x napkin change/day fully soaked with
no premenstrual symptoms noted
G1P1, NSD
Menopause at 50 years old

Review of Systems
Constitutional Symptoms
(-) weight loss (-) fatigue (-) chills (-) inc appetite

Skin
(-) itchiness; (-) excessive sweating; (-) change in color (cyanosis, pallor, jaundice, erythema)

Eyes
(-) pain; (-) blurring of vision; (-) double vision; (-) lacrimation; (-) photophobia; (+) use of eyeglasses

Ears
(-) earache; (-) deafness; (-) tinnitus; (-) ear discharge

Nose and Sinuses

(-) changes in smell; (-) nose bleeding; (-) nasal obstruction; (-) nasal discharge; (-) pain around paranasal sinus

Mouth and Throat

(-) toothache; (-) gum bleeding; (-) disturbance in taste; (-) sore throat; (-) hoarseness

Neck
(-) pain; (-) limitations of movement; (-) presence of mass
Respiratory System
(-) chest pain; (-) cough; (-) sputum production; (-) hemoptysis;

Cardiovascular System
(-) substernal pain; (-) palpitations; (-) orthopnea; (-) paroxysmal nocturnal dyspnea; (-) easy fatigability

Gastrointestinal
(-)- dysphagia; (-) constipation; (-) hematemesis; (-) regurgitation

Genitourinary Tract
(-) dysuria; (-) polyuria; (-) hematuria; (-) incontinence; (-) genital pruritus; (-) urethral discharge
Extremities
(-) edema (-)swelling of joints; (-) stiffness; (-)numbness; (-)intermittent claudication;(-) limitation of movement

Nervous System
(-) vertigo; (-) syncope; (-) loss of consciousness; (-) paralysis; (-) numbness; (-) paresthesia; (-) speech disorder; (-)
loss of memory; (-) confusion

Hematologic
(-) bleeding tendencies; (-) pallor; (-) easy bruising

Endocrine System
(-) heat/cold intolerance; (-) excessive weight gain/loss; (-) polyuria; (-) polydipsia

Physical Examination

General Survey. (ok na lacson malupa)

The patient is conscious, alert and responds to verbal tactile and painful stimuli. She is oriented to time, place, and
person. Looks her stated age and appears to be well kempt. Cooperative and responsive to all questions that were
asked. She did not have any difficulty of speaking and was able to talk spontaneously and comprehend,
communicate and express her ideas. Her memory was intact, with a euthymic mood, and had an appropriate
affect. Has normal weight and well nourished. There were no signs of distress.

Vital Signs (ok na lacson malupa)

Patient is normotensive (120/80). The pulse rate (95bpm) , respiratory rate (19 cpm) and temperature (37.5 C) are
normal.

Skin
Skin is brown, normal degree of moisture, elasticity, mobility and thickness with good skin turgor. Nails are
smooth and pink, with normal nail folds.

Head
Hair is thick, black with grayish area, evenly distributed,coarse and dry. Head is normocephalic symmetrical,
without swelling, no tenderness and masses. Temporal arteries are not visible but palpable with strong equal
pulsations. Walls not thickened.

Face
Face is oval, symmetrical, brown. Normal facie and no involuntary facial movements, no visible mass.

Eyes
Evenly distributed eyebrows and eyelashes, curled outward without matting. Eyelids have intact skin, no discharge
or discolorations, no ptosis. They close symmetrically with bilateral blinking. Negative lid lag. Palpebral
conjunctivae are pinkish. Normal set of eyeballs, no exophthalmos nor enophthalmos, no nystagmus. Non Icteric
sclera. Corneas are transparent, no lesions. Patient’s pupils are equal in size, round and has smooth border. Iris is
flat and round. Patient’s direct and consensual light reaction is normal. Lenses are transparent. Fundoscopic exam
revealed (+) ROR 2:3 AV ratio.

Ears
The patient has symmetrical auricles, auditory canal is patent, with minimal brownish discharge on both ears, walls
are pink without lesions, tympanic membrane is pearly white and intact, normal contour with visible cone of light
and has no perforation.

Nose and Paranasal sinuses

Symmetrical without lesions, deformities and tenderness, ala nasi not flared. Nasal septum is in the midline,
without perforations, mucosa is pinkish and turbinates are flat and dry. Nasal cavity is patent without discharges.
Frontal and maxillary sinuses exhibit no tenderness and positive transillumination.

Mouth and Pharynx (okay na)

Lips are pink, dry, symmetrical, moist, without lesions. Buccal mucosa is pink and smooth. Tongue is at the midline,
no fasciculation nor lesion. Hard and soft palate is pinkish, no lesions, uvula is at the midline and unenlarged.

Neck (okay na)

Neck is normal in size, symmetrical without visible mass,swelling or deformation with full of range of motion. No
neck vein distention. Trachea is in the midline, no palpable lymph nodes. Thyroid gland is neither visible nor
palpable.

Thorax and Lungs (okay na)

The skin is brown with a brown papule on the left parasternal line, thorax is elliptical and symmetric in shape with
good expansion; no kyphosis. No deformity and chest muscles are well developed and chest wall movements are
symmetrical, with no use of accessory muscles. No retractions. Chest has no scars. No dilated blood vessels. No
chest wall tenderness. No costo-vertebral angle tenderness. Normal tactile fremitus, equal over all lung fields.
Lung sounds resonant over all fields. Vesicular breath sounds are heard in all lung fields, no rales and rhonchi
present. No bronchophony, egophany, or whispered pectoriloquy noted.

Cardiovascular (okay na)

No visible neck vein. Flat precordium. Carotid arteries pulsation is strong, regular rhythm, equal pulsations and soft
consistency of the wall. Apex beat is adynamic, located at 5th ICS, 1 cm from LMCL, approximately 1x2 cm in
diameter, normal amplitude. No abnormal precordial pulsations, thursts, lifts, heaves, thrills and palpable heart
sounds. Normal intensity of heart sounds appreciated, no abnormal heart sounds.

Extremities (okay na)

Upper extremities are symmetrical, no swelling, lesions or deformities. Pulse are strong, regular, equal and soft
wall.
Lower extremities, with noted hyperpigmented, dry skin on both feet. With noted 5x6cm, erythematous, foul
smelling, gangrenous lesion on the dorsal aspect of the left foot

Abdomen (okay na)

Abdomen is symmetrical, light brown, flabby, inverted umbilicus. No visible pulsations, peristalsis and dilated
vessels. No lesions, scars, and bulging flanks. Normoactive bowel sounds. No bruit heard over the epigastrium,
right and left paraumbilical area. All abdominal quadrants are tympanitic on percussion. No abdominal mass upon
palpation. Liver is non palpable. Spleen is not palpable. Right and Left Kidneys are not palpable. No pain was
elicited when performing Kidney Punch. Negative Rebound tenderness, Psoas sign, Obturator sign and Murphy’s
sign.

Neurologic Evaluation

Cerebrum:
The patient has GCS: E:4 V:5 M:6, conscious, cooperative, appropriately groomed, oriented to time, place, and
person. Is able to recall memory, appropriate mood and affect and no emotional lability. Can understand and
communicate in spoken and written language, able to recognize an object by the use of primary senses, and has
the ability to conceive, formulate and execute complex, purposive, skilled, volitional acts on command.

Cranial nerves:
CN I: nose is patent, can identify the smell of tobacco
CN II: can read the smallest letters of the Jaeger chart at a distance of 14 inches, (+)ROR, clear media, and distinct
disc margin. Normal AV ratio, no hemorrhages, no visual field defect
CN III, IV, VI: both pupils constrict briskly reactive to light both direct and indirect. Adduction of both eyes and
constriction of both pupils on accommodation. Equal and complete opening of both eyes, can move eyes in 6
cardinal directions of gaze
CN V: can feel pain and light touch equally on both sides. Prompt and equal blinking of both eyes in corneal reflex.
Can clench teeth equally on both sides
CN VII: can frown, raise the eyebrows, and close eyes equally on both sides. Nasolabial folds are equal
CN VIII: intact gross hearing, responsive to verbal sounds
CN IX & X: no dysphonia, uvula at midline, equal elevation of palate on phonation, (+) gag reflex
CN XI: can turn head from side to side against resistance, can elevate shoulders equally
CN XII: no atrophy nor fasciculation, tongue midline on protrusion, can move tongue from side to side

Cerebral Function:
Normal finger-nose-finger test, is able to perform rapid alternating movement by patting her knees with the palm
and the back of her hands by pronation and supination, smooth movement and the heel remain on the shin (-)
dysmetria, romberg’s test and tandem walking was not performed.

Motor Function:
Size and consistency of the the muscle are normal. No atrophy or fasciculation. Normal symmetry of postures,
muscles contours and outlines. Normal muscle tone. There are no resistance to passive movements, no latent
paralysis, no pronation drift, and no involuntary movements. Flexion, extension and other movements through the
major joints without resistance and with resistance are graded with grade 5/5 on all extremities.