patient profile n.f., 55 years old filipino female, married housewife, roman catholic, from makati...

Patient Profile

N.F., 55 years old Filipino female, married housewife, Roman Catholic, from Makati City

Admitted last December 3, 2011

Patient Profile

Land lady, manages her own general merchandise (family’s primary source of income)

Lives in a bungalow (mixed concrete and wood), located along the road, with 5 occupants, 3 rooms, 1 CR, with electricity, MAYNILAD as source of water, garbage collected daily

Patient Profile

Daly activities:Doing household chores, accompanies

grandson to school Sleeping habit:

10PM-6AM and 12NN-3PM

Patient Profile

Food preference: rice, vegetables and fish

Drinks >1L/day; rarely drinks coffee; non-alcoholic beverage drinker

Non-smoker Regular BM (1x daily) Urinates 4-5x daily, total of 2.5L/day

Chief Complaint

Body weakness of 8 days duration

History of Present Illness

9 days PTA (+) fever (38°C), relieved by 1 tab of Bioflu

8 days PTA (+) body weakness described as feeling

of fatigue, advised bed rest by her daughter, avoided her usual activities

History of Present Illness

6 days PTA still with body weakness (+) decrease appetite (from the usual 1

cup of rice/meal 3x a day with snacks in between to 2-3 glasses of milk and 2-3 crackers)

History of Present Illness

2 days PTA Persistence of weakness & decrease in

appetite + vague epigastric pain (feeling of hunger, PS of 5-6/10) prompted consult at a private physician

Given Omeprazole, Mefenamic Acid and Iselpin w/c relieved the pain after taking 1 tab each

History of Present Illness

2 days PTA Advised to drink 1 glass of Ensure per

day but did not comply due to unpleasant taste

Series of laboratory examinations done

History of Present Illness

Day of admission Follow-up consult with the same

physician for laboratory results showed elevated BUN, Creatinine, FBS, total cholesterol, triglycerides, HDL, LDL, SGPT, uric acid, K, and WBC? (we still don’t have the copy of lab results done outside, sir X will try to contact the said private physician)

History of Present Illness

Day of admission (+) bipedal edema, grade 1 noted by the

physician

Advised admission

Temporal Profile

9 8 7 6 5 4 3 2 1 0

Fever

Generalized body weakness

Appetite

Epigastric pain

PTA (Days)

Inte

ns

ity

of

sy

mp

tom

Past Medical History

(+) UTI – 1997, treated for 1 month; patient claimed to be recurrent (frequency not established) though no laboratories done to support, self medicated with Bactrim 1-2 doses per episode

Past Medical History

(+) Hypertension - 2005On Losartan 50mg PRN (sorry, couldn’t find

the right term, basta pagnagagalit lang dw siya) so di xa noncompliant coz that was the exact advised daw sa kanya ng dr.

Usual BP: 130-140/80-90

(+) Diabetes Mellitus Type 2 - 2005On Gliclazide 80mg BID, with poor

compliance

Past Medical History

Use of Herbal supplements (Taheebo) for 6 months – 2005

(-) hx of nephrolithiasis, (-) chronic use of NSAIDS

(-) exposure to CT scan with contrast

Family History

(+) Hypertension (+) Diabetes Mellitus – both sides

Review of Systems General: (?) weight loss Skin: (-) rashes, (-) pruritus Eyes: (-) visual disturbances (do we need

to specify?) Respiratory: (-) cough/colds, (-) DOB Cardiovascular: (-) orthopnea, (-) dyspnea GIT: (-) nausea/vomiting, (-) hematomesis,

(-) diarrhea, (-) constipation, (-) hematochezia, (-) melena

Review of Systems Urinary: (-) dysuria, (-) polyuria, (-)

nocturia, (-) hematuria, (-) tea-colored urine Extremities: (-) cyanosis, (-) muscle cramps Nervous System: (-) headache, (-)

dizziness, (-) altered mental status, (-) loss of consciousness,

Endocrine: (-) intolerance to heat and cold, (-) neck surgery/irradiation, (-) excessive thirst/hunger, (-) thyroid problems

Admitting Physical Examination

Vital SignsBP = 140/80 mmHgHR = 93 bpmRR = 17 cpmTemperature = 36.4C

Admitting Physical Examination

Head and NeckDirty scleraePink palpebral conjunctivaeNo cervical lymphadenopathiesNo tonsillo-pharyngeal congestion

Chest and LungsSymmetric chest expansionNo retractionsClear breath sounds

Admitting Physical Examination

HeartAdynamic precordiumDistinct S1 and S2Normal rateRegular rhythmNo murmur appreciated

Admitting Physical Examination

AbdomenFlabby abdomenSoftNon-tender upon palpation

ExtremitiesFull and equal pulsesBipedal edemaNo cyanosis

Opthalmologic ExamVisual Acuity OD OS

Far vision w/ correction 20/125 20/125

w/o correction 20/125 20/100

Pinhole test 20/63 20/80

Near vision w/ correction J7 J10

w/o correction J5 J7

•Opthalmologic Impression: • Nonproliferative DM retinopathy, OD-mild,

OS-normal• Immature cataract OU