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Patient Profile

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)

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Patient Profile

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  1. Patient Profile • N.F., 55 years old Filipino female, married housewife, Roman Catholic, from Makati City • Admitted last December 3, 2011

  2. 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

  3. Patient Profile • Daly activities: • Doing household chores, accompanies grandson to school • Sleeping habit: • 10PM-6AM and 12NN-3PM

  4. 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

  5. Chief Complaint • Body weakness of 8 days duration

  6. 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

  7. 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)

  8. 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

  9. 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

  10. 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)

  11. History of Present Illness • Day of admission • (+) bipedal edema, grade 1 noted by the physician • Advised admission

  12. Temporal Profile

  13. 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

  14. Past Medical History • (+) Hypertension - 2005 • On Losartan 50mg PRN (sorry, couldn’t find the right term, bastapagnagagalitlangdwsiya) so dixa noncompliant coz that was the exact advised dawsakanyang dr. • Usual BP: 130-140/80-90 • (+) Diabetes Mellitus Type 2 - 2005 • On Gliclazide 80mg BID, with poor compliance

  15. 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

  16. Family History • (+) Hypertension • (+) Diabetes Mellitus – both sides

  17. 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

  18. 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

  19. Admitting Physical Examination • Vital Signs • BP = 140/80 mmHg • HR = 93 bpm • RR = 17 cpm • Temperature = 36.4C

  20. Admitting Physical Examination • Head and Neck • Dirty sclerae • Pink palpebral conjunctivae • No cervical lymphadenopathies • No tonsillo-pharyngeal congestion • Chest and Lungs • Symmetric chest expansion • No retractions • Clear breath sounds

  21. Admitting Physical Examination • Heart • Adynamicprecordium • Distinct S1 and S2 • Normal rate • Regular rhythm • No murmur appreciated

  22. Admitting Physical Examination • Abdomen • Flabby abdomen • Soft • Non-tender upon palpation • Extremities • Full and equal pulses • Bipedal edema • No cyanosis

  23. Opthalmologic Exam • Opthalmologic Impression: • Nonproliferative DM retinopathy, OD-mild, OS-normal • Immature cataract OU

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