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Case # 1

Case # 1. Patient Profile . N.F. is a 55 year-old Filipino female, married housewife, Roman Catholic, from Makati City Admitted last December 3, 2011. Patient Profile . Land lady and owns general merchandise w/c is the family’s primary source of income

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Case # 1

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  1. Case # 1

  2. Patient Profile • N.F. is a 55 year-old Filipino female, married housewife, Roman Catholic, from Makati City • Admitted last December 3, 2011

  3. Patient Profile • Land lady and owns general merchandise w/c is the 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, w/ electricity, MAYNILAD as source of water, garbage collected everyday

  4. Sleeping habit • sleeps from 10PM-6AM and 12NN- 3PM • Food preference: • Rice, vegetables and fish • Water intake >1L/day • Urine 4-5x/day, around 2.5L/day? • Exercise: • Walking 1 block

  5. Chief Complaint • Body weakness of 1 week duration

  6. History of Present Illness • 9 days prior to admission • (+) fever (38°), relieved by Bioflu • 8 days prior to admission • (+) body weakness described as feeling of fatigue, advised bed rest by her daughter, avoided her usual activities

  7. History of Present Illness • 6 days prior to admission • (+) decrease appetite, from the usual 1 cup of rice/meal 3x a day + snacks in between to 2-3 glasses of milk + 2-3 pieces of crackers + 1 glass water

  8. History of Present Illness • 2 days prior to admission • Persistence of weakness & decreased appetite + vague epigastric pain (feeling of hunger) , 5-6/10, on PS, prompted consult at a private physician • Given Omeprazole, MefenamicAcid and Iselpin w/c relieved epigastric pain • Advised to drink Ensure but did not comply • Series of laboratory examinations done

  9. History of Present Illness • Day of admission • Follow-up consult for laboratory results showed elevated BUN, Creatinine, FBS, total cholesterol, triglycerides, HDL, LDL, SGPT, uric acid, K, and WBC? • (+) bipedal edema noted by the physician • Advised admission

  10. Temporal Profile

  11. Past Medical History • (+) UTI – 1997, treated for 1 month, became recurrent though no laboratories done to support the impression (frequency?), self medicated with Bactrim 1-2 doses per episode • Diagnosed with Hypertension (2005) • Losartan 50mg OD • Poor compliance • BP: 130-140/80-90 • Diagnosed with Diabetes Mellitus Type 2 (2005) • Gliclazide 80mg BID • Good compliance • Use of Herbal supplements • Taheebo for 6 months (2005) • (-) hx of nephrolithiasis, chronic use of NSAIDS?

  12. Family History • Hypertension • Diabetes Mellitus – both sides

  13. Social History • Non-smoker • Non-alcoholic drinker

  14. Review of Systems • (-) fever, dizziness, nausea/vomiting, decreased sensorium • (-) cough/colds • (-) changes in BM • (-) flank pain, LUTS

  15. Admitting Physical Examination • Vital Signs • BP = 140/80 • HR = 93 • RR = 17 • Temperature = 36.4 • Head and Neck • Dirty sclerae • Pink palpebral conjunctivae

  16. Admitting Physical Examination • No cervical lymphadenopathies • No tonsillo-pharyngeal congestion • Chest and Lungs • Symmetric chest expansion • Clear breath sounds • No retractions

  17. Admitting Physical Examination • Heart • Adynamic precordium • Distinct S1 and S2 • Normal rate • Regular rhythm • No murmur • Abdomen • Flabby abdomen

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

  19. Diagnostics

  20. CBC

  21. CBC

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