Patient Profile

2. Patient Profile C.P., 77 y/o female from Quezon City Roman Catholic Filipino, speaks Bicol, Filipino and English Married Collegegraduate Retired English Teacher at Claret Wakes up at and sleeps at 10 pm Right-handed Eats three meals (usually rice, fish, vegetables) a day with snack Bedridden for almost a year Receives monthly pension

3. Patient Profile • Non-hypertensive, non-diabetic • No asthma, no allergies • S/P Total Thyroidectomy (1995), on Levothyroxine of unrecalled dose until 2010 • S/P Appendectomy (1967) • Previous admissions • UTI (2000) • Pneumonia (2010, 2011) • Cataract, both eyes (2009) • No other known co-morbidities

4. Patient Profile Has family history of hypertension and heart disease on the paternal side Her sister has thyroid disease No family history of diabetes, asthma and cancer No history of smoking and alcohol intake

5. Chief Complaint Difficulty of breathing

6. TEMPORAL PROFILE

7. Pertinent Data • Pertinent Positives • Productive cough • Increased work of breathing

8. Pertinent Data • Pertinent Negatives • No fever • No chest pain • No orthopnea • No postnasal drip

9. Review of Systems General No fever, no easy fatigability, no sweating, no weight loss, no generalized weakness Skin No pruritus, no rashes, no, no changes in hair/nails. Eyes No redness, no tearing, no pain, no discharge or trauma, no double vision Ears No gross hearing impairment, no ear pain, no discharge, no tinnitus. Nose, Throat, Mouth Normal olfaction, with hoarseness, no sore throat, with frequent cough and colds, no neck mass, no facial pain, no sinus disorder, no dental caries, no toothache. Respiratory no wheezing/asthma, no hemoptysis. No PTB exposure. Cardiovascular No palpitations, no syncope, no edema Gastrointestinal No heartburn. No dysphagia, no nausea, no vomiting, no abdominal pain, no melena, no jaundice, no bleeding, no indigestion, no hematemesis, no anorexia, no change in stool frequency/character, no hemorrhoids, no abdominal distention, no hemorrhoids.

10. REVIEW OF SYSTEMS Urinary No pain, no retention, no polyuria, no nocturia, no history of stones, no recent history of infection, no hesitancy, no urgency, no change in color, no frequency, no dribbling. Extremities No cyanosis, no clubbing, no varicosity, no ulcers Hematologic No easy bruisability, no anemia Nervous System No headache, no tremor, no fainting spells, no seizures, no dizziness, no head trauma Musculoskeletal with joint stiffness, no swelling, no muscle weakness. Endocrine System Cold intolerant, no palpitations Psychiatric No mood swings, no behavioral changes, no anxiety or depression

11. Physical Examination General survey Awake, non-ambulatory, endomorph Vital signs BP: 170/90 HR: 80RR: 35 T: 36.1 C Skin Fair, warmto touch, no lesions HEENT Anicteric sclerae, pinkpalpebral conjunctivae, no tonsillopharyngealcongestion, moist lips and oral mucosa, non-distended neck veins, no carotid bruit, no neck masses Lymph nodes No palpable cervical, axillary and inguinal nodes Chest/Lungs Equal chest expansion, increased tactile fremitus on Left lung fields, resonant, crackles on all lung fields Cardiovascular Adynamic precordium, PMI at 5th intercostal space left midclavicular line, no thrill, no sternal heave, normal rate, regular rhythm, distinct S1 and S2, no murmurs Abdomen Flabby abdomen, hyperactive bowel sounds (18/min), tympanitic, soft, no tenderness, no palpable masses Extremities Grade 3 peripheral pulses, no bipedal edema, no cyanosis, with bilateral knee contracture

12. Impression Community acquired pneumonia, moderate risk; Osteoarthritis; Iatrogenic Hypothyroidism; S/P Total Thyroidectomy (1995); S/P Appendectomy (1967)

13. Problem List

14. Problem #1: CAP, MR S> History of O> HR 80 bpm, RR 35 cpm, Temp 36.1C, O2 sat 97% Increasedtactile fremitus on left lung fields, crackles on all lung fields A> Community acquired pneumonia, moderate risk P> For CBC - 136/41/13.3/74/26/338 For Sputum GS/CS For Blood CS For CXR – (Initial Reading) Blunted left costophrenic angle, left lower lung pneumonia For 12L ECG – Normal Sinus Rhythm, Non-specific ST-T wave changes Start on Ceftriaxone 1 gm IV q12 and Levofloxacin 500 mg 1 tab OD; Nebulization with Salbutamol, 1 ampule q6 and Ambroxol 2cc q12

15. Problem #2: BILATERAL KNEE CONTRACTURE  S> 6 years history of progressive bilateral knee stiffness which eventually resulted in non-ambulation O> Has bilateral knee contracture, non-erythematous, non-tender, limited range of motion of bilateral knees A> Osteoarthritis P> For bilateral knee x-ray

16. Problem #3: S/P TOTAL THYROIDECTOMY  S> S/P Total Thyroidectomy (1995); prescribed with Levothyroxine of unrecalled dose, taken with poor compliance O> HR 80 bpm Face, hands and feet not puffy Has voice hoarseness A> S/P Total Thyroidectomy (1995) P> For TSH - 23.5 uIU/mL (high) For FT4 – 0.30 ng/dL (low) For serum calcium – 1.7 mmol/L (low) Start on Levothyroxine 25 mg/tab 1 tab OD and Caltrate 1 tab BID