JUMBO – HOTDOG

1. JUMBO – HOTDOG Samantha V. Cosalan MD 080032

2. HISTORY

3. IDENTIFYING DATA • F.D., 47 year old • Male • Single • Filipino, Roman Catholic • Lives in Mandaluyong • Works as an Area Manager of Jollibee • Source of data from the patient and his girlfriend, fair reliability • Admitted November 12, 2011 • History and Physical Exam done November 15, 2011

4. CHIEF COMPLAINT • Fever • Dizziness

5. HISTORY OF PRESENT ILLNESS • On the day of admission, patient developed persistent dizziness described as “drunk-like”, not aggravated by head movement, and was relieved by rest • Patient also had fever (Tmax 39.8 C), intermittent dry cough of 1 week duration and generalized body weakness • No associated nausea, vomiting, ear symptoms • Self medicated with Alaxan 500mg and Biogesic, minimal relief • Patient was brought to the TMC ER by his girlfriend where the initial impression was SVI vs URTI • Patient was advised admission for further work-up due to persistence of symptoms despite treatment

6. Patient was admitted at Room 1424 • (+) Discoloration or dorsal aspect of both lower extremities • Right leg: red, swollen, tender • Persistence of fever, T = 38.8 C • Diagnosis at the floors was Cellulitis, right lower extremity • On the patient’s 3rd hospital day, desaturations were noted and he was moved to the ICU • Girlfriend reports that the patient snores excessively at night at that is tired most of the day • Patient denies DOB, chest tightness, lethargy

7. PAST MEDICAL HISTORY • Asthma, no maintenance medications, last attack >30years ago • Dengue (2005) • Patient took no medications (steroids) in the past • No HTN, Diabetes, TB, Liver/Heart/Kidney Disease • No maintenance medications • No previous surgeries • No history of wading in flooded waters • No history of recent travel • No known allergies to food or medications • Patient has regular yearly check-ups with doctors

8. FAMILY HISTORY Patient’s mother – HTN, Stroke Younger brother – HTN Patient’s father – DM No TB, Asthma, Kidney/heart/liver disease

9. PERSONAL/SOCIAL • Works as an Area Manager of Jollibee • Lives with his girlfriend in Mandaluyong • Diet is “well balanced” • Pork, chicken, rice, vegetables • Girlfriend however claims that he eats very large servings • Patient has always been a heavy eater and has been overweight since childhood • He is not allowed to do strenousexercises (basketball) since his doctor claims that his knees won’t hold his weight • Recently started walking 3x/week for 30-45 min and occasionally plays badminton • Employer is monitoring his weight loss as part of Performance Management • Does not smoke, drink or take any illicit drugs

10. ROS • General: No weight changes • Skin: No lumps, sores, itching, dryness, color change, changes in hair or nails • HEENT: No history of head trauma, lightheadedness, blurring of vision, eye tenderness, double vision, flashing lights. No sore throat, hoarseness, dry mouth • Neck: No lumps, tenderness, stiffness • Respiratory: No hemoptysis, dyspnea, wheezing • Cardiovascular: No chest pain or discomfort, palpitations, dyspnea, orthopnea, edema • Gastrointestinal: No difficulty swallowing, heartburn, changes in appetite, rectal bleeding, abdominal pain, jaundice

11. Urinary: No frequency, nocturia, urgency, burning or painful urination, incontinence, hesitancy, dribbling • Genital: No hernias, discharge, testicular pain or masses • Peripheral Vascular: No claudication, leg cramps, varicose veins • Musculoskeletal: No muscle or joint pains, stiffness, arthritis, gout • Neurologic: No fainting spells, blackouts, paralysis, numbing or loss of sensation, tingling, tremors, involuntary movements • Hematologic: No easy bruising or bleeding • Endocrine: No heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria

12. PHYSICAL EXAMINATION

13. GENERAL SURVEY • Patient is alert, awake, not in respiratory distress • Patient is lying in bed, comfortable, is of heavy build, well groomed wearing a hospital gown • Patient appears agitated and is uncooperative during the interview

14. VITAL SIGNS

15. ANTHROPOMETRICS • BMI = 42 (Obese Class III)

16. HEENT • Hair is of average texture, no lesions on the scalp • Pink oral mucosa, septum midline, good dentition, no sinus tenderness • No TPC, CLAD • Supple neck, trachea midline, no neck enlargement/masses

17. CARDIOPULMONARY • Equal chest expansion, lungs resonant • Clear breath sounds with no rhochi/rales/wheezes • Adynamic precordium, normal heart rate with regular rhythm, good S1 and S2 no murmurs, no heaves or thrills, apex beat at 5thICS left MCL

18. ABDOMEN • Flabby, soft, normoactive bowel sounds • Nontender, no surgical scars, no organomegaly • Liver span 7cm in right midclavicular line • Spleen and kidneys not palpated • Traube’s space intact

19. EXTREMITIES • No atrophy and weakness on all extremities • Right lower extremity • Red, swollen, tender, warm to touch • (+) Hyperpigmentation on both lower extremities • Full and equal pulses

20. NERVOUS SYSTEM • Patient is alert and agitated, GCS 15 • Right handed • Thought is coherent and oriented to person, place and time • Cranial nerves intact • Good muscle bulk and tone, 5/5 strength, reflexes +2

21. SALIENT FEATURES • Fever and dizziness • Morbidly obese, Class III (BMI 42) • Hyperpigmentation on both lower extremities (cyanosis) • Cellulitis, right lower extremity • Patient is a heavy eater • (+) Snoring at night • Episodes of desaturation at the floors

22. WORKING IMPRESSION Cellulitis on the R lower extremity t/c Obesity Hypoventilation Syndrome

24. DIFFERENTIALS

25. OBESITY HYPOVENTILATION SYNDROME • Based on Charle’s Dickens’ book The Posthumous Papers of the Pickwick Club • Character Joe • “wonderfully fat boy, standing upright with his eyes closed”

26. Poor breathing leads to lower oxygen and higher carbon dioxide levels in the blood • Main symptoms • Sleepiness, depression and headache • Chronic hypoxia (shortness of breath, easy fatigability) • Physical Exam • Bluish color in lips, fingers, toes or skin • Right sided heart failure (swollen legs or feet, SOB) • Treatment • BiPAP, tracheostomy, oxygen • Weight loss