Date and time of interview: May 11, 2016; 6:00 in the evening

Referral: Schistosomiasis Hospital in Palo

Source of Information: The patient and his daughter
Reliability: 80%
I. Identifying Data:
Escapatora, Gorgonio, 62 years old, male, married, Roman Catholic,
unemployed has been admitted for the first time on May 11, 2016 at 3:00 in the
afternoon.
II. Chief Complaint
Dyspnea
III. History of Present Illness
Three days PTA, the patient experienced dyspnea after drinking cold water
and from lifting heavy objects. The symptom last for 3 hours. Patient claims that the
symptom was aggravated when their patient had the latter activities mentioned. It
was associated by cough that has been present for 1 week with 3 tbsp of yellowish
phlegm per spit and a two pillow orthopnea. No fever. No medication taken. No
consultation done.
Eight hours PTA, upon waking up the patients dyspnea worsens. It was
associated with fever but still with productive cough to a yellowish phlegm. Patient
present with general body malaise and fatigue hence consult at Schistosomiasis
Hospital in Palo then referred to this institution for further management.
IV. Past Medical History
A. Childhood Illness: + Chickenpox, + measles, + mumps
Immunizations: Complete immunization
B. Medical
1st: admitted for Hepatitis as claimed but did not finished the laboratory work
ups, Schistosomiasis Hospital.
2nd : admitted for difficulty of breathing; Schistosomiasis Hospital, unrecalled
medications taken, improved.
C. Surgical : None
D. Psychiatric: None
V. Family History
Mother died at 93 because of old age
Father died at 70 because of old age
10th among the 13 siblings, alive and well except one who died of stroke.
Family history of hypertension.
V. Psychosocial History:
Born and raised in Pastrana. An elementary graduate. House made up of light
materials consisting of one room. Water sealed toilet located outside the house.
Drink tuba and beer for how many glasses till drunk. Eats Fatty and salt
Born and raised in Pastrana. An elementary graduate. House made up of light
materials consisting of one room. Water sealed toilet located outside the house.
Drink tuba and beer for how many glasses till drunk. Eats Fatty and salty foods.
Drink one cup of coffee everyday. Do exercises. Smoking of 20 pack years. Not
active in any organizations.
VI. Review of Systems

General: weight loss ( 40 kg to 35 kg) , weakness, fever , no

fatigue.

Skin: No rashes, no lumps ,no sores, no itching dryness, no changes in

color; no changes In hair or nails; no changes in size and color of hair,
nail and moles.
HEENT:
Head- headache, dizziness, lightheadedness ;
Eyes: no pain, redness, excessive tearing, double or blurred vision,
spots, specks, flashing lights,
Ears: no tinnitus, vertigo, earaches, discharge, use of hearing aids
Nose and sinus: colds, nasal stuffiness, discharge of watery clear
mucus , or itching, no nosebleeds ;
Throat (mouth and pharynx): no bleeding gums, dentures, dry mouth,
frequent sore throats, hoarseness.
Neck: no goiter, lumps, pain or stiffness
Breasts: NO lumps, pain or discomfort; nipple discharge, self
examination practices.
Respiratory: dry cough, wheezing , dyspnea
Cardiovascular: no chest pain, palpitations, dyspnea. No high blood
pressure, , orthopnea, paroxysmal nocturnal dyspnea, edema
Gastrointestinal: No dysphagia, heartburn, nausea., constipation,
diarrhea. Abdominal pain, food intolerance, excessive belching or
passing of gas.
Peripheral vascular: Edema No intermittent claudication, leg
cramps, , color change especially in the finger tips or toes.
Urinary:
male: No discharges, itching, sores, lumps, sexually transmitted
disease and treatment.
Musculoskeletal: NO muscle or joint pain, stiffness.
Psychiatric: No nervousness, tension, mood, including depression,
memory change, suicide attempts.
Neurologic: Headache, dizziness. No change in mood, attention,
speech. No changes in orientation, memory, insight, judgement, ,
seizures, weakness, paralysis, numbness or loss of sensation, tingling
of pins and needles, tremors, involuntary movements.
Hematologic: No easy bruising or bleeding.

Endocrine: No heat or cold intolerance, , thirst, hunger, polyuria

Autonomic : excessive sweating
PHYSICAL EXAMINATION
Magdalena Sabio, a mesomorph, middle age adult in her late 40s,
was conscious, coherent, alert, oriented to time, place, and person, was
cooperative and responded quickly to questions.
Vital signs:
T 37.8, PR- 130 bpm , HR 130 bpm , RR 30 c[m, BP- 90/ 80.
Skin: with jaundice. Palms warm and moist. Good skin turgor,
brown complexion, no suspicious nevi, no rash, petechiae or
ecchymoses. Nail pale in color. No nail clubbing, no cyanosis, capillary
refill more than 3 seconds, smooth, no ridges, no breaks, trimmed.
HEAD
Normocephalic, no deformities, lumps or tenderness. Hair evenly
distributed, black in color. No dandruff, or lice. No scalp lesion,
tenderness, no scars, no engorged veins, no redness. Face
symmetrical, no edema, masses, or facies.
EYES
No redness, no crusting, no lesions on the eyelids, with adequate
closure; eyelashes directed outward. Pale conjunctiva, no hemorrhage,
no nodules, no swelling. Sclera icteric with no hemorrhage.Cornea and
lens has no opacities, no scars, no ulcerations. Iris brown, flat, casts no
shadow when lighted directly from temporal side. Pupils symmetrical,
constrict to 3 mm in diameter, equally round and briskly reactive to
direct and consensual light stimulation.
EARS
Ears are symmetrical and the auricles are aligned with the outer
canthus of the eyes. No impacted cerumen, no discharges, no
tenderness. Acuity of hearing is good to normal and whispered voice.
NOSE AND SINUSES
Yellowish thick discharges. Pale mucous membrane, septum at
midline, no congestion, no nasal flaring, no sinus tenderness.
MOUTH and THROAT
Lips symmetrical, pink, no lesions, no cheilosis, no angular
deviation; Buccal mucosa: pink, moist mucous membrane, no lesion;
Teeth: missing left and right upper third molar, with dentures for left
incisor, fair oral hygiene; Gingiva: no swollen gums, uvula at midline;
Tonsils: neither enlarged nor inflamed, no redness, no abscess. Pharynx
without exudates
NECK

Neck supple.
With neck vein engorgement, carotid pulse full,
neck supple, no lesions, no thyroid gland enlargement (palpable during
deglutition), trachea at midline with coordinated muscle movement. No
bruit or tenderness. No scars or masses. No lymphadenopathies.
BREAST
Symmetrical, no lumps, no masses, no discharges, everted
nipples.
CHEST and LUNGS
No chest deformities, or lesions. Normal chest expansion. No
edema, no intercostal retractions, no tenderness, no lagging. Normal
tactile fremitus. No tenderness, mass, or lumps. Both lungs resonant.
Vesicular breath sounds. Wheezes and crackles all over lung fields. No
pleural friction rub.
HEART
JVP is 6cm above the sternal angle with the head of the bed
elevated at around 30 degrees. Carotid upstrokes are brisk. Patient not
cyanotic. No venous engorgement. Thoracic cage normal, no abnormal
pulsation. No precordial bulging. Apical impulse at left fifth intercostal
space medial to the midclavicular line. No heaves, lifts, or thrills
palpated. Heat rate70 beats per minute, regular rhythm synchronous
with pulses. No murmurs, or pericardial friction rub. S1 and S2 distinct.
S1 beat heard at apex, S2 best heard at base. No pericardial friction
rub noted.

ABDOMEN
Abdomen flat. No mass, visible pulsation, abdominal scars, striae, dilated
veins, rashes, or ecchymoses. Umbilicus inverted. Normoactive bowel
sounds, no bruits, no peritoneal friction rubs. Tymphany over the stomach
and gas-filled bowels. Negative for splenic percussion sign. No shifting
dullness and negative fluid wave. No pain and tenderness in kidneys. Non
palpable liver, spleen, and kidney.
Extremities:
Inspection: no edema, no weakness, no deformities, no cyanosis, no
atrophy.
Palpation: no muscle tenderness; radial, popliteal, and dorsalis pedis
pulse equal on both sides and of regular rhythm.
Back and Spine:
Inspection: no abnormal deviations, no retractions, no bulging, no
muscle wasting.

Palpation: no paravertebral tenderness/mass

NEUROLOGIC EXAM
MENTAL STATUS:
Quiet, conscious, tidy, cooperative and oriented to time, place and person,
with good insight and judgment, with intact short term and long term
memory and able to do simple calculations
Language and speech No sensory or motor aphasia, and dysarthria
Cranial Nerves:
I no anosmia
II pupils constrict in 3mm in diameter, pupils briskly reactive to light with
direct and consensual eye reflex, good peripheral vision
III, IV, VI moves eyes, downward, upward, medially and laterally (full and
intact EOM)
V normal sensory function to pain and touch, normal corneal reflex
VII smiles, able to frown, raise eyebrows, puff cheek, no tongue deviation
s, and close eyes tightly
VIII- responsive to verbal stimuli, able to hear snapping fingers or ticking of
the wrist watch
IX, X able to swallow, normal gag reflex
XI able to turn head both sides against resistance, able to lift shoulder
against resistance
XII protrudes tongue
Motor Function
Muscle strength is grade 5/5 on major muscle groups, can flex and extend
both upper and lower extremities without limitation and against full
resistance, no atrophy of muscles, no involuntary movements, no spasticity,
no rigidity, and no flaccidity
Sensory
Sensitive to pain, touch and pressure on right and left upper and lower
extremities including the trunk, no astereognosis, intact number
identification and two point discrimination.
Cerebellar
No involuntary movements, no ataxia, incoordination, unsteady movement,
or poor position sense
Reflexes
Biceps 2+
Triceps - 2+
Brachioradialis - 2+
Pattelar - 2+
Plantar - 2+
Pathologic Reflexes
(-) Babinski reflex
(-) Ankle clonus
Meningeal Signs:

(-) Nuchal rigidity

(-) Brudzinkis sign
(-) Kernigs sign
Autonomics
No bowel or urinary incontinence, no excessive sweating
Impression:
Chronic Heart Failure Class III from Coronary Artery Disease CAP- MR
Chronic Heart Failure
Basis:
Dyspnea
Jaundice
Dizziness and weakness
Crackles and wheezing all over lung fields
Bipedal edema
Neck vein engorgement
Elevated jugular venous pressure
Hepatomegaly
CAP MR
Basis :
Disposition: Ward admission
Temp: 37.8, HR: 130, RR: 30, BP: 90/80
Differential Diagnosis
Nephrotic syndrome : Rule in
Dyspnea
Rule out
generalized edema ,non hypertensive, common in
children
Cor Pulmonale
Rule in
Dyspnea
Rule out
Ascites, abdominal pain, hx of COPD
Liver Cirrhosis
Rule in
Dyspnea
Rule out
Ascites and splenomegaly
Diagnosis
1. 2D echo with Doppler: evaluation of the heart
2. 12L ECG: for cardiac rhythm and LV hypertrophy
3. Chest xray: Cardiac size and shape
4. CBC: for anemia, bleeding
5. BUN, Crea, AST, ALT- passive congestion of the liver
Therapeutics:
1. Ace inhibitors; Captopril 25-50 mg TID

2. ARBs- Losartan 25-50 mg TID

3. Beta blockers- Cardevilol 25 mg TID
4. Digoxin 0.125 0.375 mg; symptomatic LV dysfunction and atrial
fibrillation
5. Diuretics: loop diuretics:
Inhibit the reabsorption of sodium, potassium, chloride in thick
ascending limb
Furosemide 20-40 mg/ kg OD to BId