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CLINICAL EVALUATION

Patient encounter 1: Dr. Allan Dampil


Px: Aponino (Apolonia yung nasa notes ko- Ino) Borromeo "Vicky"
Age: 61 y.o.
Time of history taking (para lang uniformed tayo): 10:30am
Address: di natin nakuha :(
Mananahi (seamstress), hypertensive, hyperlipidemia (right?) dyslipidemic yung nasa notes ko
(liezel)
2004 went to PGH for surgery on her hand (right hand)
2005 started going to SLMC to have check ups
Diagnosed Hypertensive: 140/80 BP this morning
Today was a follow up as the last time involved lowering of her dosage by past Doctor
dizziness started a week prior to consult, occurs twice a day (usually at 11am and 8pm)
Episode is less than 10 seconds
Episode usually occurs when standing up after pananahi
Umiikot ang paligid
Nahuhulog sa left side during episode
Holds onto something (not sure) and sits down when episode occurs
Knee shaking during episode (not sure pero nasa notes ko)
Medications include Amlodipine and simvastatin (10mg,20mg respectively) (one tab in the
morning and one at night)
Pag may hinahanap (aggravating)
Associated symptoms
Umiikot ang paningin - yes
Dumidilim ba ang paningin? - no
nawawalan ba ng malay - no
No feelings of vomiting (except when BP is high)
Alleviating factor water intake
She lives alone and has her niece stay with her at night
Ano naiisip habang nahihilo- naalala ang mom and husband
Mom died of pneumonia and husband died of prostate cancer
Nahihirapan matulog. Just sleeps from 11pm-3am
Marami naiisip bago mangayari ang episode -
No headaches, no tremors, no loss of consciousness, hair doesn't fall off, no problems with
hearing, nor are there any secretions coming from her ears
There is some pricking pain that occurs in the left eye with no associated unclarity: grade of eye
is 300/350
No problem with her teeth nor throat
There is a pricking feeling on her left hand, like wearing gloves, everyday
No breast lumps are found
No pain in the pusod
Normal pee with no remarkable smell or color
Normal bowel movement, twice a day
Pain is feel in both feet and toes. "Naninigas"
Occasional pain in the scapula (palikpik)
Memory is good
Ddx: orthostatic hypotension, peripheral vertigo, central vertigo, insulinoma

Vital signs
Temperature 36.5
HR 62
RR 16
BP 180/90 on the left (also supine) and 170/100 on the right (also standing)

Patient encounter 2: Dr. Allan Dampil

Date & Time: August 23, 2017; 10:13am


Name & Age: Elma Delos santos, 58 years old
Gender, Status, Occupation: Female, Married, Seamstress
Address: New Manila (Brgy. Damayang Lagi, tama ba?)
Important conditions: diabetes (since 2008)
Referral, Source, Reliability:
Chief Complaint: Mabigat ang dibdib, - chest discomfort, madaling mapagod

Present Illness
Location
Quality - Feeling of loss of oxygen
Severity
Timing (onset, dur., freq.) - Heaviness of chest started in 2008, lasts anywhere from seconds to
up to 15 minutes and occurs about 3x a week
Precipitating factor -
Aggravating factor - physical exertion (climbing up stairs, washing clothes), kapag masama ang
loob (hindi daw nangyayari pag masaya siya), ---
Alleviating factor - Patient uses pillows to elevate her head, drinks a glass of water, massage
Associated (positives) - palpitation, shortness of breath, easily fatigued, wakes up in the middle
of sleep with a feeling of drowning
(negatives) - no dizziness, falls, pain, coughing
Other symptoms
Medications - metformin 500 mg 2x, simvastatin 20 mg 2x, isosorbide 30mg 1x, Aspirin 80mg
1x (Diltiazim was removed a year ago)
Allergies
Smoking, Alcohol, Drugs - None
Past History
Childhood illnesses - Chicken pox, measles, Beke
Adult illnesses -
Medical - diabetes (2008), hypertension (2008), malaki ang puso (2008) Commented [1]: was she hypertensive? in my notes
Surgical - Carpal tunnel (3 years ago), Trigger finger? (2 years ago) kasi, she was given medicine to prevent that but then
they stopped giving her medicine kasi she didn't need it
Obstetric - no children, pregnancies naman
Psychiatric - no history of mental illness
Commented [2]: this was trigger finger pala, i couldnt
Health maintenance understand what she said kasi rh haha
Immunizations - flu vaccine given 3 years ago
Screening tests

Family History
Parents - mother died at 64 y/o due to 27 stab wounds from hold-up accident, father died at 73
(may sakit sa puso, natumba sa labas - pano to sa english haha)
Grandparents
Siblings - 4th of 5,
Children - no children, has adopted 19 y/o daughter or son?
Grandchildren - none
Family conditions
1st sibling - male, hypertension, enlarged heart
2nd sibling - female, diabetes, heart problem
3rd sibling - male, diabetes
5th sibling - male died at 40 years old, chest pain, high cholesterol, suspected to have diabetes

Personal and Social History


Educational level - high school grad
Family of origin - from Capiz City
Current household - lives with husband and adopted 19 y/o child (m or f?), has pet cat
Personal interests
Lifestyle - likes to watch the tv, attends church activities including choir and prayer meetings
Exercise, Diet - avoids sweet food like mangoes, eats 3x a day, eats bread for breakfast,
attends weekly zumba
Safety measures

Review of Systems
General - loss of weight at a steady pace -- due to change in diet
Skin - Rashes ( 2 years ago)
Head - no hair loss
Eyes - 250,250
Ears - no pain, hearing loss , no discharge,
Nose, Sinuses - ubo (dry), 2 weeks - given ambroxal, amoxillin and citirizine but coughing is still
Commented [3]: move to throat?
occuring
Commented [4]: Respiratory yata
Throat, Mouth - uses dentures
Neck - mass at the back part of the neck
Breasts - no masses felt
Respiratory - no coughing of blood, asthma during younger years
Cardiovascular -
Gastrointestinal - bowel movements 2x a day, solid, no blood,
Peripheral vascular - no
Urinary - No pain, abnormal smell or blood. Wakes up to 2x a night to urinate
Genital - no itchiness or discomfort
Musculoskeletal - Back Pain attributed to coughing (not sure if muskuloskeletal)
Psychiatric
Neurological
Hematologic - doesnt bruise easily
Endocrines

Physical Exam (yung sa ibang parts, sabihin na lang daw na normal)


General - responds quickly, looks weak, hygiene is good
Vital signs - height is 411, weight is 65 kg, BP: R: 130/70; L 140/80, HR is 70, RR is 25, temp
is 37.6 taken through ear
Skin
Head
Eyes
Ears
Nose
Throat, Mouth
Neck
Back
Posterior thorax, Lungs
Breasts, Axillae, Nodes
Upper extremities
Anterior thorax, Lungs - Normal fremitus, symmetrical breathing, no observable deformities,
no crackles or wheezes, resonant on percussion,
Cardiovascular - Grade 1 or 2 systolic murmur heard best on the apex but also radiates to the
left parasternal area (2nd ICS) ; thrills
Abdomen
Normal skin color and temperature
Abdominal contour: protuberant
No palpable mass
Liver span: 8cm; dull sounds (normal)
Bowel sounds: 21/min