ILOILO DOCTORS COLLEGE OF MEDICINE

MOLO, ILOILO CITY

INTERNAL MEDICINE II PRECEPTORIAL

LAJEL S. LACHICA MEDICINE 3 January 13, 2020

General Data
This is a case of patient JAD, a 60 year old, female, married, an Aglipay and a
resident of Dumangas, Iloilo. She was admitted last December 27, 2019. This is her
1st admission at Iloilo Doctors’ Hospital. The informant was the patient and her
husband and is 80% reliable.

Chief Complaint
Difficulty of breathing

History of Present Illness

7 weeks prior to admission, patient experienced intermittent and productive
cough early in the morning and in the afternoon with clear frothy sputum in
consistency, with no foul smelling odor noted having an amount of 1/2 teaspoon.
The patient experienced difficulty of sleeping and difficulty of breathing at night due
to cough. Patient also experienced gnawing pain while coughing at the right upper
posterior chest and right midaxillary chest that is radiating to the right midscapular
chest with a pain scale of 5 out of 10. The patient took carbocisteine 100mg capsule
three times a day for 2 days with no relief noted. She took also herbal medication
once a day for 1 week with no relief. There are no other alleviating or aggravating
factors noted.
6 weeks prior to admission, there was a persistence of productive cough and
associated signs and symptoms. No other interventions done and no other pertinent
positive and negative signs and symptoms noted until the following weeks.
2 weeks prior to admission, still with productive cough. Patient consulted a
physician and was advised for a chest xray with no medications prescribed. No other
interventions done.
1 week prior to admission, patient’s chest xray result showed right pleural
effusion and in the right lower lung field with infiltrates. It was also found out that
there was atherosclerotic aorta. She was prescribed medications such as myrin forte
(rifampicin, isoniazid, pyrazinamide, ethambutol,hydrochloride) 3 tablets once a day,
2 hours after meals, losartan once a day, furosemide 1/2 tablet once a day after
meal and levofloxacin1 tablet once a day after meal and is compliant.
2 days prior to admission, still, with persistence of productive cough and other
associated signs and symptoms. She sought consult at a district hospital and was
advised to have chest xray. Still, with the similar result with the previous one. She
was given an IV and oxygen therapy with temporary relief. She was transferred to
WVMC for better management and was admitted at the ER for 2 days. Her blood
pressure was 160/100 mmHg.
 On the day of admission, there was a persistence of signs and symptoms. The
patient was trasfered at Iloilo Doctors’ Hospital. Thus, this admission.

Past Medical History

Patient has childhood illness such as chicken pox and mumps. There is no history
of food and drug allergies. Patient had history of trauma and accidents. The patient’s
childhood immunization is complete as verbalized. Patient had pneumonia vaccine
last November 27. The patient is hypertensive with maintenance medication such as
losartan 50 mg once a day and is compliant. No other heredo-familial diseases noted
such as asthma, diabetes and cancer.

OB History
The patient’s ob score is G3P3(3003) with regular menstrual cycle that lasts for
3-7 days without dysmenorrhea and consumes 2 pads of napkin per day. Her
menarche is 17 years old. She had her menopause at 58 years old. She gave birth via
NSVD. Not using any contraceptives.

Personal History
The patient finished education until 1st year college. She works as a babysitter
for 20 years and she also sells oysters. Her husband is a fish pond operator. Patient
consumes 1 cup of rice, fish and vegetables everyday. She drinks 2 liters of water a
day. She drinks coffee three times a day and drinks soda everyday. She sleeps at 8pm
and wakes up at 5am. She sometimes exercise by doing brisk walking for 30 minutes.
The patient is non smoker and does not drink alcoholic beverages. She defecates
once a day.

Family History
The patient had 12 siblings, 3 are now dead, 2 had hypertension which is the
eldest and the 2nd sibling. she had 3 children with no other heredofamilial diseases.
Both of the patient’s parents are dead, her mother at 78, is asthmatic and her father
at 85 years old who is hypertensive. Her husband is a smoker.

Socioeconomic History
The patient is living in a non-congested, rural area. Her house is made of mixed
materials. They have 2 bedrooms and 1 flush type comfort room. They don’t have a
septic tank. Their waste is directly going to the river which is 2 meters away from
their house. They use mineral water for drinking and the deep well for household
chores. The garbage is being burned. Their monthly income is P10,000.00. No known
community illness.

Review of System

Weight loss from 43 to 41 in a week.

Physical Examination

General Survey
 Patient was lying on bed, awake, conscious, oriented to time, person and place,
afebrile and was in cardiopulmonary distres and was . She was seen on the 12 th day
of admission with the following vital signs:
BP-110/80 mmHg
CR-82 bpm Weight- 41 kg
PR-85 bpm Height- 5 feet
RR-27 bpm
T-36.4 degree Celsius BMI=17.7 kg/m2

Skin
Dry, brown, no rashes, no redness, no swelling and tenderness
HEENT
Head-
Configuration- normocephalic Hair- normal texture Scalp- no lesions,
tendernes she head is symmetric and normocephalic. No scar, injury or observable
mass noted, no palpable mass and tenderness noted
Eyes-
Sclera- white; Conjunctiva- pink; Pupils are equally round, aligned and reactive to
light and accommodation. Symmetrical corneal light reflex. Both eyes have red
orange reflex. Visual fields full to confrontation.
Ears-
pinna, tragus and external canal non tender. Tympanic membrane was gray and
clear, both ears were smooth, fine and non tender. No masses noted.
Nose-
Nose is symmetrical, no inflammation, redness, nasal septum is in midline. No
nasal discharges or flaring noted, pink nasal mucosa, no palpable masses noted.
Mouth and throat-
No redness, swelling, tenderness noted. The lips are symmetrical and smooth
and dry. Tongue is symmetrical, pinkish. Uvula is in midline. Tonsils symmetric, no
adenopathy. Pharynx without exudates. Poor dentition with 1 central incisor can be
found anteriorly and molar teeth with dental carries were noted.

Respiratory
No mass, no redness and lesions noted, no scars, there is lagging at the right
middle and lower posterior chest, absent breath sound at right and left lower lung
field.

Cardiovascular
Adynamic precordium, no lesions, no mass noted, PMI is located on the 5th
intercostal space left midclavicular line. No costochondral tenderness noted. Regular
cardiac rhythm. No gallop and heart murmurs in both systole and diastole; weak
radial pulse

Abdomen
 no presence of scars, striae, dilated veins, rashes or ecchymoses; abdomen is
flat; active bowel sounds with 5-30 clicks per minute in four quadrants; soft and
nontender; no masses or hepatosplenomegaly; the liver span is 7cm in the right
midclavicular line; the edge is smooth and palpable 1cm below the right costal
margin; negative kidney punch sign

Extremities
Upper:
Nails-no cyanosis, no clubbing Palms- nornal color, texture Muscles- normal size
Joints (including ROM)
Interphalangeal- normal ROM no deformities
Wrists- Radial pulse- weak on both

Differential Diagnosis
Pulmonary Tuberculosis
Malignancy

Initial Impression
Community Acquired Pneumonia