History..a Lot

I.
PATIENTS PROFILE
Name: Alfredo Ortiz Perida Case No: 336059

Age: 57 years old Sex: Male Civil status: Married
Address: Brgy. Guindapunan Carigara, Leyte Occupation: Fish Vendor
Religion: Roman Catholic Nationality: Filipino
Birthday: March 14, 1950 Birthplace: Barugo, Leyte
Date of Admission: April 26, 2007 Time: 1:15PM
Father: Deceased Mother: Lucena Ortiz
Wife: Rufina Perida
Attending Consultant: Dr. Zeta
Chief Complaint: “Nanluya ak, namusag, nagsirom an pangitaan ngan sumakit an akon
dughan.”
Diagnosis: Hyperglycemia, Diabetes Milletus Type II
II. History Present Illness

Few hours on the day of the admission, the patient woke up with dizziness and
body malaise. Then when he was putting ice on the fishes that he is going to sell that day,
his dizziness worsened. Not only that, the dizziness was accompanied by blurring of
vision, diaphoresis and fainting or syncope. So the patient immediately consulted a
private doctor but was not accepted. Then he was brought to the emergency room of the
Carigara District hospital. According to the patient, his BP at that time was 50/30mmhg
and then increased to 90/70mmhg. Finally the patient was refereed to this institution.
III. Past History

• The patient had experienced measles during his childhood years.
• As far as the patient can remember, he had completed his immunization.
• The patient is not allergic to any drug, food, plants and others.
• In the past, the patient did not encounter any accident or injury.
• The patient was hospitalized last 2004 still for the same reason, DM.
• The patient had a maintenance drug, which is Diamicron. He usually takes the
drug every morning and afternoon. This was for three years but he stopped for a
month now.
IV. Family History

According to the patient, his family has no history of Diabetes Milletus,
hypertension, asthma, arthritis or even cancer.
V. Lifestyle
• Before, when the patient was not yet diagnosed with DM, he admitted that he was
a strong alcoholic and smoker. But because of his condition, he minimized his
drinking and smoking habits. If before almost everyday he drinks alcoholic
beverages, now he tries very hard to drink only about 2-3 times a week and now
he also smoke sometimes.
• According to the patient, he has no difficulty sleeping.
• The patient is a fish vendor, so his usual activities is of course going to the market
and selling his fishes.
• The patient does not have any exercise regimen. One of his hobby is playing cards
especially tong-its.
VI. Social Data

• In times of stress, his family is very much supportive of him, not only financially
but especially emotionally.
• Before he became a fish vendor, he was first a driver. Then after he changed his
job to selling fish in the market.
REVIEW OF SYSTEMS
General: No weight loss, no fever and chills.
Skin: Wound on the left big toe, scars on the lower extremitied, hyperpigmented shiny
skin on the feet, no rashes and pruritus.
Head: No headache, injur or tenderness.
Eyes: Blurring of vision, no excessive tearing or no discharges.
Ears: Dizziness, no discharges, no pain
Nose: No sneezing, epistaxis or no change in sense of smell
Throat: No bleeding gums, no lesions
Respiratory: No cough, chest pain, no hemoptysis, diaphorsis.
Cardiovascular: Chest pain
Gastrointestinal: Polyphagia
Genitourinary: Polyuria
Endocrine: Fatigue
Musculoskeletal: No stiffness or limitation of movement.
PHYSICAL EXAMINATION
General: The patient is an adult, 57 years old male. He is not assuming any usual
position. He is also cooperative, pleasant and easy to talk with.
Vital Signs:
• Temperature= 37°C
• Respiratory rate: 22 breaths per minute
• Blood Pressure: 100/60mmgh
• Pulse rate: 50 beats per minute
Head: No tenderness or mass, symmetrical, absence of nodules and symmetrical facial
movements.
Skin: Ski color ranges from light to dark brown, hyperpigmented shiny skin on the feet,
no edema, wound on the left big foot, moist skin folds, good skin turgor.
Hair: Evenly distributed, no infection or infestation.
Eyes: No blurring of vision at the moment
Ears: no tenderness and no hearing impairments
Nose: symmetrical, no lesions, inflammation, or congestion.
DIAGNOSTIC EXAMS
I. Ultrasound Report (April 26, 2007)

Findings: Chest x-ray PA view
Upright film shows no definite lung parenchymal infiltrates. Trachea at midline,
heart is not enlarged. Intact both hemidiaphragms with sharp skull. The visualized soft
tissues and osseous structures shows no identifiable abnormalities.
Impressions: Normal chest findings.
II. Urinalysis (April 26, 2007)
Exam Result Normal Findings Significance

Color Yellow Colorless to dark Normal
yellow
Transparency Turbid
pH 6.0 4.6-8.0 Normal
Specific gravity 1.025 1.006-1.030 Normal
Albumin Negative Negative Normal
Sugar (+) Negative Diabetes
Pus cells 0-2/hpf
Red blood cells 0-2/hpf
Epithelial cells Some
Bacteria Few None
A.urates Few
Mucus threads Moderate
Ketones Negative Negative Normal
III. Laboratory Report
Exam Result Normal Values Significance

Glycosylated 8.4% 3.9-6.2% Increased in
Hemoglobin Diabetes Milletus
IV. Clinical Chemistry (April 26, 2007)

Sodium 135mmol/l 135-148mmol/L Normal
Potassium 4.25mmol/L 3.5-5.3mmol/L Normal
Chloride 102.5mmol/L 98-107mmol/L Normal
V. Hematology (April 26, 2007)

Hemoglobin 123g/L Male: 135-170g/L Decreased in
Female: 120-160g/L hemodilution(fluid
overload), anemia,
recent hemorrhage
Hematocrit 0.37 Male: 0.40-0.54 Decreased in
Female: 0.36-0.47 hemodilution, anemia,
and acute massive blood
loss.
Erythrocytes 4.33x1012/L Male:4.6-6.2x1012/L Decreased in anemia,
Female:4.2- fluid overload, recent
5.4x1012/L hemorrhage, leukemia.
Leukocytes 10.60x109/L 4.5-10.0x109/L Increased in infection,
leukemia, tissue
necrosis.
Granulocytes 0.79% 0.500-0.750% Increased in
inflammatory disease,
tissue necrosis, anemia,
allergic reactions.
Lymphocytes 0.18% 0.200-0.350% Decreased in AIDS,
corticosteroids,
immunosuppressive
drugs.
Monocytes 0.03% 0.20-0.060% Decreased in drug
therapy and prednisone.
MCV 86 fl 80-96 fl Normal
MCH 28.40 pg 27-31 pg Normal
MCHC 330 320-360 Normal
I. PATIENTS PROFILE
Name: Bernabe Rañin Petallana Sr. Case No: 336375

Address: Cutay, Carigara, Leyte Occupation: Motorcycle Driver
Birthday: October 8, 1970 Birthplace: Carigara, Leyte
Date of Admission: April 30, 2007 Time: 11:30 AM
Father: Deceased Mother: Milagros Petallana
Wife: Liza Petallana
Chief Complaint: “Hataas an akon hiranat ngan naglagdos an akon sorok-sorok.”
Diagnosis: Typhoid Fever with Ileitis

15 days prior to admission, the patient experienced abdominal distention which
was accompanied by fever. He did not consult to any doctor. He took Paracetamol for
relief of fever. 3 days later, he decided to consult a doctor in their area. His doctor told
him take antibiotic.
The symptoms of the patient started 15 days PTA. Often his fever occurs in the
afternoon. He experiences pain in his abdomen especially in RUQ. In a scale of 1-10
wherein 10 is most painful, the patient described the intensity of the pain he is
experiencing as 8. He felt the symptoms when he was driving the motorcycle. Other than
fever, there are no other symptoms associated with abdominal distention. According to
the patient, the pain becomes severe when he is eating. On the other hand, it dos not have
an effect whether he sits, stands or lie down.
III. Past History

• The patient is negative for childhood illnesses.
• The patient can no longer remember about his immunizations.
• The patient was never hospitalized in the past. This is the first time he was
admitted to the hospital.
• When the patient had fever, he took Paracetamol and antibiotics that was
recommended by the doctor.
IV. Family History

According to the patient, his family has no history of Diabetes Milletus,
hypertension, asthma, arthritis or even cancer.
V. Lifestyle
• Before, the patient drinks about 2 liters of tuba. He also smokes in the past. But at
the moment, he admitted that he now drinks whenever there is an occasion and he
seldom smokes.
• The patient verbalized that he usually eats fish and vegetables everyday, and he
doest not eats street foods.
• According to the patient, he has no difficulty sleeping.
• The patient is a motorcycle driver. He usually wakes up at around 7 in the
morning and goes to work and goes home at around 4 in the afternoon.
• The patient does not have any exercise regimen.
VI. Social Data

• The patient’s highest educational attainment is 3rd year high school.
• Before he was a farmer. And when he got married, he became a motorcycle driver,
about 14 years now.
• The patient does not have any medicare.
• The patient lives in a semiconcrete house in Carigara, leyte with 2 rooms. He also
lives with his wife and 5 children. Their house is located near the main road. They
have a water sealed toilet and deep well as a source of water.
REVIEW OF SYSTEMS
General: Weight loss, fever and chills.
Skin: No rashes, bruising, pruritus and no hypo or hyperpigmented skin.
Head: No headache, injury or tenderness.
Eyes: No excessive tearing or no discharges and blurring of vision.
Ears: No discharges, no pain
Respiratory: No cough nand colds, diaphoresis.
Cardiovascular: No chest pain, palpitations nor dyspnea.
Gastrointestinal: Abdominal distention, passage of yellow watery stool.
Genitourinary: No dysuria, polyuria and no oliguria.
Endocrine: Fatigue
General: The patient is conscious, coherent, and oriented to time, place and person. He is
cooperative and does not assume any unusual position. He is febrile but not in respiratory
distress.
Vital Signs:
• Temperature= 37.3°C
• Respiratory rate: 32breaths per minute
• Blood Pressure: 90/60mmgh
• Pulse rate: 81 beats per minute
Head: No tenderness or mass, symmetrical, absence of nodules and symmetrical facial
movements.
Skin: Skin color ranges from light to dark brown, no edema, good capillary refill and
good skin turgor.
Hair: Evenly distributed, no infection or infestation.
Eyes: No blurring of vision at the moment and pink palpebral conjunctiva.
Ears: no tenderness and no hearing impairments
Nose: symmetrical, no lesions, inflammation, or congestion.
Chest and Lungs: No crackles or wheeze, resonant bronchovesicular breath sounds
Heart: No palpitations.
Abdomen: Distended, Tympanic sound, globular, no shifting dllness, hypoactive bowel
sounds.
Extremities: Symmetrical, equal and no edema.
DIAGNOSTIC EXAMS
I. Urinalysis (April 30, 2007)

Color Dark yellow Colorless to dark Normal
yellow
Transparency Slight turbid Clear Due to presence of
pus cells
pH 6.0 4.6-8.0 Normal
Albumin Trace Negative
Sugar Negative Negative Normal
Pus cells 0-2/hpf 3-5/hpf Normal
Red blood cells 0-1/hpf 2-4/hpf Normal
Epithelial cells Occasional No significance Normal
Bacteria Few Rare/Few/None Normal
A.urates Moderate No significance Normal
Mucus threads Few No significance Normal
Coarse Granular 0-1/lpf
Cast
II. Hematology (April 30 2007)

Blood Type: “O” Rh Positive

overload), anemia,
recent hemorrhage
loss.
Erythrocytes 4.15x1012/L Male:4.6-6.2x1012/L
Female:4.2- Normal
5.4x1012/L
Leukocytes 7.60x109/L 4.5-10.0x109/L Normal
Granulocytes 0.78% 0.500-0.750% Increased in
allergic reactions.
Lymphocytes 0.16% 0.200-0.350% Decreased in AIDS,
corticosteroids,
immunosuppressive
drugs.
Monocytes 0.06% 0.20-0.060% Decreased in drug
therapy and prednisone.
MCV 76 fl 80-96 fl Decreased in Microcytic
anemia, iron deficiency
anemia, hypochromic
anemia, thalassemia,
lead poisoning.
MCH 24.10 pg 27-31 pg Decreased in Microcytic
anemia
MCHC 315 320-360 Decreased in Microcytic
anemia, iron deficiency
anemia, hypochromic
anemia, thalassemia.
Platelet Count 347x109/L 150-450x109/L Normal
I. PATIENTS PROFILE
Name: Kimuel Carit Yobia Case No: 337033

Age: 5 months old Sex: Male
Address: Tunga, Leyte
Birthday: November 11, 2006 Birthplace: Tunga, Leyte
Date of Admission: May 10, 2007 Time: 7:15 AM
Father: Abraham Yobia Occupation: Farmer
Mother: Rogenia Yobia Occupation: Housewife
Attending Consultant: Dr. Aspirin
Chief Complaint: Mother verbalized “Naguro-uro hiya ngan nagsuka hin makadamu.”
Diagnosis: Inguinal Hernia

The patient was referred from Carigara Hospital. Four days before his admission to
Carigara Hospital, he experienced diarrhea and vomiting occurring 2-3x a day. The onset of
the symptoms was sudden. The patient was eating before the symptoms started. This was
also associated with low-grade fever and mild cough. If the patient eats, it triggers the
occurrence of the symptoms.
1 day PTA, the patient had onset of abdominal enlargement and was associated with
tenderness. Still there was diarrhea and vomiting 2-3 x a day and low-grade fever.
III. Past History

• The patient had experienced chicken pox last month..
• The patient had been vaccinated with BCG, Hepa and anti-Measles.
• The patient is not allergic to any food, animals and plants but he is allergic to some
drugs.
• The patient had not experienced any accidents and injuries.
• This is the first time the patient was hospitalized.
IV. Family History
Both the father and the mother of the patent are apparently well with no family
history of asthma, DM, hypertension, and cancer. They also have no allergies to any food,
drug and animals.
V. Psychosocial History
The patient was born to a G4P4, 41 years old mother who had completed his pre-
natal check up.
The patient was delivered thru NSVD at their home in Tunga, Leyte with the help of
the traditional birth attendant. According to the mother, he was exclusively breastfed for
the first 3 months and at the 4th month, the mother started bottlefeeding, specifically
BONA, about 3-4 bottles a day.
REVIEW OF SYSTEMS
General: Weight loss, fever, fatigue
Skin: Red rashes on the inguinal area.
Head: No headache, injury or tenderness.
Eyes: No excessive tearing or no discharges.
Abdomen: Enlarged with tenderness, Gobular
Respiratory: Mild cough, dyspnea
Cardiovascular: Dyspnea and mild cough
Gastrointestinal: Vomiting and diarrhea
Genitourinary: No hematuria or polyuria
DIAGNOSTIC EXAMS
I. Ultrasound Report (May 11, 2007)

Findings: Chest APL and FPU
Slightly distended abdomen, gas-filled loops of bowel are noted without differential
fluid levels. Bowel wall is not thickened. Visceral margins are intact. No unsual intra-
abdominal calcifications are seen. The liver shadow appears not enlarged. There is no
evidence of portal gas air. No sub diaphragmatic air collection is appreciated. Air is present
in the rectum.
Impressions: Ileus pattern. No evidence of pneumoperitoneum. Absent air in the portal
tract. Incidental note of hilar lymphadenopathy.
II. Abdominal Ultrasound (May 11, 2007)

Findings: The liver is not enlarged, homogenous parenchymal, echogenecity and no focal mass
is noted. The intra-hepatic bile ducts are not obstructed. Vessels are intact. CBD measures
1.7mm (Normal is up to 6.6mm). Gallbladder measures 3.6x1.1cm without stones nor sludge.
Wall is not thickened, less than 3.0mm. There is no pericholecystic fluid collection. The
pancreas appears unremarkable without mass. A-P diameter of the pancreatic head is 1.0cm,
the body is 0.6cm and tail is 0.5cm. Pancreatic duct is not dilated. The spleen appears not
enlarged 5.5cm in length. Normal excursion of the diaphragm is observed. The right kidney
measure 6.1x3.1x2.1cm (CT 0.6cm), while the left kidney measures 6.0x2.9x2.3cm (CT
0.7cm). No mass. Ectasia nor stone is noted. Well- differentiated corticomedullary junction.
Ureters are not obstructed. Adequately filled urinary bladder without mass or stone is
seen. Wall is not thickened. No paravesical mass is noted.
Impression: Normal liver, gallbladder, pancreas, spleen and non-obstructed biliary tree.
Normal kidneys and urinary bladder. Increased bowel air which limits the sensivity of the
exam for mass. No evidence of intra-peritoneal fluid.
III. Ultrasound Report (May 13, 2007)

Findings: Chest xray APL view
Chest films show no demonstrable lung parenchymal infiltrates. Trachea at midline.
No atelectatic densities noted. Cardiac silhouette is not enlarged with normal shape and
orientation. Intact both hemidiaphragms with sharp and clear sulci. The visualized soft
tissues and osseous structures appear normal.
Impression: Normal radiographic chest findings.
IV. Urinalysis (May 10, 2007)

yellow
Transparency Slight Turbid Clear Due to presence of
pus cells
pH 6.0 4.6-8.0 Normal
Albumin Trace Negative Normal
Epithelial cells Some No significance Normal
Bacteria Few None/Rare/Few Normal
A.urates Some No significance Normal
Cast: CGC 1-2/hpf
V. Clinical Chemistry (April 26, 2007)

Sodium 132.3mmol/l 135-148mmol/L Decreased in alkali
deficit, Addison’s
disease and
Myxedema.
Chloride 104.5mmol/L 98-107mmol/L Normal
VI. Hematology (May 10, 2007)

overload), anemia, recent
hemorrhage
Female: 0.36-0.47 hemodilution, anemia, and
acute massive blood loss.
Erythrocytes 3.62x1012/L Male:4.6-6.2x1012/L Decreased in anemia,
Female:4.2-5.4x1012/L fluid overload, recent
hemorrhage, leukemia.
Leukocytes 3.2x109/L 4.5-10.0x109/L Decreased by bone
marrow depression
Segmenter 0.38
Lymphocytes 0.53% 0.200-0.350% Increased in infectious
mononucleosis, chronic
bacterial infections,
tuberculosis, pertussis,
lymphocytic leukemia.
Monocytes 0.06% 0.20-0.060% Normal
MCV 75 fl 80-96 fl Decreased in Microcytic
anemia, IDA,
hypochromic anemia,
thalasssemia and lead
poisoning.
MCH 28 pg 27-31 pg Normal
MCHC 375 320-360 Increased in
spherocytosis.
Platelet 35x109/L 150-450x109/L Decreased in prolonged
bleeding time, and
impaired clot retraction.
Eosinophils 0.03% 1.4% Decreases in Stress
response and cushing
syndrome.
Clotting time 2mins and 35 7-120 seconds Increased in severe
seconds coagulation problems and
therapeutic
administration of heparin.
Bleeding time 45 seconds 3-8 mins
VII. Hematology (May 13, 2007)

hemodilution, anemia,
and acute massive
blood loss.
WBC 6.40x109/L 4.5-10.0x109/L Normal
Segmenter 0.61
Lymphocyte 0.36 0.200-0.350% Increased in
infectious
mononucleosis,
chronic bacterial
infections,
tuberculosis,
pertussis,
lymphocytic
leukemia.
Eosinophils 0.03 1.4% Decreases in Stress
response and cushing
syndrome.
VIII. Hematology (May10,2007)

Platelet 420x109/L 150-450x109/L Normal
IX. Fecalysis (May 10,2007)

Color Brown
Consistency Soft
Ova or parasite None found
I. Patient’s Profile
Name: Purog, Ramil Apurillo Age: 33 y.o Sex: Male
Address: Blk 9, Lot 31, Ilang-ilang St. V&G Tac. City
Religion: Catholic Occupation: Teacher
Date of birth: 04-18-74 Birthplace: Cebu city
Mother: Fe April Purog Father: Jose Purog
Date Admission: 06-16-07 Time of Admission: 10:59 PM
Chief coplaint: LBM
Physician: Dr. C. Baligod
II. History
>Morning prior to admission, the patient experienced severe
abdominal pain on the umbilical and hypogastric region, he had more than 3 episodes
of LBM and passed out watery, pus bloody and non-mucoid stool, scanty in amount
associated with scarring abdominal pain. Other symptoms he experienced were
numbness, cold clammy, and diaphoresis. No vomiting was noted. When asked about
what may have caused the illness, patient stated that he ate food which he bought and
mixed it with some vegetables which probably precipitated his condition.
Medications taken during the onset of the disease were metronidazole, ofloxacin,
hydrite and vitamins, however these medications did not relieved the condition of the
patient. His LBM persisted for about 9 episodes which prompted consult and
admission.
III. Past History:

>The patient has had complete immunizations when he was still a
child.
>Patients had many hospitalizations a few of them which he can still
remember are back when he was in high school when he was bitten by a dog, another
was when he was operated because of abscess on his lower head, and the most recent
was last September 6, 2006 because of amoebiasis.
>Patient did not experienced any serious accidents that lead to
fractures and major injuries, though he claimed that he had a very minor accident
when he was playing with his bicycle and accidentally fell.
>Patient has allergies in foods with MSG, especially junk foods and
“dagmay”. He said whenever he eats these foods he would develop a lesion which
heals poorly.
>Patient claimed that he had a history of asthma when he was a child,
and a pulmonary infection when he aged 23 and the patient said that the cause
probably was because of chalk dust that irritated his lungs.
>He did not had any blood transfusions in the past.
IV. Lifestyle:
>The patient experienced smoking back when he was in his high
school years but claimed that he only tried few times only because of peer pressure
but did not continue on this vice because he knew that it would be bad for his health.
The patient at present is an occasional alcoholic beverage drinker but he revealed that
when he was in his 4th year high school he drank alcohol almost weekly with his
friends and it was only during 1st yr college that he stopped drinking too much.
>Patient is a vegetarian, he takes supplements such as multivitamins
and vitamin C (Cecon); he is able to consume 8 glasses of water per day and drinks
juice every meal. He has good appetite but he complained of experiencing nausea last
night. Today the patient had 4 bowel movements and passed out a slightly formed pea
sized stool, “mga 25 mg” as stated by the patient. With regards to his urinary
elimination, the patient voided 10 times this day with an amount of more than 1L as
stated by the patient. Patient has no difficulty in urinating and defecating.
>The patient claimed that he does exercise every morning and the
usual types of exercises he performs are the non-strenuous ones such as jogging and
swimming. During his spare time he keeps himself busy by doing some leisure
activities such as going to the beach, playing basketball and gardening (planting
vegetables).
>With regards to patient’s self care, at present the patient stated that he
needs assistance in going to the bathroom and in dressing, however in eating he is
able to feed himself. Patient is mobile and ambulatory.
>With regards to the patient’s sleep pattern, he said that he has no
sleep onset problems though sometimes he sleeps late, at present he usually has early
awakenings because of the need to go to the bathroom to urinate. He also stated that
he isn’t able to sleep well because he is not that comfortable with his room.
V. Family History:
>The patient has a family history of hypertension specifically on his
paternal side. But he does not have any family history of DM, heart diseases, arthritis,
epilepsy, cancer and psychosis.
VI. Social Data

>The patient is single and currently lives with his parents at V&G
subdivision. He works as a high school economics teacher.
>In cases of problems, it is his family who helps him a lot and
supports him emotionally. He claims that he has many sets of friends and he is able to
get along well with others.
>Financially, he is able to support himself and able to provide his own
needs with his own income.
>He is a religious person, and values his spiritual faith a lot.
PHYSICAL EXAMINATION:
A. General Health: patient is a 33 y.o male adult. He is cooperative, easy to talk with,
and frequently smiles. He has a good posture and good body built.
B. Vital Signs:
BP: 110/80 mm Hg HR: 76 bpm
RR: 20 cpm Temp: 36°C
C. Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or
mass, absence of nodules.
D. Hair: Inspection: Evenly distributed, scalp has no infection or infestation;
Palpation: moderately thick, resilient hair
E. Nails: Inspection: Convex curvature, capillary bed is pale-light pink in color;
Palpation: smooth texture, slight delay in return of capillary refill (about 5
seconds; normal is less than 4 seconds)
F. Skin: Inspection: light brown in color, no presence of edema, there is some scars
on patient’s feet as a result of the lesions he got from his previous allergic
reaction; Palpation: skin is moderately warm to touch, has good skin turgor.
G. Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids
have no discharge and no discoloration, and sclera appears white and anicteric,
pupils are equally round and reactive to light and accommodation, no visual
disturbances; Palpation: light pink conjunctiva, no periorbital edema, no
tenderness over lacrimal gland..
H. Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, able
to hear with normal voice tones; Palpation: auricles are mobile, firm and not
tender
I. Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions
J. Mouth: Inspection: uniform pink in color, able to purse lips, good set of teeth,
pinkish gums, no dentures, tongue moves freely; Palpation: soft, moist and
smooth texture
K. Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible;
Palpation: no palpable lymph nodes
L. Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall
intact, symmetric chest expansion, no use of accessory muscles, no retractions,
quiet, effortless respiration; Palpation: no tenderness and no masses, Auscultation:
no wheeze or crackles
M. Cardiovascular: Inspection: precordium no abnormal pulsations; Palpation:
palpable radial pulse; Auscultation: no abnormal heart sound, no murmurs
N. Abdomen: Inspection: flat and rounded, no evidence of enlargement of liver;
Palpation: soft, slight tenderness
O. Musculoskeletal: Inspection: no contractures, no tremors, with slight weakness of
muscles of the body; Palpation: no tenderness or swelling, with good handgrip,
P. Mental Status: Oriented to time, place and person, alert and responsive, with
intact memory
REVIEW OF SYSTEMS:
A. General Health: No weight loss, no fever and chills, not diaphoretic, no colds
B. Skin: no pruritus, no itchiness
C. Head: no headache, no dizziness, not nauseated
D. Eyes: no blurring of vision, no visual difficulties
E. Ears: no ringing of ears, no tenderness
F. Nose: no change in sense of smell, no colds, no bleeding
G. Mouth: no bleeding gums, no difficulty in swallowing and chewing of food
H. Respiratory: not dyspneic, not out of breath when moving, no difficulty breathing
when supine
I. Cardiovascular: no chest pain, no syncope
J. Gastrointestinal: moderate pain on abdomen, 4 episodes of bowel movement with
slightly formed stool in moderate amount
K. Genitourinary: voided 10 times fro more than 1L in amount, no pain and
discomfort during urination
L. Musculoskeletal: slight weakness of body, still needs assistance in some of self
care activities such as toileting and dressing.
I. PATIENTS PROFILE
Name: Menchie Militante Miranda Case No: 51527-2007

Age: 31 years old Sex: Female Civil status: Married
Address: Brgy. Cabuynan Tanauan, Leyte Occupation: Housewife
Birthday: October 22, 1975 Birthplace: Tanauan, Leyte
Date of Admission: June 18, 2007 Time: 3:26 AM
Father: Mauricio Militante Age: 50+ Occupation: Fisherman
Mother: Anacorita Militante Age:50+ Occupation: Dressmaker
Husband: Marcello Miranda Age: 35 Occupation: Junior salesman
Attending Consultant: Dr. M. Tan and Dr. J. Borrinaga
Chief Complaint: “Nalinop ako, nagsirom an ak pangitaan tas diri ak nakahinga.”
Admitting diagnosis: Syncope and Vertigo

Few hours PTA, while the patient was sleeping, she suddenly woke up to read the
text message on her cellphone. When she was about to reach her cellphone, she suddenly
experienced syncope episodes. This was followed by vertigo and dyspnea. So these
symptoms lead the patient to the hospital.
According to the patient, the symptoms she felt was just sudden last night.
Although she was having headaches for about a week now. The headache occurs only
when she is so tired or stressed. She only feels pain in her head, in which according to
her, the intensity is about 7 in a scale of 1-10. The symptoms that she is feeling occur
only when she is very tired and when she is reading. Before, when she has headache, she
just relax and sometimes drink Biogesic.
III. Past History
• The patient had experienced measles, chicken pox and mumps during her
childhood years.
• The patient has complete immunization.
• The patient has been hospitalized many times before, but unable to recall exactly
when it happened. Among the reasons for hospitalizations are due to fever,
stomachache and when she gives birth.
IV. Family History

According to the patient, her family has a history of heart disease, diabetes
mellitus, hypertension and arthritis.
V. Lifestyle
• The patient drinks alcohol specifically Tube about 7-8 glasses occasionally.
• She eats three meals a day and does not like to take snacks.
• She is the one who cooks for her family.
• Her typical diet comprises rice, fish and vegetables. She seldom eats meat, or
sometimes eats meat only during Sundays or during occasions.
• The patient usually sleeps at around 9PM and wakes up at 2AM. She wakes up
early because she needs to prepare for her kids. But in the afternoon, she usually
takes a nap for an hour. Before, she had insomnia.
• She dos not have any exercise regimen and doing the household work is her form
of exercise.
VI. Social Data

• In times of stress, her family is very much supportive of her, not only financially
• The patient is a college graduate. She is already a licensed teacher but was unable
to land on a job. So now, she is a housewife.
• Her family lives in Brhy. Cabuynan Tanauan Leyte. They have a one room house
made of concrete and wood. Their water source is NAWASA and their electrical
source is DORELCO. They have one toilet.
REVIEW OF SYSTEMS
Skin: No rashes, no bruising, no itching and no change in skin color.
Head: Headache, and dizziness.
Eyes: Blurring of vision, changes in visual field, no pain and no discharges.
Nose: No sneezing, no allergies, no epistaxis.
Respiratory: No cough, no chest pain, no hemoptysis, dyspnea.
Cardiovascular: Dyspnea, no edema or no chest pain.
Gastrointestinal: No dysphagia, no heartburn, no ulcer, no indigestion.
Genitourinary: No dysuria, no hematuria, no nocturia.
Endocrine: Fatigue, no weight change, no polyphagia, polyuria and polydipsia.
General: The patient is an adult, 31 years old female. She is not assuming any unsual
position. She is also cooperative, pleasant and easy to talk with.
Vital signs:
BP: 180/100 RR: 24 cpm HR: 88bpm
Integument:
Inspection: Skin color ranges form light to deep brown; generally uniform skin
color except in areas exposed to the sun; no edema, no lesions or abrasions.
Palpation: Skin warm to touch, and with good capillary refill.
Hair:
Inspection: Evenly distributed hair; thin hair; no infection or infestation.
Nails:
Inspection: Convex curvature, capillary bed is light pink in color, intact
epidermis.
Palpation: Smooth texture and good capillary refill.
Eyes:
Inspection: Eyebrows symmetrically aligned with equal movement, eyelids have
no discharge and no discoloration, and sclera appears white and anicteric, pupils are
equally round and reactive to light and accommodation, no visual disturbances.
Palpation: Light pink conjunctiva, no periorbital edema, no tenderness over
lacrimal gland.
Ears:
Inspection: Symmetrical, auricle aligned with outer canthus of the eye, able to
hear with normal voice tones.
Palpation: Auricles are mobile, firm and not tender
Nose:
Inspection: No discharge or flaring.
Palpation: Not tender, no lesions
Mouth:
Inspection: Uniform pink in color, able to purse lips, good set of teeth, pinkish
gums, no dentures, and tongue moves freely.
Palpation: Soft, moist and smooth texture.
Neck:
Inspection: Able to flex hyperextend and rotate, thyroid gland not visible.
Palpation: No palpable lymph nodes
Thorax:
Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact,
symmetric chest expansion, no use of accessory muscles, no retractions, and quiet,
effortless respiration.
Palpation: No tenderness and no masses:
Auscultation: No wheeze or crackles
Cardiovascular:
Inspection: Precordium no abnormal pulsations.
Palpation: Palpable radial pulse.
Auscultation: No abnormal heart sound, no murmurs
Abdomen:
Inspection: Flat and rounded, no evidence of enlargement of liver.
Auscultation: Audible bowel sounds
Palpation: No tenderness, relaxed abdomen with smooth consistent tension.
Musculoskeletal:
Inspection: No contractures, no tremors.
Palpation: No tenderness or swelling, with good handgrip,
Mental Status:
Oriented to time, place and person, alert and responsive, with intact memory
DIAGNOSTIC EXAMS
I. Ultrasound Report (June 18, 2007)

Findings: Chest x-ray PA view
• Lung fields are clear.
• Heart shadow is not enlarged.
• Trachea is in the midline.
• Hemidiaphragms and sulci are intact.
• Other structures are unremarkable.
Impressions: Essentially unremarkable cardio pulmonary findings.
II. Urinalysis (June 18, 2007)

Color Light yellow Colorless to dark Normal
yellow
Transparency Slightly turbid Clear Normal
pH 6.0 4.6-8.0 Normal
Epithelial cells Occasional
Bacteria Few None
A.urates Rare
Mucus threads rare
Ketones Negative Negative Normal
III. Clinical Chemistry (April 26, 2007)

Sodium 139.9mmol/l 135-148mmol/L Normal
Cal-D 2.21mmol/L 2.15-2.57mmol/L Normal
Uric-E 0.38mmol/L 0.17-035mmol/L Increased in gouty
arthritis, acute
leukemia,
lymphomas treated
by chemotherapy
and toxemia of
pregnancy.
Gluc-D 3.51mmol/L 3.90-6.40mmol/L Decreased in
hyperinsulinism,
hypothyroidism, late
hyperpituitarism,
pernicious vomiting,
addison’s diseas and
extensive hepatic
damage.
Chol-E 4.3mmol/L 3.9-6.7mmol/L Normal
Trig-E 2.06mmol/L 0.46-1.88mmol/L Increased
HDL 1.78mmol/L 0.00-1.68mmol/L Increased in folic
acid deficiency,
increased risk for
vascular disease and
homosystinuria.
LDL 1.5mmol/L
IV. Hematology (April 26, 2007)

overload), anemia,
recent hemorrhage
loss.
WBC 4.7x109/L 4.5-11.3x109/L Normal
Neutrophils 0.54 0.45-0.65 Normal
Eosinophils 0.07 0.02-0.04 Increased in
allergic reactions.
Lymphocytes 0.35 0.20-0.35 Normal
Monocytes 0.04 0.02-0.06 Normal
I. Patients Profile:
Name: Alcantara, Consuelo Chua Age: 71 y.o Sex: F Civil Status: Married
Religion: Catholic Date of Birth: 12-03-35
Birthplace: Borongan E. Samar Citizenship: Filipino
Address: Brgy. Mabini, Laping Northern Samar
Date of admission: 06-19-07 Time of admission: 3:39 PM
Physician: Del Pilar, Jose Carlo, MD
Chief Complaint: Cough
Diagnosis: CAP (Community Acquired Pneumonia)
II. History of Present Illness

>The condition of the patient started 2 weeks prior to admission where she experienced
chest pain and productive cough with thick whitish to yellow sputum, not associated with
dyspnea and fever. When patient was asked about what caused the occurrence of her
condition, she stated that this condition of hers has been a recurrent one; she even had
her previous hospitalization with the same chief complaint. Patient tried to relieve the
symptoms by taking an antibiotic; however this measure did not totally alleviate the
condition. Morning prior to admission the symptoms persisted thus prompted consult and
admission.
III. Past History

>The patient had her immunizations during childhood but can’t recall if she had completed
them for according to the patient “diri pa man sugad kauso an mga bakuna hadto, diri
parehas yana”. With regards to the patient’s previous hospitalizations, she claimed that
just last May 2007 she was admitted at EVRMC for the same chief complaint. Other
hospitalizations of the patient she can’t recall anymore. The patient did not suffer any
accidental injuries and fractures in the past. Other illnesses that the patient currently
has are asthma, arthritis and heart problem (Heart failure), in association with these
illnesses she stated that she takes her maintenance medications such as Diclofenac for
her arthritis and take this only when her joints become inflamed and painful and Captopril
for her heart problem. She has a known history of hypertension but no history of DM,
has no known allergies to any food and drugs, and has not had any blood transfusions in
the past. According to the patient her asthma is the main cause of her present condition
and this was aggravated because of her heart problem.
IV. Lifestyle
>The patient is a non-smoker and non-alcoholic beverage drinker. She no difficulty in
eating and swallowing but she stated that at present she isn’t able to eat as much food as
she wants for she has some diet restrictions. According to her she doesn’t eat foods that
are “makatol”, those high in fat, and vegetables with seeds. She does not take any
supplements. With regards to her fluid intake, she claimed that she drinks a lot of water.
In fact she is even able to consume more or less 20 glass of water per day, though at
present because of her condition she isn’t able to drink that much because she was told
that she must be able to consume at least only about 1L of water a day. Today the patient
has no bowel movement, and according to her that this is only normal because her normal
BM pattern is every 2 or 3 days interval. With regards to her urinary elimination, at
present she voided twice this morning and once this afternoon with no difficulty or
discomforts.
The patient stated that she don’t usually perform exercise, whenever she has
nothing else to do, during her leisure times she just usually sit down, do nothing and
sometimes sleeps, though oftentimes she also walks around their house. With regards to
her sleep pattern, according to her she has no sleep onset problems, but at present
because of her productive cough and difficulty of breathing she isn’t able to sleep well a
night. In performing self care activities, she said that she still needs assistance in lying
down and getting up from bed, in going to the bathroom and in dressing, however in eating
and in standing from sitting position, she is able to do it by herself.
V. Family history
>The patient has a family history of hypertension. But she does not have any family
history of DM, heart diseases, arthritis, epilepsy, cancer and psychosis.
VI. Social Data

>The patient is married to Vivencio Alcantara and has 10 children. She is a plain housewife
while her husband was a formerly a farmer before but at present he also has no work, he
stopped because he said he is already old and weak. She and her husband live with their
daughter Eufemia Alcantara together with her own family. Financially, they just ask for
help and support from their daughter. In case of stressful situations and problems, she
said she usually just prays and ask for a divine intervention, and sometimes talk to her
husband and seek support.
Q. General Health: Patient is a 71 y.o female adult, awake, cooperative, answers to questions and
is easy to talk with, but appear fatigued.
R. Vital Signs:
RR: 19 cpm Temp: 36.3°C
S. Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass, absence
of nodules.
T. Hair: Inspection: white with some strands of black hair, evenly distributed, scalp has no
infection or infestation; Palpation: thick, resilient hair
U. Nails: Inspection: Convex curvature, capillary bed is pale-light pink in color; Palpation: smooth
texture, delay in return of capillary refill (about 5 seconds; normal= less than 4 seconds)
V. Skin: Inspection: light brown in color with visible age spots, is saggy and wrinkled, with slight
non-pitting edema on lower extremities (left leg). Palpation: skin is moderately warm to touch,
dry, with poor senile skin turgor.
W. Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no
discharge and no discoloration, and sclera appears white and anicteric, pupils are equally round
and reactive to light and accommodation, no visual disturbances; Palpation: light pink
conjunctiva, no periorbital edema, no tenderness over lacrimal gland.
X. Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, unable to hear
effectively with normal voice tones; Palpation: auricles are mobile, firm and not tender
Y. Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions
Z. Mouth: Inspection: uniform light pink in color, able to purse lips, not complete set of teeth on
lower teeth with brown to black discoloration of the enamel of the remaining teeth, pinkish
gums, no dentures, tongue moves freely; Palpation: soft, moderately dry and smooth texture
AA. Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible; Palpation: no
palpable lymph nodes
BB. Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact, with
shallow respiration, use of accessory muscles, no retractions, with some effort in respiration,
with productive cough; Palpation: with moderate chest pain and no masses, Auscultation: with
crackles
CC. Cardiovascular: Inspection: precordium no abnormal pulsations; Palpation: small weak radial
pulse
DD. Abdomen: Inspection: flabby and rounded. Palpation: soft, no evidence of enlargement of liver
EE. Musculoskeletal: Inspection: no contractures, no tremors, with slight weakness of muscles of
the body; Palpation: no tenderness or swelling, with good handgrip,
FF. Mental Status: Oriented to time, place and person, drowsy but responsive, unable to recall
some past memories, fatigued, restless at times, no difficulty in walking, able to balance.
REVIEW OF SYSTEMS:
M. General Health: No weight loss, no fever and chills, not diaphoretic

N. Skin: no pruritus, no itchiness
O. Head: no headache, no dizziness, not nauseated
P. Eyes: no blurring of vision, no visual difficulties, no use of eyeglasses
Q. Ears: no ringing of ears, no tenderness, with some difficulty in hearing but does not use any
hearing aid.
R. Nose: no change in sense of smell, no colds, no bleeding
S. Mouth: no bleeding gums, no difficulty in swallowing and chewing of food
T. Respiratory: has productive cough with thick, difficult to expectorate whitish sputum
dyspneic, has difficulty in breathing, shortness of breath
U. Cardiovascular: with chest pain, no syncope,
V. Gastrointestinal: no tenderness, has no bowel movement, with good appetite, not nauseated
W. Genitourinary: voided 3 times from morning to afternoon with, no pain and discomfort during
urination
X. Musculoskeletal: slight weakness of body, still needs assistance in some of self care activities
such as toileting and dressing.
Y. Neurologic: with feeling of body weakness, no paralysis of any body part, no numbness, no
tremors.
LABORATORY EXAMS
Date Lab Exam Result Normal Significance

Value
06-19- Urinalysis Color: yellow Pale yellow- >Normal
07 deep amber
Transparency: Slight Clear >Increased in concentration of
Turbid urine
pH: 6.0 5.5-6.5 >Normal
Specific Gravity: 1.015 1.002-1.035 >Normal
Protein: (-) Negative >Normal
Sugar: (-) Negative >Normal
Pus cells: 0-2/hpf 0-2/hpf >Normal
Red cells: none <3/hpf >Normal
Epith. Cells: few Rare-few >Normal
Mucus threads: rare Rare-few >Normal
A. Urates/phosphates: Rare-few >Normal
few
Bacteria: rare None >Normal
K: 4.99 mmol/L 3.50-5.30 >Normal
CREA-B: 132.6 umol/L 53.0-115.0 >Increased in renal failure
06-19- Special TSH:0.07 0.25-5.0 >Decreased in secondary
07 Chemistry uU/mol hypothyroidism; high doses of
dopamine
FT3: 6.66 4.0-8.3 >Normal
pmol/L
FT4: 19.16 9-20 pmol/L >Normal
06-19- Prothrombin Test: 109.6%
07 Time
12.5 sec 9.5-12 sec >slightly increased by deficiency
of factors I, II, V, VII, and X
INR: 1.021 1.0
Control: 100%
13.7 sec
INR: 1.16
06-19- Hematology Hgb: 106 g/L F: 120-160 >Decreased in all anemias and
07 excessive fluid intake, but in the
case of the patient since she has
heart failure, this is a way to
compensate to reduce the fluid
volume in the body.
Hct: 0.32 F: 0.36-0.46 >Decreased in severe anemias and
acute massive blood loss
WBC: 5.7 x 10~9/L 4.5-11.3 >Normal
Differential Ct.:
Neutrophils: 0.6 0.45-0.65 >Normal
Lymphocytes: 0.28 0.20-0.35 >Normal
Monocytes: 0.05 0.02-0.06 >Normal
Eosinophils: 0.05 0.02-0.04 >Increased in allergy, parasitic
disease, and subacute infections
Stabs: 0.02 0.02-0.04 >Normal
Value
06- Heamatology Platelet Count: 245 x 140-440 >Normal
20-07 10~9/L
Reticulocyte ct: 0.8% 0.5-1.5% >Normal
Clinical Lab GLUC-b: 6.78 mmol/L 3.90-6.40 >Increased in Diabetes Mellitus
and Nephritis
CHON-E: 5.2 mmol/L 3.9-6.7 >Normal
TRIG-E: 1.07 mmol/L 0.46-1.88 >Normal
HDL-BM: 1.79 mmol/L 0.80-1.68 >Increased
LDL: 3.0mmol/L
Test HbAIC Test: 4.8% 4.5-6.3% >Normal
I. Test: Gram’s & AFB

Specimen: sputum
A. Gram: Few organisms are seen consisting of gram (+) cocci in pairs of gram (-) bacilli.
Few leukocytes are present
B. AFB: Negative
II. Test: Peripheral smear

Specimen: Blood
Result: The red cell are normocytic and normochromic. There are no abnormal leukocytes,
the platelets are adequate.
I. PATIENTS PROFILE
Name: Ernesto Abocejo Abarientos Case No: 345123

Address: Brgy. Candaro, Dulag, Leyte Occupation: Businessman
Birthday: 7/15/1965 Birthplace: Dulag, Leyte
Date of Admission: July 2, 2007 Time: 10:30 AM
Father: Ernesto Abarientos Sr. Mother: Reynalda Abarientos
Wife: Genelyn M. Abarientos
Chief Complaint: “Nagsinakit it akon likod, tas naginubo gihap ngan nakurian ak
pagginhawa.”
Diagnosis: Thyrotoxic Heart Disease; Cardiomegaly; AF; CHF II; CAP moderate risk.

3 months PTA, the patient experienced on and off non-productive cough. This was
associated with easy fatigability and 2 pillow orthopnea. But there was no consultation
done. Instead the patient just took his maintenance medication which is the
Propylthiouracil 50mg 1tablet TID PO.
2 weeks PTA, the patient had productive cough with yellowish phlegm. This was
associated with fever, dyspnea and 3 pillow orthopnea. Still the patient has not consulted
a doctor.
Last June 30, the patient started feeling back pain. First, he though it would just
subside after some rest. But the back pain became severe, and then was associated with
dyspnea. So, he was brought to EVRMC, hence was admitted.
III. Past History

• According to the patient, he had chicken pox, measles, and mumps when he was
young.
• The patient is not sure if his immunizations are complete.
• He has no allergies with any food, drugs or other things.
• Last January 1986, the patient had a car accident.
• The patient has been hospitalized many times in different hospital.
• Among his maintenance medications are Lanoxin, PTU, Lasix, Propanolol and
captopril.
IV. Family History

According to the patient, his family has history of diabetes and asthma but has no
history of heart diseases.
V. Lifestyle
• The patient is a known smoker. He usually consumes 1-2 packs a day. He is also
an occasional alcoholic beverage drinker. He can drink about a grandy of beer and
tuba.
• He loves to eat meat, vegetables and hard types of foods.
• He usually is the one who cooks at home.
• The patient usually sleeps at around 7PM and wakes up at around 6 in the
morning. Lately, he had difficulty in sleeping due to dyspnea and orthopnea. He
also experiences palpitations and back pain.
• The patient’s form of exercise is walking and his hobby is just singing.
VI. Social Data

• The patient is a college graduate. In fact, he is both a civil and electrical engineer.
• Before the patient was a contractor, then he became plant maintenance, then
authorized representative and now he is a businessman. He has a meat shop in
Dulag as well as piggery.
• The patient and his family lives in Dulag, Leyte. Their house is made of concrete,
bamboo and other native material. It is a 3 bedroom house with 2 toilet rooms.
Their water source is from the deep well and they also have a supply of electricity.
Their house is about 150meter away from the main road and about 50meters
distance from their neighbors. Aside from the piggery, they also have dogs and
cats in their house.
REVIEW OF SYSTEMS:
Z. General Health: Weight loss, no fever and chills, easy fatigability and diaphoresis.
AA.Skin: no pruritus, no itchiness
BB.Head: no headache, no dizziness, not nauseated
CC.Eyes: no blurring of vision, no visual difficulties
DD.Ears: no ringing of ears, no tenderness
EE.Nose: no change in sense of smell, no colds, no bleeding
FF. Mouth: no bleeding gums, no difficulty in swallowing and chewing of food
GG.Respiratory: Dyspnea, cough, no hemoptysis and no chest pain.
HH.Cardiovascular: Dyspnea. Orthopnea, palpitations, no chest pain and no tightness.
II. Gastrointestinal: No ulcer, no constipation, no abdominal pain.
JJ. Genitourinary: No dysuria, no nocturia and no incontinence.
KK.Musculoskeletal: No limitation of movement, no muscle weakness.
LL.Endocrine: Heat and cold intolerance, weight change, fatigue.
General Health: Patient is a 45 y.o male adult. He is cooperative, easy to talk with, and
frequently smiles. He has a good posture and good body built.
Vital Signs:
Head:
Inspection: normocephalic and symmetrical.
Palpation: No tenderness or mass, absence of nodules.
Hair:
Inspection: Evenly distributed, scalp has no infection or infestation but with
dandruff.
Palpation: moderately thick, resilient hair
Nails:
Inspection: Convex curvature, capillary bed is pale-light pink in color, intact
epidermis but with dirty nails.
Palpation: smooth texture, slight delay in return of capillary refill (about 5
seconds; normal is less than 4 seconds)
Skin:
Inspection: Dark brown in color, no presence of edema, has uniform skin color.
Palpation: skin is moderately warm to touch at the upper extremities but cold to
touch at lower extremities.
Eyes:
Inspection: hair in the eyebrows evenly distributed, skin intact and symmetrically
aligned, eyelashes equally distributed and curled slightly outward, eyelids with yellowish
discoloration and closes symmetrically, PERRLA.
Palpation: pale conjunctiva, no periorbital edema, no tenderness over lacrimal
gland.
Ears:
Inspection: symmetrical, auricle aligned with outer canthus of the eye, able to
hear with normal voice tones.
Palpation: auricles are mobile, firm and not tender
Nose:
Inspection: no discharge or flaring, nasal septum intact at midline.
Mouth:
Inspection: uniform non-pinkish in color, able to purse lips, dry lips, pale gums
and yellowish teeth.
Neck:
Inspection: able to flex, hyperextend and rotate, anterior neck mass.
Chest and Lungs:

Inspection: Breast symmetrical and equa in size, no lumps and discharges,
rounded thorax.
Palpation: Warm to touch
Auscultation: Rales and crackles.
Heart:
Inspection: abnormal pulsations.
Palpation: palpable radial pulse.
Auscultation: abnormal heart sound.
Abdomen:
Inspection: flat and rounded, no evidence of enlargement of liver.
Palpation: soft, slight tenderness
Musculoskeletal:
Inspection: no contractures, no tremors, with slight weakness of muscles of the
body.
Palpation: no tenderness or swelling, with good handgrip,
Mental Status: Oriented to time, place and person, alert and responsive, with intact
memory.
LABORATORY EXAMS:
I. Hematology (July 2, 2007)

Hemoglobin 165g/L Male: 135-170g/L Normal
Female: 120-160g/L
Hematocrit 0.49 Male: 0.40-0.54 Normal
Female: 0.36-0.47
Leukocytes 17.15x109/L 4.5-10.0x109/L Increased in infection,
leukemia, tissue
necrosis, and acute
infectious diseases.
Monocytes
Exam 0.03Result 0.020-0.060
Normal Values Normal
Significance
Eosinophils
Test 0.01
14.6 seconds 0.01-0.04
10-13 seconds Normal
Increased
Control 12.0seconds 1.5-2.0 seconds Increased
INR 1.41 seconds 2.0-3.0 seconds Decreased in MI,
thrombophlebitis
and pulmonary
embolism.
II. Radiographic findings (July 2, 2007)

Chest PA: Examination of the chest reveals enlargement of the cardiac shadow with mild
distension of hilar vessels. Trachea at midline, not unusual.
Impression: Cardiomegaly with mild pulmonary congestion.
III. Protime (July 4, 2007)
IV. Clinical Chemistry (July 4, 2007)

Sodium 129.6mmol/L 135-155mmol/L Decreased in
vomiting, diarrhea,
gastric suction,
SIADH, tissue injury,
low-Na diet, burns
and salt-wasting
renal disease.
Potassium 3.37mmol/L 3.5-5.5mmol/L Decreased in
vomiting, diarrhea,
DHN, malnutrition,
stress, trauma,
injury, gastric
suction, metabolic
acidosis, burns, and
diabetic acidosis.
Creatinine 59umol/L 53-106umol/L Normal
II. PATIENTS PROFILE
Name: Severa Pore Obiña Case No: 343283

Address: Brgy. Daro, Jaro, Leyte Occupation: N/A
Birthday: November 13, 1940 Birthplace: Jaro, Leyte
Father: Julian Pore Mother: Florentina Pore
Husband: Sulpicio Obiña Age: 72 Occupation: Coco farmer
Attending Consultant: Dr. Egos
Chief Complaint: “Nagkukuri man hiya paghinga.” Stated by the significant others.
Admitting diagnosis: Acute LV failure, Thyrotoxic Heart Disease

Five days prior to admission, client was discharged from EVRMC with an
improved condition from EVRMC diagnosed from Hyperthyroidism, Intestinal amoebiasis
with dehydration. Was ordered to come back on June 29, 2007 for check-up with take
home meds enumerated as follows: Metronidazole 500mg 1 ½ tab TID x 7 days, PTU
50mg 4 tab TID, Propanolol 40mg OD and Ranitidine 300mg at HS. Stayed at home at
Jaro, Leyte from from June 26 to June 28 with noticeable weakness.
Two days before admission, client according to daughter was continuously vomiting and
wretching during the day. Headed to Tacloban and arrived at four o’clock in the afternoon
and arrived an hour later still with noticeable weakness. Stayed at her daughter’s house
in Paterno still with episodes of vomiting. Poor appetite observed by significant others.
Noted activities were sitting and lying on bed. Self-care activities assisted by significant
others. Wretches in every change in position. Went to EVRMC the next day at six
o’clock in the morning for check-up. Doctor noted improved condition except for low
potassium level due to prior existing dehydration. Maintenance medications abated as
ordered by doctor. Arrived at house of daughter at Paterno around 10:30 in the morning.
Still weakness noted by significant others. Wretches and vomits ingested food and were
restless. Given small feedings by significant others. Skin was warm to touch and flushed
face noted. At one o’clock in the morning, June 30, 2007, Daughter planned to take
client to said hospital as the client was experiencing sleeplessness and fatigability. “Sige
iya yakan, hagoy hagoy.” Due to transportation constraints, daughter decided to take
mother to hospital in the morning. Thirty minutes before the admission, client verbalized,
“Gusto ko na umuli”, referring to home at Jaro, Leyte significant others noted. Weak
speech, reddened eyes, capillaries evident (eye), use of accessory respiratory muscles,
cyanotic lips and upper extremities, flushed face. Brought to hospital assisted by
significant others by way of a tricycle at eight o’clock in the morning, hence, admission.
III. Past History

• 2002: Hospitalized at Bethany hospital with chief complaint of dyspnea; unable to
recall diagnosis.
• 2006: Hospitalized at City Hospital with chief complaint of dyspnea, still unable to
recall diagnosis.
• 2007: June 15, diagnosed with hyperthyroidism, intestinal amoebiasis with
dehydration ordered to return for check-up (June 29, 2007) and prescribed with
the following home medication:
1. Metronidazole 500mg 1 ½ tab TID x 7 days
2. PTU 50mg 4 tab TID
3. Propanolol 40mg OD
4. Ranitidine 300mg at HS.
• Never had any surgical procedures or operations as recalled.
• OTC drugs used includes Biogesic for fever, neozep for colds and Medicol for
headache; no nutritional supplement taken.
• Recalls mother telling her about having had chicken pox (date unknown), no
complications and no other childhood diseases.
• No immunizations; states “ Waray pa man ion hira hadto.”
• No known allergies to foods, medications or any environmental elements.
• Can’t recall clients injuries and accidents.
IV. Family History

• Mother died from heart disease at the age of 70.
• Father died from hypertension at the age of 67.
• No other known family-linked health problems.
• Negates any family member having had problems similar to throne of
those of the client.
V. Lifestyle
Client is a nonsmoker; occasional alcoholic beverage drinker, 5-8 glasses of
tuba. Likes to drink coffee, 3 glasses a day. Typical 24 hour diet includes food guide
pyramid groups. Usually eats fish. Sleeps an average of 7 hours a day. Usually sleps
at 10PM and wakes up at 6AM. Negates any sleeping difficulties. Able to perform
ADL without difficulties prior to June 15 admission.
VI. Social Data

Lives at Barangay Daro, Jaro, Leyte with husband and with youngest child.
House made of concrete with two rooms and one toilet and with modern conveniences
of electricity. Secures water from deep well. House is cleaned regularly by the client.
Dog stays outside. Neighborhood is usually safe. House is about 15-30 minutes away
from the main road per habal-habal. A high school graduate, used to have own business
until became a plain housewife.
VII. Psychologic Data

Describes family as self-sufficient with children giving additional support
financially. Does recognize stress until she became very nervous with SOB, trembling
hands. With good family support system.
VIII. Patterns of Healthcare

Visits hospital when sick. Sees the dentist only when something bothers her,
can’t remember last visit. No vision check since can remember.
LABORATORY EXAMINATION
CLINICAL CHEMISTRY- July 3, 2007

Sodium 118.4mmol/l 135-155mmol/L Decreased in
vomiting, diarrhea,
gastric suction,
low-Na diet, burns
and salt-wasting
renal disease.
CLINICAL CHEMISTRY- June 30, 2007

vomiting, diarrhea,
gastric suction,
low-Na diet, burns
and salt-wasting
renal disease.
HEMATOLOGY- June 30, 2007

Female: 120-160g/L
Female: 0.36-0.47
WBC 4.90x109/L 4.5-10.0x109/L Normal
Segmenter 0.50 0.6-0.7 Decreased in viral
diseases, leukemias,
agranulocytosis, aplastic
and iron deficiency
anemias.
Eosinophils 0.12 0.01-0.04 Increased in allergies,
parasitic diseases,
cancer and phlebitis.
Progress Notes
7/3/07
3-11
3:00PM  Received lying awake on bed, dyspneic and unresponsive with an

IVF of D5W 500cc- infusing well.
 With O2 inhalation at 3L/min per nasal cannula.
3:30PM
PNSS 1 L
 Seen and examined by Dr. Ehos with new orders.
 Replaced to ongoing IVF above and regulated to KVO.
 NGT inserted by Dr.Egos
 On blenderized feeding at 1,500 kcal/day in 4 divided feedings.
4:00 PM
 V/S taken and recorded:
BP=130/90mmhg RR= 35cpm
HR= 105 bpm Temp= 38.1°C
 TSB instructed and done by significant others.
6:00PM
 NGT feeding done after checking its proper placement with aspiration precaution.
 For repeat CBC.
 For chest xray PA view.
6:10PM
 PRN meds given for temp 38.1°C
 Health teachings imparted:
1. Frequent turning to sides
2. Continue TSB if febrile
3. Assist to assume position of comfort.
7/4/07
3-11
3:00PM
 Received awake lying on bed, dyspneic with an IVF of 0.9 NaCl 1liter at 975cc level-
infusing well.
 With NGT in placed.
 With FBC attached to urobag in placed draining to lightyellow colored urine output.
 Seen and examined by Dr. Egos with new orders.
 Above IVF regulated to fast drip to consume 100cc then regulated at 20gtts/min.
 For CVP line insertion.
 V/S monitored every 1 hour.
4:00 PM
4:20PM
 Suctioned secretions by clerk on duty PRN.
5:00PM
5:10PM
 CVP line insertion-hold temporarily- as ordered.
7:00PM
2. Continuous TSB if febrile
3. Proper oral hygiene
REVIEW OF SYSTEMS:
Integumentary: Circumscribe patches on the face, no rashes, no lesions, no sores, no
bruising.
Head: Negates headache, vertigo, syncope.
Eyes: Gradual change in vision, no pain, no discharges.
Ears: Hears only with loud voice, no pain, no discharges, negates tinnitus.
Nose and Sinuses: Negates epistaxis, obstruction, no pain, no discharge, no snoring.
Mouth: No bleeding gums, no lesions, no dysphagia, and no altered taste.
Neck: No stiffness, non-tender

Cardiovascular: Palpitations with cold extremities, no edema, no paresthesia.
Endocrine: heat intolerance, thinning hair.
Respiratory: Cough, dyspnea, no hemoptysis, no pain, no wheezing.
Gastrointestinal: Blenderized feeding per NGT, constipation,, epigastric pain.
Urinary: No hematuria, no dysuria.
Musculoskeletal: Limited movements, generalized muscle weakness, no joint swelling.
Neurologic: No seizures, no paralysis.
Date of Examination: July 3, 2007
General Survey:
Symmetrical body, no deformities, lying in bed with oxygen inhalation via nasal
cannula at 3L/min with IVF of 0.9NaCl 1 L at right arm, with intact NGT, clean, neatly
dressed, slurred speech, flat facial expression, restless, sweating.
Vital signs:
BP= 130/90mmhg RR= 35cpm
HR= 105bpm Temperature= 38.1°C
Skin:
Inspection: No lesions, no ecchymosis, circumscribed irregular brown patch, near right
eye, approximately 1-1.5cm, visible age spots on lower and upper extremities especially areas
exposed to sun.
Palpation: Warm, moist, poor skin turgor.
Nails:
Inspection: Onycholysis at left index feet, pale nail beds, no clubbing, trimmed
fingernails.
Palpation: Firm nail base, smooth capillary refill at 6seconds.
Head:
Inspection: Normocephalic, no lesions, shiny scalp, symmetrical facial features.
Palpation: No masses, no depressions, smooth skull contour, non-tender.
Hair:
Inspection: Equally distributed with visible white hairs.
Palpation: Fine, brittle, no infestations.
Eyes:
Inspection: Symmetrical, pale palpebral conjunctiva, anicteric sclerae, PERRLA, pupil
dilatation=3-4mm, no proptosis, no lesions, ptosis.
Ears:
Inspection: Symmetrical, auricles aligned with outer canthus of the eye, no lesions, no
discharges, hears with loud voice.
Palpation: Non-tender, auricles recoil when pinched.
Nose:
Inspection: With NGT attached at right nare, at midline, no discharges.
Palpation: Non-tender sinus.
Throat and Mouth:

Inspection: Dark red lips, moist oral mucosa, pinkish tongue at midline, no lesions with
gag reflex, with clear to yellowish sputum, reddened uvula, one lower incisor teeth only, foul
breath.
Neck:
Inspection: Visible neck mass, symmetrical neck muscles, use of sternocleidomastoid
muscle for breathing.
Palpation: Palpable thyroid gland both at left and right lobe, smooth, soft, slightly
enlarged but less than twice the size of a normal thyroid gland, tender non enlarged lymph nodes.
Thorax and Lungs:

Anterior:
Inspection: Symmetrical chest walls, clavicles at same height, with effort breathing on
inspiration, rib angle 45°, retracted ICS during inspiration, tachypnea=35cpm
Palpation: Non-tender, symmetric chest expansion, no nodules nor mass.
Percussion: (resonant)
Auscultation: Bronchovesicular breath sounds.
Posterior:
Inspection: Scapula at same height bilaterally, spine at midline.
Palpation: Non tender, no nodules, no mass.
Percussion: (resonant)
Auscultation: Bronchovesicular breath sounds.
Heart:
Inspection: Not observable apical pulse.
Palpation: No thrilss, no heaves, PMI at 5th ICS MCL
Percussion: Dullness over heart.
Auscultation: Irregular heart rhythm, murmur at PMI, tachycardia=105bpm
Abdomen:
Inspection: Symmetrical bilaterally with uniform color and pigmentation.
Auscultation: Bowel sounds
Percussion: Tymphanic over stomach, dullness over liver.
Palpation: Non tender, non palpable spleen and kidney, non enlarged liver.
Extremities:
Upper
• with good sensation
• Palpable radical and brachial pulses
• With reflexes
Lower
• With good sensation
• Palpable popliteal, posterior tibial, dorsalis pedis pulse.
• Negative babinski reflex
Muscle strength:
Cardiovascular System:
Arterial pulses:
Rate:
Rhythm: Irregular
Amplitude: Scale +4
Neurologic system:
Confused, follows command at times, flat facial expression
Glasgow Coma Scale: Level of Consciousness

Eye opening= 3
Motor response= 4
Verbal response= 4
_______
11/15 Interpretation: Stuporous
Functional level Classification:

3= requires the use of equipment or device and help from other people.
. PATIENTS PROFILE
Name: Mrs. O Case No: 343283

Address: Brgy. Daro, Jaro, Leyte Occupation: N/A
Birthday: November 13, 1940 Birthplace: Jaro, Leyte
Date of Admission: June 30, 2007Time: 8:00 AM
Husband: Mr. O Age: 72 Occupation: Coco farmer
Attending Consultant: Dr. Egos
Chief Complaint: “Nagkukuri man hiya paghinga.” Stated by the significant
others.
Admitting diagnosis: Acute LV failure, Thyrotoxic Heart Disease

Five days prior to admission, client was discharged from EVRMC with an
improved condition from EVRMC diagnosed from Hyperthyroidism, Intestinal
amoebiasis with dehydration. Was ordered to come back on June 29, 2007 for
check-up with take home meds enumerated as follows: Metronidazole 500mg 1
½ tab TID x 7 days, PTU 50mg 4 tab TID, Propanolol 40mg OD and Ranitidine
300mg at HS. Stayed at home at Jaro, Leyte from from June 26 to June 28 with
noticeable weakness.
Two days before admission, client according to daughter was continuously

vomiting and wretching during the day. Headed to Tacloban and arrived at four
o’clock in the afternoon and arrived an hour later still with noticeable weakness.
Stayed at her daughter’s house in Paterno still with episodes of vomiting. Poor
appetite observed by significant others. Noted activities were sitting and lying on
bed. Self-care activities assisted by significant others. Wretches in every change
in position. Went to EVRMC the next day at six o’clock in the morning for check-
up. Doctor noted improved condition except for low potassium level due to prior
existing dehydration. Maintenance medications abated as ordered by doctor.
Arrived at house of daughter at Paterno around 10:30 in the morning. Still
weakness noted by significant others. Wretches and vomits ingested food and
were restless. Given small feedings by significant others. Skin was warm to touch
and flushed face noted. At one o’clock in the morning, June 30, 2007, Daughter
planned to take client to said hospital as the client was experiencing
sleeplessness and fatigability. “Sige iya yakan, hagoy hagoy.” Due to
transportation constraints, daughter decided to take mother to hospital in the
morning. Thirty minutes before the admission, client verbalized, “Gusto ko na
umuli”, referring to home at Jaro, Leyte significant others noted. Weak speech,
reddened eyes, capillaries evident (eye), use of accessory respiratory muscles,
cyanotic lips and upper extremities, flushed face. Brought to hospital assisted by
significant others by way of a tricycle at eight o’clock in the morning, hence,
admission.
III. Past History

• 2002: Hospitalized at Bethany hospital with chief complaint of dyspnea;
unable to recall diagnosis.
• 2006: Hospitalized at City Hospital with chief complaint of dyspnea, still
unable to recall diagnosis.
• 2007: June 15, diagnosed with hyperthyroidism, intestinal amoebiasis with
dehydration ordered to return for check-up (June 29, 2007) and prescribed
with the following home medication:
1. Metronidazole 500mg 1 ½ tab TID x 7 days
2. PTU 50mg 4 tab TID
3. Propanolol 40mg OD
4. Ranitidine 300mg at HS.
• Never had any surgical procedures or operations as recalled.
• OTC drugs used includes Biogesic for fever, neozep for colds and Medicol
for headache; no nutritional supplement taken.
• Recalls mother telling her about having had chicken pox (date unknown),
no complications and no other childhood diseases.
• No immunizations; states “ Waray pa man ion hira hadto.”
• No known allergies to foods, medications or any environmental elements.
• Can’t recall client’s injuries and accidents.
IV. Family History

• Mother died from heart disease at the age of 70.
• Father died from hypertension at the age of 67.
• No other known family-linked health problems.
• Negates any family member having had problems similar to throne
of those of the client.
V. Lifestyle
Client is a nonsmoker; occasional alcoholic beverage drinker, 5-8
glasses of tuba. Likes to drink coffee, 3 glasses a day. Typical 24 hour diet
includes food guide pyramid groups. Usually eats fish. Sleeps an average of 7
hours a day. Usually sleps at 10PM and wakes up at 6AM. Negates any
sleeping difficulties. Able to perform ADL without difficulties prior to June 15
admission.
VI. Social Data

Lives at Barangay Daro, Jaro, Leyte with husband and with youngest
child. House made of concrete with two rooms and one toilet and with modern
conveniences of electricity. Secures water from deep well. House is cleaned
regularly by the client. Dog stays outside. Neighborhood is usually safe. House is
about 15-30 minutes away from the main road per habal-habal. A high school
graduate, used to have own business until became a plain housewife.
VII. Psychologic Data

Describes family as self-sufficient with children giving additional support
financially. Does recognize stress until she became very nervous with SOB,
trembling hands. With good family support system.

Visits hospital when sick. Sees the dentist only when something bothers
her, can’t remember last visit. No vision check since can remember.
July 7, 2007
URINALYSIS
Exam Result Normal Findings
Color yellow Colorless to dark yellow
Transparency Slight turbid Clear

pH 5.0 4.6-8.0
Specific gravity 1.010 1.006-1.030
Albumin POSITIVE Negative
Sugar Negative Negative
Pus cells 4-6/hpf 3-5/hpf
Red blood cells 18-20/hpf 2-4/hpf
Epithelial cells rare No significance
Bacteria Few Rare/Few/None
A.urates few No significance
Mucus threads Some No significance
July 5,2007 MICROSCOPY RESULT

Specimen: Sputum
Exam done: Gram Stain
>25 <25
Pus cells X
Epithelial cells X
Result: Gram (+) cocci in pairs
July 7, 2007 CLINICAL CHEMISTRY
Test Normal values Result
Glucose (FBS) 4.20-4.4 mmol/l 4.74

BUN 2.5-6.5mmol/L 4.30
July 6, 2007 CLINICAL CHEMISTRY
Test Normal values Result
Creatinine 44-9-80umol/L 57.1
CLINICAL CHEMISTRY
Clinical chemistry: Normal values 7-5-07 7-3-07
Na 135-155mmol/L 128.5 118.4
K 3.5-5.5 mmol/L 3.74 3.74
CLINICAL CHEMISTRY- July 3, 2007

vomiting, diarrhea,
gastric suction,
low-Na diet, burns
and salt-wasting
renal disease.
CLINICAL CHEMISTRY- June 30, 2007

vomiting, diarrhea,
gastric suction,
low-Na diet, burns
and salt-wasting
renal disease.

Female: 120-160g/L
Female: 0.36-0.47
WBC 4.90x109/L 4.5-10.0x109/L Normal
Segmenter 0.50 0.6-0.7 Decreased in viral
diseases, leukemias,
agranulocytosis, aplastic
and iron deficiency
anemias.
parasitic diseases,
cancer and phlebitis.
CHEST X-RAY 6-15-07
Findings: chest film shows hyperlucent lung fields with mild widening of the intercostal
spaces and low lying hemidiaphragms with blunted sulci. Heart is narrowed. Calcified
aortic arch. Trachea at midline. Visualized soft tissues and osseous structures shows no
identifiable abnormalities.
Impression: emphysematous changes

Atheromatius aorta
T3-T4-TSH test Normal values Result
T4 60-120 nmol/L 255.10

TSH 0.25-5nIU/L Less than 0.05
Urinalysis- 6- 15 – Urinalysis- 6- 21 – 07 Hematology 6- 21 – 6-16-07

07 07
Color- yellow Color- light yellow Hgb-137

Transparency Transparency -slightly Hct- .31 .33g/L
-slightly turbid turbid
pH-5 pH-5 WBC-7.35 x 10 9/L 6.20x10^9/L
Specific gravity- Specific gravity-1.005 Segmenter-0.62 .86
1.025
Pus cells-3-7hpf Pus cells-0-2 hpf Lymphocyte-0.23 .12
RBC-0-2hpf RBC-0-1hpf Eosinophils-0.15 .02
Epithelial cells- Epithelial cells- some
moderate
Bacteria- some Bacteria-few
A. urates- some A. urates- some
Mucus thread -rare Mucus thread -rare
Cast-CGC- 2-4/hpf
TGC-1-3/hpf
Hyaline cast-0-
2/lpg
Clinical chemistry: Normal values 6-15-07 6-19-07

Na 135-155mmol/L 132.4 135.2
K 3.5-5.5 mmol/L 3.24 3.12
creatinine 44-88umol/L 93.0
Fecalysis 6-15-07
Color- light brown Consistency –watery
Microscopic:
RBC- 12-16/hpf Ova: no parasitic ova seen
Pus-2-3/hpf
Others-(+) for E. histolytica cyst
ECG 6-15-07
Rate : 150cpm rhythm :sinus

=180º T waves-upright
PR interval=0.12sec ST segment-is
QRS Complex
Remarks :
Sinus tachycardia normal axis; no ischemic
or hypermorhic pattern
Progress Notes
7/3/07
3-11
3:00PM  Received lying awake on bed, dyspneic and unresponsive with an

IVF of D5W 500cc- infusing well.
3:30PM
PNSS 1 L
 Seen and examined by Dr. Ehos with new orders.
 Replaced to ongoing IVF above and regulated to KVO.
 NGT inserted by Dr.Egos
4:00 PM
 TSB instructed and done by significant others.
6:00PM
 For repeat CBC.
 For chest xray PA view.
6:10PM
2. Continue TSB if febrile
3. Assist to assume position of comfort.
7/4/07
3-11
3:00PM
 Received awake lying on bed, dyspneic with an IVF of 0.9 NaCl 1liter at 975cc level-infusing well.
 With NGT in placed.
 With FBC attached to urobag in placed draining to lightyellow colored urine output.
 Seen and examined by Dr. Egos with new orders.
 Above IVF regulated to fast drip to consume 100cc then regulated at 20gtts/min.
 For CVP line insertion.
 V/S monitored every 1 hour.
4:00 PM
4:20PM
 Suctioned secretions by clerk on duty PRN.
5:00PM
5:10PM
 CVP line insertion-hold temporarily- as ordered.
7:00PM
2. Continuous TSB if febrile
3. Proper oral hygiene
REVI EW OF SY ST EMS
Integumentary: Vitiligo all over extremities especially on areas exposed to sun, no

rashes, no lesions, no sores, no bruising.
Eyes: Gradual change in vision, no pain, no discharges.
Ears: Hears only with loud voice, no pain, no discharges, negates tinnitus.
Nose and Sinuses: Negates epistaxis, obstruction, no pain, no discharge, no snoring.
Mouth: No bleeding gums, no lesions, no dysphagia, and no altered taste.
Cardiovascular: Palpitations with cold extremities, no edema, no paresthesia.
Endocrine: heat intolerance, thinning hair.
Respiratory: Nonproductive cough, dyspnea, no hemoptysis, no pain, wheezig,

crackles, subcostal and suprasternal retractions, 2-pillow orthopnea.
Gastrointestinal: Blenderized feeding per NGT, constipation,, epigastric pain.
Musculoskeletal: Limited movements, generalized muscle weakness, no joint swelling.
Neurologic: No seizures, no paralysis, nervousness and tremors.
Date of Examination: July 3, 2007
General Survey:
Symmetrical body, no deformities, lying in bed with oxygen inhalation via nasal
cannula at 3L/min with IVF of 0.9NaCl 1 L at right arm, with intact NGT, clean, neatly
dressed, slurred speech, flat facial expression, restless, sweating, fatigue, generalized
weakness.
Vital signs:
Skin:
Inspection: No lesions, no ecchymosis, vitiligo approximately 2cm at right outer
canthus of eyes and all over extremities especially areas exposed to the sun.
Palpation: Warm, moist, poor skin turgor.
Nails:
Inspection: Onycholysis at left index feet and left index finger, pale nail beds, no
clubbing, trimmed fingernails.
Head:
Hair:
Inspection: Equally distributed with visible white hairs.
Eyes:
Inspection: Symmetrical, pale palpebral conjunctiva, anicteric sclerae, PERRLA,
pupil dilatation=3-4mm, no proptosis, no lesions, ptosis.
Ears:
Inspection: Symmetrical, auricles aligned with outer canthus of the eye, no
lesions, no discharges, hears with loud voice.
Nose:
Inspection: With NGT attached at right nare, at midline, no discharges.
Throat and Mouth:

Inspection: Dark red lips, moist oral mucosa, pinkish tongue at midline, no
lesions with gag reflex, with clear to yellowish sputum, reddened uvula, one lower
incisor teeth only, foul breath.
Neck:
Inspection: Visible neck mass, symmetrical neck muscles, use of
sternocleidomastoid muscle for breathing.
Palpation: Palpable thyroid gland both at left and right lobe, smooth, soft, slightly
enlarged but less than twice the size of a normal thyroid gland, tender non enlarged
lymph nodes.
Thorax and Lungs:

Anterior:
Inspection: Symmetrical chest walls, clavicles at same height, with effort
breathing on inspiration, rib angle 45°, retracted ICS during inspiration, subcostal and
suprasternal retractions, tachypnea=35cpm
Percussion: flat
Auscultation: Bilateral crackles in inspiration, and wheezes on expiration.
Posterior:
Percussion: flat
Auscultation: Bilateral crackles in inspiration, and wheezes on expiration.
Heart:
Palpation: No thrills, no heaves, PMI at 5th ICS MCL
Percussion: Dullness over heart.
Auscultation: Irregular heart rhythm, split S2 sound, tachycardia=105bpm.
Abdomen:
Inspection: Symmetrical bilaterally with uniform color and pigmentation.
Auscultation: Bowel sounds= 1 in every 20 minutes
Percussion: Tymphanic over stomach, dullness over liver.
Extremities:
Arms
• Mild weakness
• With flexion and extension
• With reflexes
Legs
• Severe weakness
• No flexion and no extension
• Negative babinski reflex
Muscle strength:
Arterial pulses
Rate: 105 bpm
Rhythm: Irregular
Amplitude: Pulsus alterans
Scale +4
Neurologic system:
Confused, follows command at times, flat facial expression
Glasgow Coma Scale: Level of Consciousness

Eye opening= 3
Motor response= 5
Verbal response= 5
_______
13/15 Interpretation: Lethargic
Functional level Classification: 4
ANA TOMY AND PHYSIOL OGY
Anatom y of the Heart
The essential function of the heart is to pump blood to various parts of the body. The mammalian
heart has four chambers: right and left atria and right and left ventricles. The two atria act as
collecting reservoirs for blood returning to the heart while the two ventricles act as pumps to eject
the blood to the body. As in any pumping system, the heart comes complete with valves to prevent
the back flow of blood. Deoxygenated blood returns to the heart via the major veins (superior and
inferior vena cava), enters the right atrium, passes into the right ventricle, and from there is ejected
to the pulmonary artery on the way to the lungs. Oxygenated blood returning from the lungs enters
the left atrium via the pulmonary veins, passes into the left ventricle, and is then ejected to the
aorta.
The inner edge of the tricuspid and the mitral valves end in filamentous connective tissue (chordae
tendineae). These are attached to small columns of muscle (papillary muscles) arising out of the
inner surface of the ventricles. As the pressure builds in the ventricles, the valves snap shut, and the
papillary muscles prevent the valves from blowing into the atrium and opening.
Pumpin g Action of the Heart
The pumping action starts with the simultaneous contraction of the two atria. This contraction serves
to give an added push to get the blood into the ventricles at the end of the slow-filling portion of the
pumping cycle called "diastole." Shortly after that, the ventricles contract, marking the beginning of
"systole." The aortic and pulmonary valves open and blood is forcibly ejected from the ventricles,
while the mitral and tricuspid valves close to prevent backflow. At the same time, the atria start to fill
with blood again. After a while, the ventricles relax, the aortic and pulmonary valves close, and the
mitral and tricuspid valves open and the ventricles start to fill with blood again, marking the end of
systole and the beginning of diastole. It should be noted that even though equal volumes are ejected
from the right and the left heart, the left ventricle generates a much higher pressure than does the
right ventricle.
Electr ica l Activit y of the Heart
When vertebrate muscles are excited, an electrical signal (called an "action potential") is produced
and spreads to the rest of the muscle cell, causing an increase in the level of calcium ions inside the
cell. The calcium ions bind and interact with molecules associated with the cell's contractile
machinery, the end result being a mechanical contraction. Even though the heart is a specialized
muscle, this fundamental principle still applies.
One thing that distinguishes the heart from other muscles is that the heart muscle is a "syncytium,"
meaning a meshwork of muscle cells interconnected by contiguous cytoplasmic bridges. Thus, an
electrical excitation occurring in one cell can spread to neighboring cells. Another defining
characteristic is the presence of pacemaker cells. These are specialized muscle cells that can generate
action potentials rhythmically.
Under normal circumstances, a wave of electrical excitation originates in the pacemaker cells in the
sinoatrial (S-A) node, located on top of the right atrium. Specialized muscle fibers transmit this
excitation throughout the atria and initiate a coordinated contraction of the atrial walls. Meanwhile,
some of these fibers excite a group of cells located at the border of the left atrium and ventricle
known as the atrioventricular (A-V) node. The A-V node is responsible for spreading the excitation
throughout the two ventricles and causing a coordinated ventricular contraction.
Ho w Your Thyr oid W orks
Your thyroid gland is a small gland, normally weighing less than one ounce,
located in the front of the neck. It is made up of two halves, called lobes, that lie along
the windpipe (trachea) and are joined together by a narrow band of thyroid tissue,
known as the isthmus.
The thyroid is situated just below your "Adams apple" or larynx. During
development (inside the womb) the thyroid gland originates in the back of the tongue,
but it normally migrates to the front of the neck before birth. Sometimes it fails to
migrate properly and is located high in the neck or even in the back of the tongue
(lingual thyroid) This is very rare. At other times it may migrate too far and ends up in
the chest (this is also rare).
The function of the thyroid gland is to take iodine, found in many foods, and
convert it into thyroid hormones: thyroxine (T4) and triiodothyronine (T3). Thyroid
cells are the only cells in the body which can absorb iodine. These cells combine iodine
and the amino acid tyrosine to make T3 and T4. T3 and T4 are then released into the
blood stream and are transported throughout the body where they control metabolism
(conversion of oxygen and calories to energy). Every cell in the body depends upon
thyroid hormones for regulation of their metabolism. The normal thyroid gland
produces about 80% T4 and about 20% T3, however, T3 possesses about four times
the hormone "strength" as T4.
The thyroid gland is under the control of the pituitary gland, a small gland the
size of a peanut at the base of the brain (shown here in orange). When the level of
thyroid hormones (T3 & T4) drops too low, the pituitary gland produces Thyroid
Stimulating Hormone (TSH) which stimulates the thyroid gland to produce more
hormones. Under the influence of TSH, the thyroid will manufacture and secrete T3
and T4 thereby raising their blood levels. The pituitary senses this and responds by
decreasing its TSH production. One can imagine the thyroid gland as a furnace and the
pituitary gland as the thermostat. Thyroid hormones are like heat. When the heat gets
back to the thermostat, it turns the thermostat off. As the room cools (the thyroid
hormone levels drop), the thermostat turns back on (TSH increases) and the furnace
produces more heat (thyroid hormones).
The pituitary gland itself is regulated by another gland, known as the

hypothalamus (shown in our picture in light blue). The hypothalamus is part of the
brain and produces TSH Releasing Hormone (TRH) which tells the pituitary gland to
stimulate the thyroid gland (release TSH). One might imagine the hypothalamus as the
person who regulates the thermostat since it tells the pituitary gland at what level the
thyroid should be set.
Norma l ana to my
• Two lateral lobes are connected by a thin isthmus

• Thyroid gland is anterior and lateral to upper trachea and esophagus,
just below level of cricoid cartilage
• Parathyroid glands and recurrent laryngeal nerve are just behind
thyroid gland
• Develops from evagination of pharyngeal epithelium at foramen
caecum (base of tongue), descends as a component of the
thyroglossal duct from anterior neck in midline; fully developed by
week 14 of gestation
• Lateral thyroid develops from ultimobranchial body that gives rise to
C cells, is considered a fifth branchial pouch
• May be lingual/subhyoid (too high) or substernal (too low)
• Pyramidal lobe, present in 40%, is vestige of thyroglossal duct
• Normal weight in adults is 15-25g
• Divided into lobules of 20-40 follicles, each with a single layer of
cuboidal to low columnar epithelium, filled with thyroglobulin that is
secreted by follicular cells as colloid
• Colloid is scalloped and pale in follicles with active secretory activity;
densely eosinophilic if inactive
• Intrafollicular stroma contains C cells, formerly called parafollicular
cells, derived from neural crest; they secrete calcitonin, which lowers
serum calcium by promoting bone absorption of calcium and
inhibiting bone resorption by osteoclasts
Sand erson ’s polst ers: collections of small follicles projecting into the lumen of large
actively secreting follicles
On co cy te s (Hür thl e cells, oxyphil ic ce lls, As kanazy cells ) have abundant
granular cytoplasm and numerous mitochondria
• Thyroid gland blood supply is superior and inferior thyroidal arteries, regulated
by cervical sympathetic ganglia.
Posi ti ve sta ins: foll ic ular cells and co ll oid - thyroglobulin, T3 (triiodothyronine),
T4 (thyroxine)
• Follicles also stain with low molecular weight keratin, EMA, vimentin, estrogen
beta (not alpha) and progesterone receptors
• C cells stain for calcitonin, low molecular weight keratin, chromogranin A and B,
synaptophysin, CEA; but NOT for thyroglobulin
• Colloid contains birefringent calcium oxalate crystals, particularly in nodular
goiter
Norma l p hys iol ogy

Hypothalamus releases thyroid releasing factor (TRF) into hypothalamic-pituitary
portal blood circulation, which travels to pituitary, which releases thyroid stimulating
hormone (TSH) into blood. Follicular cells normally synthesize thyroglobulin and
secrete it into the follicular lumen, where it is stored as colloid. In response to TSH,
follicular cells pinocytize colloid and convert thyroglobulin to T4 (thyroxine) and T3,
which are secreted into bloodstream. Conversion to T4/T3 occurs via thyroid
peroxidase, which catalyzes tyrosine iodination and coupling of iodotyrosyl residues.
Most T4/T3 is reversibly bound to thyroid binding globulin, which maintains levels
within narrow limits.
Free T4/T3 enters cells, binds to nuclear receptors, increases carbohydrate and fat
catabolism and protein synthesis (basal metabolic rate).
Decreased T3/T4 stimulates release of TRF and TSH via negative feedback regulation;
elevated levels have opposite effect.
Chronically stimulated (hyperplastic) follicular cells are tall and columnar, may be
papillary.
Goi tr ogens : suppress T3/T4 synthesis causing an increased TSH which causes goiter
(enlargement of thyroid gland); examples include propylthiouracil, which inhibits
oxidation of iodide and blocks T3/T4 production, and iodides in large doses, which
inhibit thyroglobulin proteolysis.
Th e Th yr oid Gla nd
The thyroid gland synthesizes and secretes:

• thyroxine (T4) and
• calcitonin
T4 and T 3
(T4 ) is a derivative of the amino acid tyrosine with four atoms of iodine. In target
cells (e.g. liver cells), one atom of iodine is removed from T4 converting it into
triiodothyronine (T3). T3 is the active hormone. It has many effects. Among the most
prominent of these are:
• an increase in metabolic rate (seen by a rise in the uptake of oxygen);
• an increase in the rate and strength of the heart beat.
The thyroid cells responsible for the synthesis of T4 take up circulating iodine from
the blood. This action, as well as the synthesis of the hormones, is stimulated by the
binding of TSH to transmembrane receptors at the cell surface.
PROGNOSIS
Hyperthyroidism is a condition due to excessive production of the thyroid gland
hormone, thyroxine. It is characterized by increased synthesis & secretion of T3 & T4,
lending to an increase metabolic rate. There are 3 major complications of
hyperthyroidism; the exophthalmus, heart disease & thyroid storm.
In our patient, his complication is the heart disease which leads him to have left
ventricular heart failure & thyrotoxic heart disease. Management of thyrotoxic heart
disease usually takes place in a hospital setting, with care managed by the physician,
nurse & pharmacists. Proper management through correcting or increasing cardiac
output, effective gas exchange & tissue perfusion, tolerance in activity, and stabling
the vital signs could mean a higher chance of recovery. However, if untreated, left
ventricular heart failure could lead to complications in the lungs, kidneys & liver which
can also causes death.
In the case of our patient, prognosis is good, considering the fact that thyrotoxic
heart disease is being managed properly by giving medication & monitoring the
patient’s condition. The client also shows signs of improvement.
CONCL USI ON
This is a case of Mrs. O, 66 years old, female from Barangay Daro, Jaro, Leyte.
She was admitted at EVRMC last June 30, 2007 with the chief complaint of dyspnea
and diagnosed with Acute left ventricular heart failure and thyrotoxic heart disease.
The risk factors included in our nursing care plan are Impaired gas exchange,
ineffective airway clearance, Hyperthermia, Risk for impaired skin integrity, Activity
Intolerance, Imbalanced nutrition, Impaired physical mobility, Ineffective peripheral
tissue perfusion and decreased cardiac output.
Hyperthyroidism is a condition in which an overactive thyroid gland is producing
an excessive amount of thyroid hormones that circulate in the blood. ("Hyper" means
"over" in Greek). Thyrotoxicosis is a toxic condition that is caused by an excess of
thyroid hormones from any cause. Thyrotoxicosis can be caused by an excessive intake
of thyroid hormone or by overproduction of thyroid hormones by the thyroid gland.
Since the patient is undergoing treatment, it is therefore concluded that patient
will be able to go through the disease process with proper understanding of it, its
manifestations, treatment and when to seek medical assistance.
REC OM ME NDA TION
In view of all circumstances, the following are thereby recommended:

• Prompt diagnosis and treatment of hyperthyroidism to reduce and possibly
eliminate associated cardiovascular symptoms.
• Careful and thorough assessment of gerontologic clients to avoid overlooking of
manifestations.
• Early initiation of adjunctive therapy of hyperthyroidism to prevent occurrence of
thyrotoxic storm.
• Attention to health teachings be emphasized on medication compliance and the
need for follow-up appointments with physician.
OBJECTIVES
1. To present a reliable patient’s profile and history of the patient

2. To state the results and significance of diagnostic and laboratory examination of the patient.
3. To illustrate and explain briefly the CNS.
4. To site the pharmacology of the medication of the patient.
PATIENTS PROFILE
Name: Mrs.HN
Age: 67 Sex: Female Marital status: married
Address: Brgy. Batang Hernani, Eastern Samar
Birthday: July 13, 1939 Birthplace: Hernani,Samar
Husband: Mr. HN AGE:65 Occupation: columnist
Chief Complaint: Loss of consciousness
Diagnosis: CVA- hemorrhagic
HISTORY OF PRESENT ILLNESS
A case of Mrs. HN 67 yrs.old, female, Filipino, residing at Brgy. Batang, Hernani Eatern Samar, was admitted for the first time
at Bethany Hospital last June 19, 2007 at 8:30 am referred from Banawa Hospital Llorente, Eastern Samar with chief complaint of “loss
of consciousness”.
Patient condition started June 12, 2007 about twelve noon, when patient experienced sudden vertigo, headache, blurring of
vision’ numbness of upper extremities then followed by loss of consciousness. The patient was noted by husband with a loud cry, rolling
eyeballs upward, stiffening of lower and upper extremities, with head extended with a preferential gaze to the right which lasted for
approximately 4 minutes. Vomiting was noted. The patient was immediately brought to the nearest hospital via tricycle which was 6
kilometers away. During transportation while patient is still in the state of unconsciousness, seizure attacks recurred for 3 more times
with same characteristics as previously with an interval of approximately 5-8 minutes. Before onset of manifestation patient was noted
to be angry and irritable because she was prohibited to eat the foods she likes. A spoon was inserted on top of the tongue as a seizure
precaution by the husband.
The patient was then admitted at Baconawa Hospital, Llorente, Eastern Samar, with an admitting impression of cerebrovascular
disease. Upon admission had BP of 180/100, the patient was noted to have facial asymmetry to the left, protrusion of tongue to the left,
a Glascow Coma Scale of 9, and a Bp of 120/100 mmHg, oxygen inhalation was administered at 4-5 L/min and was maintained on
NPO for one day. The patient was prescribed with the following medications: Mannitol 20% to infuse 100 cc q 6˚, Ranitidine 50 mg I
amp IVTT, Furosemide20 mg I amp IVTT, Diazepam 10 mg I amp IVTT, Captopril 25 mg I tab 3 x a day SL.
Three day after admission, the patient was noted to have a non-productive cough and was instructed to drink plenty of water.
The patient was then prescribed Cefuroxime 750 mg IVTT q 8˚ and Salbutamol nebulization I neb OD and was advised to undergo CT-
scan and X-ray, hence discharged on June 15, 2007 in fair condition and was referred to a tertiary hospital of choice. However, due to
financial constraints, the patient was not immediately admitted and stayed for3 more days at her daughter’s house in Marasbaras,
Tacloban City with no seizure attacks noted.
On June 19, 2007 at 8:03 am when patient was conscious and ambulatory, decided to comply with the referral from Baconawa
Hospital, hence subsequently admitted.
PAST MEDICAL HISTORY

Patient had chickenpox and measles when she was in grade school. No known allergy to foods and drugs. No major accidents
nor injuries that cause medical attention.
Patient had three previous hospitalizations. Last 2006, was her first admission in Manila and was diagnosed of CVA, and was
found out to be hypertensive. No paralysis noted. The patient was given take home prescriptions but fail to comply due to financial
constraints. Husband fails to recall take home prescriptions.
Patient’s second hospitalization was last December 2006 in Manila, still diagnosed with CVA, with paralysis noted hemiplegia
(left), but recovered immediately without consultation to a physical therapist. With take home medications, yet fails to comply again.
Patient’s third hospitalization was last January 2007, still diagnosed with CVA, paralysis noted hemiplegia (left), but recovered
immediately with seizures noted 2 times during hospital stay and was advised to undergo CT-Scan yet fails to comply with this
diagnostics exam.
Patient has been suffering from ulcer since she was 25 years old up to the present, with consultation but no medications taken.
FAMILY HEALTH HISTORY
Both parents had hypertension and a relative died from liver disease. Patient negates any other heredo-familial diseases
LIFESTYLE HISTORY
Patient is a non-smoker, occasional beverage drinker, usually drinks Red horse along with friends. Abstain from drinking since
diagnosed of CVA. Loves to eat fatty foods especially fried chickens and loves sauces especially toyo with calamansi. Patient always
feel thirsty and could consume up to 2-3 liters a day. Patient can sleep well in the presence of her favorite pillow. Usually sleeps 6-8
hours a day.
Patient’s daily routine activity are watching TV and doing household chores, like washing the dishes, and sweeping the floor,
easy fatigability noted by husband.
PSYCHOSOCIAL HISTORY
Patient is currently living with her son in Batang, Eastern Samar. Household occupants include 8 people and usually divide
household chores. Highest educational attainment was grade 5 and had worked 40 years ago in a private nursery school.
HOUSING CONDITION
Patient is living in a semi concrete house along the highway with electricity and potable water supply.
DIAGNOSTIC EXAM
Blood Chemistry 6/19/07

Exam Normal Values Results Significance
Sodium 135-148mmol/L 136.8 mmol/L normal
Potassium 3.5-5.3 mmol/L 3.55 mmol/L normal
Crea-B 53-115 mmol/L 74.0 mmol/L Normal
Hematology 6/19/07
Hemoglobin 120-160 g/dL 106 g/dL Anemia
Hematocrit 0.36-0.46 0.32 Anemia
WBC 4.5-11.3 x10 9/L 2.2x10 9/L Bone arrow depression
Neutrophils 0.45-0.65 0.60 Normal
Lymphocytes 0.20-0.35 0.36 Chronic bacterial infection
Monocytes 0.02-0.06 0.02 Normal
Stabs 0.02-0.04 0.02 Normal
Urinalysis 6/19/07
Color Pale yellow-deep amber Yellow Normal
Transparency Clear Slightly turbid Normal
pH 4.5-8.0 6.5 Normal
Specific Gravity 1.002-1.035 1.005 Normal
Protein S Negative (-) Normal
Sugar Negative (-) Normal
Pus Cells 0-2/hpf 0-1/hpf Normal
Red Blood Cells 0-2/hpf None Normal
Epithelial Cells Rare Rare Normal
Mucus Threads Rare None Normal
Amorphous Urates Rare Moderate Normal

Bacteria None - few rare Normal
Chest PA (x-ray) 6/19/07

Chest PA View:
The lung fields are clear. Heart shadow is not enlarged. Trachea is in the midline. Hemidiaphragms and sulci are
intact. Other chest structures are unremarkable.
Impression: Essentially unremarkable cardio pulmonary findings.
CT Scan 6/20/07
Report: Plain and contrast scan of the brain using fused 5.0 and 10.0mm axial slice was done. There is a hypodensity noted
on the right temporo-parietal lobe. No enhancement noted after contrast examination. The midline structures are in placed. The
cisterns, sulci and ventricles are prominent. The mastoids are well aerated. No fracture of the cranial vault noted.
Impression: Cerebral infarction, right temporo-paraital lobe, likely chronic; Cerebral atrophy.
PROSENCEPHALON
Function:
• Chewing
• Directs Sense Impulses Throughout the Body
• Equilibrium
• Eye Movement, Vision
• Facial Sensation
• Hearing, Phonation
• Intelligence
• Memory, Personality
• Respiration
• Salivation, Swallowing
• Smell, Taste
Location:
• The prosencephalon is the most anterior portion of the brain. It is also called the forebrain.
Structures:
• The prosencephalon consists of the telencephalon, striatum, diencephalon, lateral ventricle and third ventricle.
MESENCEPHALON
Function:
• Controls Responses to Sight
• Eye Movement
• Pupil Dilation
• Body Movement
• Hearing
Location:
• The mesencephalon is the most rostral portion of the brainstem. It is located between the forebrain and brainstem.
Structures:
• The mesencephalon consists of the tectum and tegmentum.
RHOMBENCEPHALON
Function:
• Attention and Sleep
• Autonomic Functions
• Complex Muscle Movement
• Conduction Pathway for Nerve Tracts
• Reflex Movement
• Simple Learning
Location:
• The rhombencephalon is the inferior portion of the brainstem.
Structures:
• The rhombencephalon is comprised of the metencephalon, the myelencephalon, and the reticular formation.
BASAL GANGLIA
Function:
• Controls Cognition
• Movement Coordination
• Voluntary Movement
Location:
• The basal ganglia is located deep within the cerebral hemispheres in the telencephalon region of the brain. It consists of the
corpus stratium, subthalamic nucleus and the substantia nigra.
BROCA'S AREA
Function:
• Controls Facial Neurons
• Controls Speech Production
• Understanding Language
Location:
• Broca's area is located in the left frontal lobe, around the opercular and triangular sections of the inferior frontal gyrus.
CENTRAL SULCUS (FISSURE OF ROLANDO)
Function:
• The central sulcus is the large deep groove or indentation that separates the parietal and frontal lobes.
CEREBELLUM
Function:
• Controls Fine Movement Coordination
• Balance and Equilibrium
• Muscle Tone
Location:
• The cerebellum is located just above the brainstem, beneath the occipital lobes at the base of the skull.
CEREBRAL CORTEX
Function:
• Determines Intelligence
• Determines Personality
• Interpretation of Sensory Impulses
• Motor Function
• Planning and Organization
• Touch Sensation
Location:
• The cerebral cortex is the outer portion (1.5mm to 5mm) of the cerebrum. It is divided into lobes: frontal, parietal, temporal and
occipital. The insula is also found in this region of the brain.
FRONTAL LOBES
Function:
• Motor Functions
• Higher Order Functions
• Planning
• Reasoning
• Judgement
• Impulse Control
• Memory
OCCIPITAL LOBES
Function:
• Controls Vision
• Color Recognition
Location:
• The occipital lobes are the most caudal portion of the cerebral cortex.
PARIETAL LOBES
Function:
• Cognition
• Information Processing
• Pain and Touch Sensation
• Spatial Orientation
• Speech
• Visual Perception
Location:
• The parietal lobes are superior to the occipital lobes and posterior to the central sulcus (fissure) and frontal lobes
TEMPORAL LOBES
Function:
• Emotional Responses
• Hearing
• Memory
• Speech
Location:
• The temporal lobes are anterior to the occipital lobes and lateral to the Fissure of Sylvius.
INSULA
Function:
• Associated With Visceral Functions
• Integrates Autonomic Information
Location:
• The insula is located within the cerebral cortex, beneath the frontal, parietal and temporal opercula.
DIENCEPHALON
Function:
• Chewing
• Directs Sense Impulses Throughout the Body
• Equilibrium
• Eye Movement, Vision
• Facial Sensation
• Hearing
• Phonation
• Respiration
• Salivation, Swallowing
• Smell, Taste
Location:
• The diencephalon is located between the cerebral hemispheres and above the midbrain.
Structures:
• Structures of the diencephalon include the thalamus, hypothalamus, the optic tracts, optic chiasma, infundibulum, Ventricle III,
mammillary bodies, posterior pituitary gland and the pineal gland.
TELENCEPHALON
Function:
• Determines Intelligence
• Determines Personality
• Interpretation of Sensory Impulses
• Motor function
• Planning and Organization
• Sense of Smell
• Touch Sensation
Location:
• The telencephalon is the anterior portion of the brain, rostral to the midbrain.
Structures:
• The telencephalon consists of the cerebral cortex, basal ganglia, corpus striatum and olfactory bulb.
THE BRAIN
Most brains exhibit a substantial distinction between the gray matter and white matter. Gray matter consists primarily of the cell
bodies of the neurons, while white matter is comprised mostly of the fibers (axons) which connect neurons. The axons are surrounded
by a fatty insulating sheath called myelin (oligodendroglia cells), giving the white matter its distinctive color. The outer layer of the brain
is gray matter called cerebral cortex. Deep in the brain, compartments of white matter (fasciculi, fiber tracts), gray matter (nuclei) and
spaces filled with cerebrospinal fluid (ventricles) are found.
The brain innervates the head through cranial nerves, and it communicates with the spinal cord, which innervates the body through
spinal nerves. Nervous fibers transmitting signals from the brain are called efferent fibers. The fibers transmitting signals to the brain
are called afferent (or sensory) fibers. Nerves can be afferent, efferent or mixed (i.e., containing both types of fibers).
The brain is the site of reason and intelligence, which include such components as cognition, perception, attention, memory and
emotion. The brain is also responsible for control of posture and movements. It makes possible cognitive, motor and other forms of
learning. The brain can perform a variety of functions automatically, without the need for conscious awareness, such as coordination of
sensory systems (eg. sensory gating and multisensory integration), walking, and homeostatic body functions such as heart rate, blood
pressure, fluid balance, and body temperature.
Many functions are controlled by coordinated activity of the brain and spinal cord. Moreover, some behaviors such as simple
reflexes and basic locomotion, can be executed under spinal cord control alone.
The brain undergoes transitions from wakefulness to sleep (and subtypes of these states). These state transitions are crucially
important for proper brain functioning. (For example, it is believed that sleep is important for knowledge consolidation, as the neurons
appear to organize the day's stimuli during deep sleep by randomly firing off the most recently used neuron pathways; additionally,
without sleep, normal subjects are observed to develop symptoms resembling mental illness, even auditory hallucinations). Every brain
state is associated with characteristic brain waves.
Neurons are electrically active brain cells that process information, whereas Glial cells perform supporting function. In addition to
being electrically active, neurons constantly synthesize neurotransmitters. Neurons modify their properties (guided by gene expression)
under the influence of their input signals. This plasticity underlies learning and adaptation. It is notable that some unused neuron
pathways (constructions which have become physically isolated from other cells) may continue to exist long after the memory is absent
from consciousness, possibly developing the subconscious.
The study of the brain is known as neuroscience, a field of biology aimed at understanding the functions of the brain at every level,
from the molecular up to the psychological. There is also a branch of psychology that deals with the anatomy and physiology of the
brain, known as biological psychology. This field of study focuses on each individual part of the brain and how it affects behavior.
REVIEW OF SYSTEMS
General: Weight gain; no fever, no chills, no night sweats.

Skin: No rashes, no pruritus, no bruising, no changes in color.
Head: Headache, no injury, no tenderness.
Eyes: Blurring of vision, with eyeglasses, pupils equally round and reactive to light, cannot read newsprint.
Ears: Change in hearing, no tinnitus, no pain, no discharges, and no dizziness.
Nose: Clear nasal discharges, sneezing, no epistaxis, no loss of sense of smell.
Throat and Mouth: 5 missing teeth, dental caries in the molars, no mouth sores,no difficulty of swallowing, no ulcerations, and no
lesions.
Respiratory: non productive cough, no chest pain, no dyspnea, no hemoptysis.
Cardiovascular: No chest pain, no palpitations, no shortness of breath.
Gastrointestinal: with ulcer, constipation, no indigestion, no food intolerances, no diarrhea, and no abdominal pain.
Genitourinary: Nocturia present with incontinence, no dysuria, no hematuria.
Endocrine: Thyroid gland palpable on the left.
Musculoskeletal: Limitation of movement at the left upper arm, weakness, no stiffness, no joint swelling, with easy fatigability and
restlessness.
Vital Signs
Pulse Rate: 74 bpm
Respiratory rate: 22 breaths/min
Temperature: 37°C
Blood Pressure: 130/80 mm Hg
General Survey: Fairly groomed with visible fat deposits in abdomen and extremities, conscious, lying in bed, with adult diaper, with an
IVF of .9 NaCl1L @ 10 gtts/min @ left hand.
Integument:
Inspection: Brown in complexion, uniform in color through out body, brown “age spots” on exposed body areas, dry and pallor,
scar @ lower extremities
Palpation: Fair skin turgor, warm to touch
Nails:
Inspection: Untrimmed, dirty fingernails, smooth, nail plate-convex curvature
Palpation: Thick, capillary refill = 5 seconds.
Head:
Inspection: Normocephalic skull, grayish evenly distributed hai, no infestation
Palpation: Smooth skull contour, dry brittle hair
Eyes:
Inspection: Symmetrical, glossy white circle around the periphery of the cornea, pale palpebral conjunctiva, pupils equally
round and reactive to light; pupils dilatation: 3-4mm, cannot read newsprint.
Ears:
Inspection: Symmetrical, auricles aligned with the outer canthus of the eye, cannot hear normal voice tone.
Palpation: No discharge, non tender.
Nose:
Inspection: Symmetrical at midline with clear discharges and frequent sneezing.
Palpation: Non tender sinus, patent nasal passages.
Throat and Mouth:

Inspection: Moist oral mucosa, smooth yellow tooth enamel, 5 missing teeth, dental caries on molars, able to purse lips,
whitish tongue, moves freely, reddened uvula, non-inflamed tonsils, no dysphagia.
Neck:
Inspection: Coordinated movements with no discomforts, thyroid gland not visible.
Palpation: Non-enlarged lymph nodes, palpable thyroid gland
Chest & Lungs:

Anterior:
Inspection: Symmetrical chest, irregular respiratory rhythm, tachypnea (RR=22cpm)
Percussion: Resonance
Auscultation: Clear breath sounds
Posterior:
Inspection: Humpback on spine; spine on midline.
Palpation: Non-tender, no nodules nor mass.
Heart:
Inspection: Not observable apical pulse
Palpation: No thrills, PMI at 5th ICS Midclavicular
Percussion: Dullness over heart
Auscultation: Regular heart rhythm, good S1 and S2.
Abdomen:
Inspection: Uniform color, round in shape.
Auscultation: Regular bowel sound (7 per min.)
Percussion: Dullness over liver, tymphany over stomach.
Palpation: No tenderness, non-palpable spleen and kidneys.
Extremities:
Upper:
• With reflexes on the right
• Palpable peripheral pulses
• No resistance at left upper arm.
Lower:
• With reflexes
• With less resistance on left extremities.
Neurologic System:
Not oriented to place and time, oriented to person, gradual memory loss, affect appropriate to situation, irritable at times and
confusion, poor judgment, slow movement and decrease in speed walking.
Level of Consciousness: Glasgow Coma scale
Eye opening= 4
Motor response= 6
Verbal response= 4
______
14/15
Functional level classification: 1; requires use of equipment or device.
Cranial Nerve Assessment:

I: Can identify objects through smell
II: Cannot see far objects; cannot read newsprint.
III: With extraocular eye movement, pupils equally round and reactive to light, pupil dilation= 3-4mm.
IV: Can move eyeballs downward and upward.
V: Can chew food, with sensation on face, and with positive blink reflex.
VI: Moves eyeballs laterally.
VII: Different kinds of facial expression.
VIII: Negative balance, cannot hear normal voice tone.
IX: with gag reflex.
X: No hoarseness of speech can swallow.
XI: Can move head with resistance
XII: Move tongue and can draw tongue out.
CEREBROVASCULAR ACCIDENT
A cerebrovascular accident is also called a CVA, brain attack, or stroke. It occurs when blood flow to a part of the brain is suddenly
stopped and oxygen cannot get to that part. This lack of oxygen may damage or kill the brain cells. Death of a part of the brain may
lead to loss of certain body functions controlled by that affected part.
CAUSES:
• A piece of fatty plaque (debris) that is formed in a blood vessel breaks away and flows through the bloodstream going to the
brain. The plaque blocks an artery which causes a stroke. This is called an embolic stroke.
• A thrombus (blood clot) formed in an artery (blood vessel) and blocked blood flow to the brain. This is called a thrombotic
stroke.
• A torn artery in the brain, causing blood to spill out. This is called a cerebral hemorrhage or hemorrhagic stroke. It often results
from high blood pressure.
• Blockage of certain small blood vessels inside the brain.
RISK FACTORS:
• Cigarette smoking, cocaine use, or drinking too much alcohol.
• Diabetes (high blood sugar).
• You or a close family member has had a stroke.
• Atherosclerosis (hardening of the arteries) or fatty cholesterol deposits on artery walls.
• Heart disease, such as coronary artery disease.
• High blood cholesterol (fat).
• High blood pressure.
SIGNS AND SYMTPOMS:
• numbness (no feeling)
• tingling,
• weakness
• paralysis (cannot move) on one side of the body
• trouble walking, swallowing, talking, or understanding
• vision (sight) may be blurred or doubled
• severe headache
• feel dizzy
• confused or pass out.
A stroke occurs when the blood supply to the brain is disturbed in some way. As a result, brain cells are starved of oxygen causing
some cells to die and leaving other cells damaged.
Types of stroke
Most strokes occur when a blood clot blocks one of the arteries (blood vessels) that carries blood to the brain. This type of stroke is
called an ischaemic stroke.
Transient ischaemic attack (TIA) is a short-term stroke that lasts for less than 24 hours. The oxygen supply to the brain is restored
quickly, and symptoms of the stroke disappear completely. A transient stroke needs prompt medical attention as it is a warning of
serious risk of a major stroke.
Cerebral thrombosis occurs when a blood clot (thrombus) forms in an artery (blood vessel) supplying blood to the brain. Furred-up
blood vessels with fatty patches of atheroma (arteriosclerosis) may make a thrombosis more likely. The clot interrupts the blood supply
and brain cells are starved of oxygen.
Cerebral embolism is a blood clot that forms somewhere in the body before travelling through the blood vessels and lodging in the
brain. This causes the brain cells to become starved of oxygen. An irregular heartbeat or recent heart attack may make you prone to
forming emboli.
Cerebral haemorrhage occurs when a blood vessel bursts inside the brain and bleeds (haemorrhages). With a haemorrhage, extra
damage is done to the brain tissue by the blood that seeps into it.
PROGRESS NOTES
3/20/07
3-11
3:00PM
 Received conscious, lying on bed with on going IVF of 0.9NaCl I liter at 10gtts/min at 900cc level infusing well at left hand.
 On low salt, low fat diet- instructed.
 Afebrile with temperature of 36.8°C.
 Vital signs taken and recorded:
BP: 13/80 Temp: 36.5°C
RR: 17cpm PR: 68bpm
 Neuro vital signs taken and recorded.
 Still for CBC in the morning.
 Bedside care done.
 Due meds given by NOD.
 Health teachings imparted with emphasis on the following:
o Compliance to medications.
o Safety precautions.
o Foods low in salt and fats.
CONCLUSION
This is a case of Mrs. HN, 67 years old, female from Barangay Batang Hernani, Eastern Samar. She was admitted at Bethany
Hospital last June 19, 2007 with the chief complaint of loss of consciousness and was later diagnosed as cerebrovascular accident.
The risk factors included in our nursing care plan are Ineffective cerebral tissue perfusion, disturbed thought process, impaired
physical mobility, risk for injury and incontinence.
Cerebrovascular accident is also called a CVA, brain attack, or stroke. It occurs when blood flow to a part of the brain is
suddenly stopped and oxygen cannot get to that part. This lack of oxygen may damage or kill the brain cells. Death of a part of the brain
may lead to loss of certain body functions controlled by that affected part.
Treatments recommended for the patients are anticoagulants and antithrombotics with goals t achieve maximum benefit with
fewest side effects. Good nursing care is fundamental in maintaining skin care, feeding, hydration, positioning, and monitoring vital
signs such as temperature, pulse and blood pressure.
Since the patient is undergoing treatment, it is therefore concluded that patient will be able to go through the disease process
with proper understanding of CVA, its manifestations, treatment and when to seek medical assistance.
RECOMMENDATION
• Stress the importance of compliance to medications.

• Encourage SO to notify physicians if symptoms of complications occur.
• Encourage SO and the patient’s family to provide holistic emotional, psychosocial support and care to the patient.
• Encourage patient and SO to comply with health teachings, treatment and regimen.
• Encourage SO to promote safety within home vicinity and observe proper sanitation.
• Encourage patient to eat foods low in salt and fat.
• Encourage the use of supportive measure thru stroke rehabilitation.
PROGNOSIS
A cerebrovascular accident prognosis will tell a patient what to expect after a stroke. It is a medical doctor’s professional
opinion about the course and likelihood of recovery after a stroke (also known as a CVA). The prognosis can include information about
the expected recovery time, the risk of complications, the probable outcomes, and likelihood of survival after a stroke.
CVA are the third leading cause of death in developed countries. Of those people who survive a CVA, only about ten percent
will recover most or total functioning. The CVA prognosis for half of all stroke survivors will leave them with some degree of long-term
disability. Forty percent of all stoke survivors will require long term nursing care after a cerebrovascular accident.
A patients’ cerebrovascular accident prognosis will depend on a number of factors such as the type of stroke suffered, the
extent of resulting brain damage, the presence of related medical problems, the risk of complications, and the likelihood of suffering
additional strokes. Early treatment for a stroke can greatly improve a patient’s cerebrovascular accident prognosis. Prompt treatment
can mitigate the extent of brain damage that a patient suffers.
The type of treatment required to improve a patient’s cerebrovascular accident prognosis will depend on the type of stroke that
they suffered. An ischemic stroke involves a blockage in blood flow in or to the brain.The prognosis for an ischemic stroke can be more
favorable in cases where a patient has received prompt medical attention to restore blood flow in and to the brain.
It will also depend on the likelihood and occurrence of complications. Complications that can compromise a CVA prognosis
can include: paralysis, cognitive deficits, speech problems, emotional difficulties, daily living problems, and pain. This complications will
typically develop soon after a stroke though recurring strokes and other related health problems can also cause these complications.
Disability affects 75% of stroke survivors enough to decrease their employability. Stroke can affect patients physically,
mentally, emotionally, or a combination of the three. The results of stroke vary widely depending on size and location of the lesion.
Dysfunctions correspond to areas in the brain that have been damaged.
Some of the physical disabilities that can result from stroke include paralysis, numbness, pressure sores, pneumonia,
incontinence, apraxia (inability to perform learned movements), difficulties carrying out daily activities, appetite loss, vision loss, and
pain. If the stroke is severe enough, coma or death can result.
Emotional problems resulting from stroke can result from direct damage to emotional centers in the brain or from frustration
and difficulty adapting to new limitations. Post-stroke emotional difficulties include anxiety, panic attacks, flat affect (failure to express
emotions), mania, apathy, and psychosis.
30 to 50% of stroke survivors suffer post stroke depression (Post stroke depression), which is characterized by lethargy,
irritability, sleep disturbances, lowered self esteem, and withdrawal.[23] Depression can reduce motivation and worsen outcome, but can
be treated with antidepressants.
Cognitive deficits resulting from stroke include perceptual disorders, speech problems, dementia, and problems with attention
and memory. A stroke sufferer may be unaware of his or her own disabilities, a condition called anosognosia. In a condition called
hemispatial neglect, a patient is unable to attend to anything on the side of space opposite to the damaged hemisphere.
Up to 10% of all stroke patients develop seizures, most commonly in the week subsequent to the event; the severity of the
stroke increases the likelihood of a seizure.
Lower Glasgow coma scores are associated with poorer prognosis and higher mortality. A larger volume of blood is associated
with a poorer prognosis. The presence of blood in the ventricles is associated with a higher mortality rate.
The patient’s CT Scan result revealed cerebral infarction which affected the right temporo-parietal lobe and resulted to cerebral
atrophy. The patient also developed complications of CVA such as pain and cognitive deficit leading to a poor prognosis for Mrs. HN.
PATHOPHYSIOLOGY
RISK FACTORS
• Advancing age (67 Y/O) • Poor compliance to medications
• Hypertensive • Fatty food preferences
• Prior stroke (3 times) • Family history of hypertension
Related/ Continuous injury to normal artery

(Right middle cerebral artery)
Changes in smooth muscle cells Loss of thromboresistance in endothelial cells
Production of collagen, grounded substances and elastin Local thrombin formation
Matrix of the fibrofatty plaque formation Fibrofatty plaque formation
Trapping of lipid within the plaque
Neointima formation
Further platelet fibrin microthrombi formation
Atherosclerotic plaque increases in size
Arterial stenosis
Lack of O2 supply to the ischaemic neurons
ATP depletion
Membrane ion transport system stops functioning
Depolarization of neurons
Efflux of Potassium Influx of Calcium, sodium,

chloride and water
Excitotoxicity
Further depolarization of cell
Further calcium influx
Triggering of inflammatory response
Cerebral infarction in right temporo-paraital lobe
CLINICAL MANIFESTATIONS:
• Dizziness
• Blurring of vision
• Numbness of upper extremities
• Loss of consciousness
• Loss of balance
• Cannot hear normal voice tone
• Not oriented to time and place
• Gradual memory loss
• Seizure attacks
• Rolling of eyeballs upward
• Stiffening of lower and upper extremities
• Head extended with preferential gaze to the right
• Glasgow coma scale of 9
• Facial asymmetry to the left
• Protrusion of tongue to the left
PATIE NTS PRO FILE
Name: Lolita Obero Javines Case No: 325528

Address: Barangay Culasian Capoocan Leyte Occupation: Housewife
Birthday: July 20, 1962 Birthplace: Capoocan, Leyte
Date of Admission: 8/27/07 Time: 1:30 PM
Father: Deceased Mother: Encarnacion Cabiltes
Husband: Dino Javines Age: 43 years old Occupation: farmer
Attending Consultant:: Dr. Henry Salubon
Chief Complaint:: Removal of Implant (ROI)
Histo ry Present Il lness

Last April 23, 2007, the patient was involved in an accident. Around 6 in the evening that day, she was
walking towards their house at the side of the streets, when suddenly a motorcycle driver hit her. The driver was under
the influence of alcohol. Immediately after the accident, the patient lost her consciousness and was brought to the
hospital. She regained her consciousness the following day in St. Paul’s hospital where her son brought him. When
she woke up, her right arm has a cast and her leg had a bandaged. She stayed in the hospital for 5 days. During which
she was operated In her right leg. Her cast was removed after three weeks and she went on a regular check-up. Then
last August 27, 2007, she was admitted in this institution for the removal of her implant.
Past Hi stor y
According to the patient, the only childhood illness she can remember that she had was measles. Her
immunizations was complete. She has no allergies to any food, drug, animal, plant or others. She was hospitalized first
in St. Pauls Hospital last April 23, 2007 because of the accident.. She was confined there for 5 days only and was
operated on her right leg and had a cast on her right arm.
Fa mi ly Hi sto ry
Acco rding to the patient, her fami ly has a histo ry of hyper tension but no asthma,
diabetes , heart disea ses o r other s.
Psy chosoc ial histo ry :

The patient is a plain and devoted housewife. She takes care of her family. Her usual activities of daily living
are cooking, cleaning the house, washing their clothes and utensils, and others. Household chores is her form of
exercise. She does not smoke but admitted she drinks tuba before, but now is afraid to drink because of the accident.
Sometimes the patient has difficulty in sleeping because of the setting in the hospital.
Soc ial Data

The patient has 6 children. Some of her children has their own family and lives separately. Her highest
educational attainment was Grade 6. Before, she was working in a restaurant as a cook. The patient’s house has 2
bedrooms, 1 toilet, has no electricity, only lampara, and their source of water is from the faucet in the barangay. Their
house is made of cement and wood and is about 150 meters away from the main road.
REVIEW OF SYSTEMS:

Skin: No rashes, pruritus, bruising, change in color, lumps, sores, itching, nor dryness
Head: No headaches, injury, tenderness nor dizziness
Eyes: no change in visual field, glasses, contact lenses, diplopia, pain, excessive discharge nor
dry eyes.
Ears: No Change in hearing, tinnitus, pain, discharge nor dizziness
Nose: no allergies, sinus problem, obstruction, polyps, loss of sense of smell, sneezing nor
epistaxis.
Throat: no toothaches, loose teeth, bleeding gums, mouth sores, hoarseness, dysphagia,
ulcerations nor lesions
Respiratory: no chest pain, dyspnea, cough nor hemoptysis
Cardiovascular: no Chest pain, pressure/ tightness, palpitations, orthopnea, SOB, nor edema.
GIT: no dysphagia, heartburn, ulcer, indigestion, diarrhea, constipation, abdominal pain, food
intolerance nor hemorrhoids.
GUT: no urgency, frequency, nocturia, dysuria, hematuria, UTI nor incontinence
Endocrine: no Heat/cold intolerance, weight change, fatigue, polydipsia, polyuria, polyphagia nor
change in hair distribution
Musculoskeletal: limitation in movement, slight weakness, pain in her right leg.
Vital Signs
Pulse Rate: 90 bpm
Temperature: 37°C
Blood Pressure: 140/90mm Hg
General Survey: Fairly groomed, conscious, sitting on bed with no IVF.

Integument:
Inspection: Brown in complexion, scar at right extremity.
Nails:
Inspection: trimmed, clean fingernails, smooth, nail plate-convex curvature
Head:
Inspection: Normocephalic skull, blackish evenly distributed hair, no infestation
Palpation: Smooth skull contour
Eyes:
Inspection: Symmetrical, PERLLA, can read newsprint, pinkish palpebral conjunctiva
Ears:
Inspection: Symmetrical, auricles aligned with the outer canthus of the eye, can hear
normal voice tone.
Nose:
Inspection: Symmetrical at midline with no discharges and no frequent sneezing.
Throat and Mouth:

Inspection: Moist oral mucosa, able to purse lips, pinkish tongue, moves freely, reddened
uvula, non-inflamed tonsils, no dysphagia.
Neck:
Chest & Lungs:

Anterior:
Inspection: Symmetrical chest, regular respiratory rhythm, eupnea (RR=20cpm)
Posterior:
Inspection: spine on midline.
Heart:
Abdomen:
I. Date: August 20, 2007 X RAY

Impression: No significant chest findings
II. Date: August 20, 2007 Hematology

Female: 120-160g/L
Female: 0.36-0.47
WBC 5.9x109/L 4.5-10.0x109/L Normal
Segmenter 0.65 0.6-0.7 Normal
Lymphocytes 0.30% 0.200-0.350% Normal
Clotting time 4mins and 6seconds 7-120 seconds Increased in severe
coagulation problems and
therapeutic administration
of heparin.
Bleeding time 1minute and 38 3-8 mins Decreased
seconds
III. Date: August 20, 2007 Urinalysis

yellow
Transparency Slight Turbid Clear Normal
pH 5.0 4.6-8.0 Normal
Albumin Positive Negative Proteinuria, severe
stress, acute
infectious disease
WBC 8-12/hpf 3-4/hpf UTI, fever, strenuous
exercise, renal
disease
Bacteria Few None Normal
A.urates Few No significance Normal
Mucus threads Moderate No significance Normal
Reaction Acidic Acidic Normal
IV. Date: August 21, 2007 Clinical Chemistry

FBS 5.19mmol/L 3.89-5.84mmol/L Normal
Cholesterol 3.62 mmol/L Up to 5.7mmol/L Normal
Creatinine 51 umol/L 50-100umol/L Normal
BUA 445 umol/L 135-357umol/L Increased
HDL 1.78 mmol/L More than Increased
1.68mmol/L hypolilolproteinemia,
acute MI, DM, Diet high
in saturated fats
LDL 1.63mmol/L Less than 3.9mmol/L Normal
Triglycerrides 0.46mmol/L 0.46-1.60mmol/L Normal
NA 141mmol/L 135-148mmol/L Normal
K 3.89mmol/L 3.5-5.3mmo/L Normal
PATIE NTS PRO FILE
Name: Jojo Sarmiento Lagrimas Case No: 346529

Address: Barangay Macatingog Calbayog City Occupation: Motorcycle driver
Birthday: December 26, 1978 Birthplace: Calbayog City
Date of Admission: 7/23/07 Time: 11 PM
Father: Bienvenido Lagrimas Mother: Flora Sarmiento
Wife: Alhpy Lagrimas Age: 23 years old
Attending Consultant:: Dr. Jude Macasil
Chief Complaint:: Vehicular accident

Last July 2007, the patient was involved in a vehicular accident in Calbayog City. While he was driving his
motorcycle, a truck driver was out of the line and hit his motorcycle. The truck driver was under the influence of alcohol.
After he was hit, he became unconsciousness, and when he woke up he was already in the hospital in Calbayog city.
He had many wounds, fracture on his extremities especially the left femur. Aside from the fracture, the patient now has
fever. Whenever he changes his position, he feels the pain in his leg. This is relieved by meds and rest.
Past Hi stor y
According to the patient, he had measles, chicken pox and mumps when he was a child. His immunizations
are complete. According to his mother, he has allergy to a certain type of fish but was unable to recall that certain fish.
His first hospitalizations was in Calbayog city after the accident.
Fa mi ly Hi sto ry
Acco rding to the patient, her fami ly has a histo ry of asth ma but no HPN , diabetes, heart
di seases or othe rs.

The patient is a motorcycle driver in Calbayog city. So because of that, his usual ADL is driving. He doest not
exercise regularly and doest not drink alcoholic beverages and does not smoke. He has no problems with his sleeping
patterns.
Soc ial Data

The patient has two children. His highest educational attainment is 1st year high school. Their house has 1
bedroom, no toilet and their source of water is the faucet in the barangay. They have electricity and their house is made
of wood.
REVIEW OF SYSTEMS:
General: weight loss, fever and no chills.

Skin: Bruising, change in color, scars, drying, wounds
dry eyes.
epistaxis.
Musculoskeletal: limitation in movement, stiffness, redness, weakness.
Vital Signs
Pulse Rate: 102 bpm
Temperature: 38.4°C
General Survey: Fairly groomed, conscious, lying on bed, with scars on his extremities, fracture
and bandages on his extremities also and ongoing IVF of D5LR.
Integument:
Inspection: Brown in complexion, scars at extremities and shoulder and forehead, not
uniform in color throughout the body.
Nails:
Head:
Eyes:
Inspection: Symmetrical, PERLLA, can read newsprint, pale palpebral conjunctiva
Ears:
normal voice tone.
Nose:
Throat and Mouth:

Inspection: Moist oral mucosa, able to purse lips, pale tongue, moves freely, reddened
Neck:
Chest & Lungs:

Anterior:
Posterior:
Heart:
Abdomen:
Auscultation: Regular bowel sound
I. Date: July 20, 2007 Hematology

Clotting time 2 minutes 40 7-120 seconds Increased in severe
of heparin.
Bleeding time 1 minute and 10 3-8 minutes Decreased
seconds
II. Date: July 30, 2007 Hematology

hemorrhage
Erythrocytes 1.81x1012/L Male:4.6-6.2x1012/L Decreased in anemia, fluid
Female:4.2-5.4x1012/L overload, recent
Granulocytes 0.52% 0.500-0.750% Normal
Monocytes 0.10% 0.20-0.060% Decreased in aplastic
anemia and lymphocytic
anemia
MCH 31pg 27-31 pg Normal
III. Date: July 31, 2007 Hematology

Hemoglobin 118g/L Male: 140-180g/L Decreased in all anemias
Female: 120-160g/L and excessive fluid intake,
but in the case of the
patient since she has heart
failure, this is a way to
compensate to reduce the
fluid volume in the body.
Hematocrit 0.35 Male: 0.42-0.47 Decreased in severe
Female: 0.37-0.42 anemias and acute
massive blood loss
I. PATIENTS PROFILE
Name:VALENZONA MERALUNA MAZO

Age:8 years old Sex: Female Civil status: elementary pupil
Address: Brgy. Magauhan Baybay, Leyte Occupation: N/A
Birthday: July 11, 1999 Birthplace: Baybay, Leyte
Date of Admission:August 28, 2007 Time: 4:15 PM
Father: Mario Valenzona Mother: Alona Mazo
Occupation: farmer Occupation: housewife
Chief Complaint: “Nabari an iya kamot kay nagslide hiya”, as verbalized by the father.
Post-op Diagnosis: Supracondylar fracture. Open Type II, Left humerus
Operation Performed: “E” ORIF, Crosspinning, Debridement

Last August 8,2007 at around 5pm while on her way home from school, patient passed on a slope
area where she accidentally slide and fractured her left arm. She was sent home by a friend crying for pain
then they took her to a known “hilot” in the barrio. The “hilot” immobilized the arm affected by putting a sling.
Two days after, her father noticed that the fractured site was swelling so they decided to bring her in brgy,
health center near their place but still offers no relief. They decided to bring her to EVRMC for further
evaluation and care but they still had to ask for monetary assistance from their Brgy. Captain and Mayor. It
took them 18 days more to finally gather enough money for hospitalization, thus on Aug. 28, 2007; the
patient was brought to the institution and was admitted the same day and she had her operation last
September 1, 2007.
III. Past History

o No known allergies to foods, medications or any environmental elements.
o Never had any surgical procedures or operations.
o OTC drugs used includes Biogesic for fever, neozep for colds and no nutritional
supplement taken.
o She completed her immunizations, according to father.
o No previous serious injuries and accidents.
IV. Childhood Illness

o Patient haven’t experienced measles and chicken pox.
o She had mumps when she was 6 years old.
o According to her father, patient has asthma since she was a younger.
V. Family History
o Her grandfather on father’s side has hypertension.
o Her mother has asthma.
o On her father side there is also a history of diabetes meliitus.
VI. Lifestyle
Patient is a 4th child among six children. She is a grade II pupil in an elementary school near
their barangay. She just walks in going to school with her brother. According to her father, patient loves
to play with her brothers and sisters after doing their assignment in the evening. But since the accident
happen, she stopped going to school and rarely plays with her siblings anymore due to the fracture on
her left arm.
VII. Social Data

Patient lives at Brgy. Magauhan Baybay, Leyte with her parents and four siblings. Their house is
made of light materials and conveniences of electricity. Secures water from “tubod” near the house. Dog,
pigs and chickens stays outside. Neighborhood is usually safe.

Visits Brgy. Health Center (also called "sentro” by the father) when sick usually with fever or
asthma. She had never visited a dentist.
HEMATOLOGY- August 28, 2007

Hemoglobin 112g/L Male: 135-170g/L Normal;
Female: 120-160g/L
WBC 8.90x109/L 4.5-10.0x109/L Normal;
Segmenter 0.53 0.6-0.7 Decreased in viral diseases,

leukemias, agranulocytosis,
aplastic and iron deficiency
anemias.
Lymphocytes 0.34 0.200-0.350 Normal;

parasitic diseases, cancer
and phlebitis.
MISCELLANEOUS- August 28, 2007

Color: yellow yellow Yellow Normal
Transparency clear clear Normal
pH 6.0 5.5-6.5 Normal

Specific Gravity 1.010 1.002-1.035 Normal
Albumin negative Negative Normal

Sugar negative Negative Normal
Pus cells 3-5/hpf 0-2/hpf Increased in infection
Red cells 0-2/hpf >3/hpf Normal
Epith. Cells few Rare-few Normal
Mucus threads rare Rare-few Normal
A. Urates/ phosphates few Rare-few Normal
Bacteria: some none Increased in infection
REVIEW OF SYSTEMS:
Integumentary: no rashes, no lesions, no sores, no bruising.

Eyes: no pain, no discharges.
Ears: no pain, no discharges, negates tinnitus.
Nose and Sinuses: with colds, negates epistaxis, no obstruction, no pain
Mouth: No bleeding gums, no lesions, no dysphagia, and no altered taste, no toothache
Cardiovascular: no edema, no palpitations
Endocrine: no excessive sweating
Respiratory: no cough, no dyspnea, no hemoptysis, no wheezing.
Gastrointestinal: on DAT, no constipation,, no epigastric pain.
Musculoskeletal: with fracture on left arm, limited movements, with pain when moving affected arm
Date of Examination: September 2, 2007
General Survey:
Symmetrical body, with fractured left arm, lying in bed with IVF of D50.3%NaCl 500cc at right arm,
neatly dressed, sad facial expression, restless and febrile.
Vital signs:
RR= 28cpm
Skin:
Inspection: No lesions, no ecchymosis, with presence of scars on extremities
Palpation: Warm, moist, good skin turgor.
Nails:
Inspection: pinkish nail beds, no clubbing, dirty fingernails.
Head:
Hair:
Inspection: Equally distributed, there is no presence of lice
Eyes:
Inspection: Symmetrical, pinkish palpebral conjunctiva, anicteric sclerae, no lesions, no ptosis.
Ears:
Inspection: Symmetrical, auricles aligned with outer canthus of the eye, no lesions, no discharges
Nose:
Inspection: With colds, at midline
Throat and Mouth:
Inspection: with red lips, moist oral mucosa, pinkish tongue at midline, no lesions with gag reflex,
with clear to yellowish sputum, reddened uvula, with cavities
Neck:
Inspection: no neck mass, symmetrical neck muscles
Palpation: non-tender, non enlarged lymph nodes.
Thorax and Lungs:

Anterior:
Inspection: Symmetrical chest walls, clavicles at same height, with no effort on breathing
Auscultation: bronchovesicular breath sounds.
Posterior:
Heart:
Palpation: No thrills, no heaves
Auscultation: with regular heart rhythm, no murmur, HR=103bpm
Abdomen:
Inspection: Symmetrical bilaterally with uniform color.
Extremities:
Upper
• With fractured left arm, pain on movement

• Palpable radical and brachial pulses(right arm)
Lower
• Palpable popliteal, posterior tibial, dorsalis pedis pulse.
Heart Rate: 103bpm

Rhythm: regular
Neurologic:
Patient is oriented to person, place and time.
No headache.
I. PATIENTS PROFILE
Name:ESTOLERO, SELVESTRE BAGALAN

Age:27 years old Sex: Male Civil status: single
Address: Brgy.san Antonio, Basey,Samar Occupation: None
Birthday: January 15, 1980 Birthplace: Basey, Samar
Date of Admission: June 28, 2007 Time: 2:30 PM
Father: -desceased- Mother: Anna Estolero
Chief Complaint: “Nagcrash ako ha motor asya tak pagnginanhi” as verbalized by the pt.

Last June 24, 2007 at around 9pm, driving a motorcycle alone on his way home, patient was drunk
and he was from a beach with his friends where they had drinking session. He felt asleep while driving that’s
why all of the sudden he barely noticed that he had already an accident. According to the patient he doesn’t
have any other injury aside from a fractured knee. After the accident, he didn’t loss his consciousness. He
was then brought directly to EVRMC by his brother-in-law for management and care.
III. Past History

o He has known allergies to foods, such as noodles and canned foods. No known allergies
to medications or any environmental elements.
o He was hospitalized 5yrs ago for dengue and had surgical operations due to stab wound
on his right shoulder..
o OTC drugs used includes Biogesic for fever, neozep for colds and no nutritional
supplement taken.
o He completed his immunizations.
o He has no known medical illness.
IV. Childhood Illness

• Recalls mother telling him about having had chicken pox (date unknown) and mumps, no
complications and no other childhood diseases.
V. Adult Illness
o Patient has no HPN, DM, TB, or asthma.
IV. Family History

o The patient has a family history of hypertension specifically on his paternal side. But he
does not have any family history of DM, heart diseases, arthritis, epilepsy, cancer and
psychosis.
VII. Lifestyle
• The patient is a known alcoholic and states that he can’t estimate how many liters he drinks every
session. He claims that he drinks any alcoholic beverage which ever is available 2-4 times a week.
According to him he never tries to smoke. He loves to eat meat, fish, vegetables and hard types of
foods.
• He usually is the one who cooks at home.
• The patient’s form of exercise is walking and his hobby is just singing.
V. Social Data
o The patient is single and currently lives with his parents at Basey, Samar.. He has no
works and refer himself as “tambay”. In cases of problems, it is his family who helps him a
lot and supports him emotionally. He claims that he has many sets of friends and he is
able to get along well with others.
o Financially, he can’t support himself and can’t provide his own needs for he has no work.

Visits hospital when sick. Sees the dentist only when something bothers him, can’t remember last
visit. No vision check since can remember.
Clotting time 2 mins 55 sec 7-120sec Prolonged in severe

therapeutic administration of
heparin
Bleeding time 0 mins and 30 sec 1-9 min Prolonged in

thrombocytopenia, defective
platelet function and aspirin
therapy
Hemoglobin 104g/L Male: 135-170g/L Decrease; various anemias,

Female: 120-160g/L severe or prolonged
hemorrhage and with
excessive fluid intake
Decrease; severe anemias,
Hematocrit 0.29 Male:0.40-0.54 acute massive blood loss
Female: 0.36-0.47
RBC 3.65x10^12/L Male: 4.6-6.2 Decrease; all anemias, after

Female: 4.2-5.4 hemorrhage and when blood
volume has been restored
WBC 11.30x109/L 4.5-10.0x109/L increase; acute infectious
disease
Segmenter 0.53 0.6-0.7 Decreased in viral diseases,
leukemias, agranulocytosis,
aplastic and iron deficiency
anemias.
Lymphocytes 0.26 0.200-0.350 Normal;
Monocytes 0.05 0.01-0.04 Increased in allergies,

parasitic diseases, cancer
and phlebitis.
MCV 81.00fl 80-96 Normal

MCH 28.59pg 27-31 Normal
Radiologic Exam- June 25,2007
Exam: left thigh to include left knee joint APL
Impression:
Fracture left femur
Left thigh/knee APL
Complete displaced fracture involving the distal half of the left femur. No knee dislocation
noted.
REVIEW OF SYSTEMS:
Integumentary: no rashes, no lesions, no sores, no bruising, swelling on left thigh

Eyes: no pain, no discharges.
Ears: no pain, no discharges, negates tinnitus.
Nose and Sinuses: with colds, negates epistaxis, no obstruction, no pain
Mouth: No bleeding gums, no lesions, no dysphagia, and no altered taste, no toothache
Cardiovascular: no edema, no palpitations
Endocrine: no excessive sweating
Respiratory: no cough, no dyspnea, no hemoptysis, no wheezing.
Gastrointestinal: on DAT, no constipation, no epigastric pain.
Musculoskeletal: with fracture on left arm, limited movements, with pain when moving affected arm
Date of Examination: September 2, 2007
General Survey:
Symmetrical body, with fractured left arm, sitting on bed without IVF, patient wearing no shirt
Vital signs:
RR= 21cpm
PR= 63bpm Temperature= 36.8°C
BP: 110/70mmHg
Skin:
Inspection: No lesions, no ecchymosis, with presence of scars on extremities and on left shoulder
area from stab wound
Palpation: Warm, moist, good skin turgor.
Nails:
Inspection: pale nail beds, no clubbing, dirty fingernails and hands
Head:
Hair:
Inspection: Equally distributed, there is no presence of lice
Eyes:
Inspection: Symmetrical, pinkish palpebral conjunctiva, anicteric sclerae, no lesions, no ptosis.
Ears:
Inspection: Symmetrical, auricles aligned with outer canthus of the eye, no lesions, no discharges
Nose:
Inspection: With colds, at midline
Throat and Mouth:

Inspection: with red lips, moist oral mucosa, pinkish tongue at midline, no lesions with gag reflex,
with clear to yellowish sputum, reddened uvula, with cavities
Neck:
Inspection: no neck mass, symmetrical neck muscles
Palpation: non-tender, non enlarged lymph nodes.
Thorax and Lungs:

Anterior:
Inspection: Symmetrical chest walls, clavicles at same height, with no effort on breathing
Posterior:
Heart:
Palpation: No thrills, no heaves
Auscultation: with regular heart rhythm, no murmur, PR=63bpm
Abdomen:
Inspection: Symmetrical bilaterally with uniform color.
Extremities:
Upper
• Palpable radical and brachial pulses

Lower
• With fractured left thigh, with slight pain on movement
• Palpable popliteal, posterior tibial, dorsalis pedis pulse(right leg)
Pulse Rate: 63bpm

Rhythm: regular
Neurologic:
Patient is oriented to person, place and time.
No headache.
PATIE NTS PRO FILE
Name: Jojo Sarmiento Lagrimas Case No: 346529

Address: Barangay Macatingog Calbayog City Occupation: Motorcycle driver
Birthday: December 26, 1978 Birthplace: Calbayog City
Date of Admission: 7/23/07 Time: 11 PM
Father: Bienvenido Lagrimas Mother: Flora Sarmiento
Wife: Alhpy Lagrimas Age: 23 years old
Attending Consultant:: Dr. Jude Macasil
Chief Complaint:: Vehicular accident

Last July 2007, the patient was involved in a vehicular accident in Calbayog City. While he was driving his
motorcycle, a truck driver was out of the line and hit his motorcycle. The truck driver was under the influence of alcohol.
After he was hit, he became unconsciousness, and when he woke up he was already in the hospital in Calbayog city.
He had many wounds, fracture on his extremities especially the left femur. Aside from the fracture, the patient now has
fever. Whenever he changes his position, he feels the pain in his leg. This is relieved by meds and rest.
Past Hi stor y
According to the patient, he had measles, chicken pox and mumps when he was a child. His immunizations
are complete. According to his mother, he has allergy to a certain type of fish but was unable to recall that certain fish.
His first hospitalizations was in Calbayog city after the accident.
Fa mi ly Hi sto ry
Acco rding to the patient, her fami ly has a histo ry of asth ma but no HPN , diabetes, heart
di seases or othe rs.

The patient is a motorcycle driver in Calbayog city. So because of that, his usual ADL is driving. He doest not
exercise regularly and doest not drink alcoholic beverages and does not smoke. He has no problems with his sleeping
patterns.
Soc ial Data

The patient has two children. His highest educational attainment is 1st year high school. Their house has 1
bedroom, no toilet and their source of water is the faucet in the barangay. They have electricity and their house is made
of wood.
REVIEW OF SYSTEMS:
General: weight loss, fever and no chills.

Skin: Bruising, change in color, scars, drying, wounds
dry eyes.
epistaxis.
Musculoskeletal: limitation in movement, stiffness, redness, weakness.
Vital Signs
Pulse Rate: 102 bpm
Temperature: 38.4°C
General Survey: Fairly groomed, conscious, lying on bed, with scars on his extremities, fracture
and bandages on his extremities also and ongoing IVF of D5LR.
Integument:
Inspection: Brown in complexion, scars at extremities and shoulder and forehead, not
uniform in color throughout the body.
Nails:
Head:
Eyes:
Inspection: Symmetrical, PERLLA, can read newsprint, pale palpebral conjunctiva
Ears:
normal voice tone.
Nose:
Throat and Mouth:

Inspection: Moist oral mucosa, able to purse lips, pale tongue, moves freely, reddened
Neck:
Chest & Lungs:

Anterior:
Posterior:
Heart:
Abdomen:
Auscultation: Regular bowel sound
I. Date: July 20, 2007 Hematology

Clotting time 2 minutes 40 7-120 seconds Increased in severe
of heparin.
Bleeding time 1 minute and 10 3-8 minutes Decreased
seconds
II. Date: July 30, 2007 Hematology

hemorrhage
Erythrocytes 1.81x1012/L Male:4.6-6.2x1012/L Decreased in anemia, fluid
Female:4.2-5.4x1012/L overload, recent
Granulocytes 0.52% 0.500-0.750% Normal
Monocytes 0.10% 0.20-0.060% Decreased in aplastic
anemia and lymphocytic
anemia
MCH 31pg 27-31 pg Normal
III. Date: July 31, 2007 Hematology

Hemoglobin 118g/L Male: 140-180g/L Decreased in all anemias
Female: 120-160g/L and excessive fluid intake,
but in the case of the
patient since she has heart
failure, this is a way to
compensate to reduce the
fluid volume in the body.
Hematocrit 0.35 Male: 0.42-0.47 Decreased in severe
Female: 0.37-0.42 anemias and acute
massive blood loss
PATIE NTS PRO FILE
Name: Lolita Obero Javines Case No: 325528

Address: Barangay Culasian Capoocan Leyte Occupation: Housewife
Birthday: July 20, 1962 Birthplace: Capoocan, Leyte
Date of Admission: 8/27/07 Time: 1:30 PM
Father: Deceased Mother: Encarnacion Cabiltes
Husband: Dino Javines Age: 43 years old Occupation: farmer
Attending Consultant:: Dr. Henry Salubon
Chief Complaint:: Removal of Implant (ROI)

Last April 23, 2007, the patient was involved in an accident. Around 6 in the evening that day, she was
walking towards their house at the side of the streets, when suddenly a motorcycle driver hit her. The driver was under
the influence of alcohol. Immediately after the accident, the patient lost her consciousness and was brought to the
hospital. She regained her consciousness the following day in St. Paul’s hospital where her son brought him. When
she woke up, her right arm has a cast and her leg had a bandaged. She stayed in the hospital for 5 days. During which
she was operated In her right leg. Her cast was removed after three weeks and she went on a regular check-up. Then
last August 27, 2007, she was admitted in this institution for the removal of her implant.
Past Hi stor y
According to the patient, the only childhood illness she can remember that she had was measles. Her
immunizations was complete. She has no allergies to any food, drug, animal, plant or others. She was hospitalized first
in St. Pauls Hospital last April 23, 2007 because of the accident.. She was confined there for 5 days only and was
operated on her right leg and had a cast on her right arm.
Fa mi ly Hi sto ry
Acco rding to the patient, her fami ly has a histo ry of hyper tension but no asthma,
diabetes , heart disea ses o r other s.

The patient is a plain and devoted housewife. She takes care of her family. Her usual activities of daily living
are cooking, cleaning the house, washing their clothes and utensils, and others. Household chores is her form of
exercise. She does not smoke but admitted she drinks tuba before, but now is afraid to drink because of the accident.
Sometimes the patient has difficulty in sleeping because of the setting in the hospital.
Soc ial Data

The patient has 6 children. Some of her children has their own family and lives separately. Her highest
educational attainment was Grade 6. Before, she was working in a restaurant as a cook. The patient’s house has 2
bedrooms, 1 toilet, has no electricity, only lampara, and their source of water is from the faucet in the barangay. Their
house is made of cement and wood and is about 150 meters away from the main road.
REVIEW OF SYSTEMS:

Skin: No rashes, pruritus, bruising, change in color, lumps, sores, itching, nor dryness
dry eyes.
epistaxis.
Musculoskeletal: limitation in movement, slight weakness, pain in her right leg.
Vital Signs
Pulse Rate: 90 bpm
Temperature: 37°C
General Survey: Fairly groomed, conscious, sitting on bed with no IVF.

Integument:
Inspection: Brown in complexion, scar at right extremity.
Nails:
Inspection: trimmed, clean fingernails, smooth, nail plate-convex curvature
Head:
Eyes:
Inspection: Symmetrical, PERLLA, can read newsprint, pinkish palpebral conjunctiva
Ears:
normal voice tone.
Nose:
Throat and Mouth:

Inspection: Moist oral mucosa, able to purse lips, pinkish tongue, moves freely, reddened
Neck:
Chest & Lungs:

Anterior:
Posterior:
Heart:
Abdomen:
I. Date: August 20, 2007 X RAY

Impression: No significant chest findings
II. Date: August 20, 2007 Hematology

Female: 120-160g/L
Female: 0.36-0.47
WBC 5.9x109/L 4.5-10.0x109/L Normal
Segmenter 0.65 0.6-0.7 Normal
Lymphocytes 0.30% 0.200-0.350% Normal
Clotting time 4mins and 6seconds 7-120 seconds Increased in severe
of heparin.
Bleeding time 1minute and 38 3-8 mins Decreased
seconds
III. Date: August 20, 2007 Urinalysis

yellow
Transparency Slight Turbid Clear Normal
pH 5.0 4.6-8.0 Normal
Albumin Positive Negative Proteinuria, severe
stress, acute
infectious disease
WBC 8-12/hpf 3-4/hpf UTI, fever, strenuous
exercise, renal
disease
Mucus threads Moderate No significance Normal
Reaction Acidic Acidic Normal
IV. Date: August 21, 2007 Clinical Chemistry

FBS 5.19mmol/L 3.89-5.84mmol/L Normal
Cholesterol 3.62 mmol/L Up to 5.7mmol/L Normal
Creatinine 51 umol/L 50-100umol/L Normal
BUA 445 umol/L 135-357umol/L Increased
HDL 1.78 mmol/L More than Increased
1.68mmol/L hypolilolproteinemia,
acute MI, DM, Diet high
in saturated fats
LDL 1.63mmol/L Less than 3.9mmol/L Normal
Triglycerrides 0.46mmol/L 0.46-1.60mmol/L Normal
NA 141mmol/L 135-148mmol/L Normal
K 3.89mmol/L 3.5-5.3mmo/L Normal
I. PATIENTS PROFILE
Name: Stanley Josydre Castroverde Busante Case No: 029599

Age: 5 years old Sex: Male Civil status: Single
Address: Brgy. 63 Mangga Sagkahan Tacloban City
Birthday: November 13, 2001 Birthplace: Tacloban City
Date of Admission: September 8, 2007 Time: 2:00PM
Father: Marlon Tan Mother: Rhaila Czarina Busante
Attending Consultant: Dr. Troyo/ Dr. Añover
Chief Complaint: Fall
Diagnosis: Fracture closed proximal 3rd right thigh

Few hours PTA, patient was riding a bicycle together with his neighbors.
Suddenly, they had an accident, and the patient landed on his right side, injuring his right
thigh. Immediately, the patient felt severe and unbearable pain. There was also swelling
and redness. So, his parents immediately decided to bring him to RTR hospital without
moving his right thigh, hence admission.
III. Past History

• This is the second time the patient was hospitalized. First was in St. Paul’s
hospital last 2003 due to pneumonia.
• The patient had measles when he was one year old and mumps when he was 4
years old.
• He has complete immunizations but except for chicken pox.
• The patient has no allergies to food, drugs and animals.
• The patient takes Ascorbic Acid as his supplement.
IV. Family History

The patient’s family has a history of both hypertension and asthma. Hypertension
is from the maternal side and asthma on the paternal side.
V. Lifestyle
• As a child, the patient loves to play with his playmates.
• He has no problems with regards to his sleeping pattern.
• He usually wakes up at around 6AM because he has to go to school.
• He sleeps in the afternoon after school, then wakes up at 5 PM then sleeps at
around 10PM.
Review of Systems:
General:
Patient is conscious, coherent, and responsive and oriented to time, place and
person. Patient is afebrile.
Skin:
There are no complaints of rashes, itching, and dryness of skin.
Heent:
Head: Patient has no headache or dizziness.
Eyes: Patient does not wear glasses or contact lenses; negates having blurred
vision, double vision excessive tearing, redness and pain.
Ears: Negates having hearing problems, vertigo, ear ache, tinnitus and abnormal
ear discharges.
Nose: Patient has no episodes of epistaxis, no colds and no nasal discharges.
Neck: Negates having nuchal pain and stiffness.
Respiratory:
Negates having dry cough and difficulty of breathing.
Cardiovascular:
Negates being hypertensive, there’s no complaints of chest pain and discomfort,
no palpitations, orthopnea, or heartburn.
Gastrointestinal:
Negates having problems swallowing, nausea, lose of appetite, and heartburn.
There is no abdominal pain, food intolerance and excessive belching.
Musculoskeletal:
Complaints of pain on right thigh especially upon movement.
Physical Examination
General Survey: Conscious, coherent and respomsive
V/S: RR:22 cpm HR:88 bpm T: 36°C
Skin:
Inspection: uniformly distribute skin color on the unaffected side, no areas of
increased vascularities, ecchymosis or bleeding with dry and intact dressing on right
thigh, pale skin color on right thigh.
Palpation: warm, good skin turgor but cold clammy skin on right thigh
Nails:
Inspection: pale nail beds distal to affected area (right thigh)
Palpation: firm nail base, smooth
Head:
Inspection: normocephalic, symmetrical, with intact shiny scalp, evenly
distributed hair.
Palpation: Smooth skull contours, non tender, without masses or depressions.
Eyes:
Inspection: symmetrical, pinkish palpebral conjunctiva, PERRLA, no discharges;
no lesions.
Ears:
Inspection: symmetrical, auricles aligned with outer canthus of eye, no lesions, no
discharges
Palpation: non tender auricles, recoil when pinched.
Nose:
Inspection: symmetrically in midline of face, without swelling, discharges, lesions
Palaption: non tender, non swelling sinus, patent nostrils
Throat and mouth:

Inspection: moist mucus membrane, no evidence of lesions, or inflammation, with
gag reflex.
Neck:
Inspection: symmetric muscles, without masses or spasms.
Palpation: no enlargement of thyroid gland, no masses, or tenderness, no enlarged
lymph nodes
Auscultation: no presence of bruits observed.
Thorax and Lungs:

Inspection: symmetric chest walls, shoulders at same height, scapula at same
height bilaterally, no retractions, or bulging ICS, with regular rhythmic breathing.
Palpation: no tender symmetric chest expansion, no nodules or masses
Percussion: resonant overall lung fields
Auscultation: bronchovesicular lung sounds
Heart:
Inspection: not observable apical pulse
Palpation: no thrills, nor heaves,
Percussion: dullness over heart
Auscultation: no murmurs, S1,S2 sounds
Abdomen:
Inspection: with uniform color and pigmentation, symmetrical bilateral
Percussion: tympany over stomach, dullness over liver
Palpation: no tenderness, no palpable spleen and kidney non enlarged liver
The musculo-skeletal system

• Pain, pale skin color, capillary refill of 6, cold clammy skin on affected area.
• With limitation of movement
• Weakness
PATIENTS PROFILE
Name: Christopher Panistan Maballo Case No: 353692

Age: 2 years old Sex: Male
Address: Brgy. Rizal, La Paz Leyte
Religion: N/A Nationality: Filipino
Birthday: March 24, 2005 Birthplace: La paz, Leyte
Date of Admission: September 16, 2007 Time: 3:50PM
Father: Eduardo Maballo Occupation: Farmer
Mother: Nilda Maballo Occupation: Housewife
Attending Consultant: Dr. Arcano/ Verano/ Dadizon
Chief Complaint: Abscess left gluteal area

Five days prior to admission, patient was playing outside their house when suddenly he fell on his
left side. The following days, he had an abscess on his left gluteal area. It gradually becomes bigger
everyday. Patient complains of severe pain through crying. Symptoms associated with the chief complaint
are fever, cough and colds. When patient is sitting or lying on his left side, the pain becomes very severe.
Hence parents decided to bring the patient to this center.
III. Past History

This is the first time the patient was hospitalized. He had not yet experienced chicken pox,
measles, mumps or any other childhood disease but according to his parents, he had complete
immunizations. He has no allergies to any food or drug. The patient takes multivitamins everyday.
IV. Family History

According to the significant others, patient’s family has no history of asthma, DM, hypertension, nor
heart disease.
Patient as a child loves to play with his siblings and to watch programs on television. In the past
few days, due to his abscess, he had sleeping difficulties. According to his mother, patient cannot sleep well
at night due to severe pain.
VI. Social Data

Patient’s family lives in Barangay La Paz Leyte. They live in a one bedroom house along side the
main road. They have one toilet. Their electricity is from DORELCO and their water source is from the
“bomba”.
LABORATORY EXAMS:
I. X-ray report ( 9/16/07)

Chest Xray PA view
Impression: Normal radiographic chest findings.
II. Laboratory Report (9/17/07)

Specimen: discharge
Result: Gram (+) cocci in pairs, short chain and small clusters. Pus cells: 10-19/hpf
III. Hematology (9/16/07)

Female: 120-160g/L hemodilution(fluid overload),
anemia, recent hemorrhage
Hematocrit 0.15 Male: 0.40-0.54 Decreased in hemodilution,
Female: 0.36-0.47 anemia, and acute massive
blood loss.
WBC 14.1x109/L 5-10.0x109/L increase;acute infectious
disease
Segmenter 0.86 0.5-0.7 Increased acute infections,
inflammatory disease, tissue
damage.
Lymphocytes 0.14 0.25-0.40 Decreased in leukemia,
aplastic anemia,
agranulocytosis, renal failure.
REVIEW OF SYSTEMS
General: With fever and chills.

Skin: Bruising, change in color on left gluteal area.
Eyes: no change in visual field, glasses, contact lenses, diplopia, pain, excessive discharge nor dry eyes.
Nose: no allergies, sinus problem, obstruction, polyps, loss of sense of smell, sneezing nor epistaxis.
Throat: no toothaches, bleeding gums, mouth sores, hoarseness, dysphagia, ulcerations nor lesions
Respiratory: no chest pain, dyspnea, nor hemoptysis but with non productive cough.
GIT: no dysphagia, heartburn, ulcer, indigestion, diarrhea, constipation, abdominal pain, food intolerance nor
hemorrhoids.
Endocrine: no Heat/cold intolerance, weight change, fatigue, polydipsia, polyuria, polyphagia nor change in
hair distribution
Musculoskeletal: limitation in movement, weakness and pain on left gluteal area.
Physical Examination
General Survey: Conscious, coherent and respomsive
V/S: RR:31 cpm HR:132 bpm T: 37.5°C
Skin:
Inspection: Uniform skin color on some areas, with scars on upper extremities, no bleeding,
ecchymosis but with bruising skin color on left gluteal area.
Palpation: good skin turgor, warm to touch
Nails:
Inspection: pale nail beds trimmed, clean fingernails, smooth, nail plate-convex curvature
Palpation: firm nail base, smooth
Head:
Inspection: normocephalic, symmetrical, with intact shiny scalp, evenly distributed hair.
Palpation: Smooth skull contours, non tender, without masses or depressions.
Eyes:
Inspection: symmetrical, pinkish palpebral conjunctiva, PERRLA, no discharges; no lesions.
Ears:
Inspection: symmetrical, auricles aligned with outer canthus of eye, no lesions, and no discharges
Palpation: non tender auricles, recoil when pinched.
Nose:
Inspection: symmetrically in midline of face, without swelling, discharges, lesions
Palpation: non tender, non swelling sinus, patent nostrils
Throat and mouth:

Inspection: moist mucus membrane, no evidence of lesions, or inflammation, with gag reflex.
Neck:
Inspection: symmetric muscles, without masses or spasms.
Palpation: no enlargement of thyroid gland, no masses, or tenderness, no enlarged lymph nodes
Thorax and Lungs:

Inspection: symmetric chest walls, shoulders at same height, scapula at same height bilaterally, no
retractions, or bulging ICS, with regular rhythmic breathing.
Palpation: no tender symmetric chest expansion, no nodules or masses
Percussion: resonant overall lung fields
Auscultation: bronchovesicular lung sounds
Heart:
Inspection: not observable apical pulse
Palpation: no thrills, nor heaves,
Percussion: dullness over heart
Auscultation: no murmurs, S1,S2 sounds
Abdomen:
Inspection: with uniform color and pigmentation, symmetrical bilateral
Percussion: tympany over stomach, dullness over liver
Palpation: no tenderness, no palpable spleen and kidney non enlarged liver
The musculo-skeletal system
• Pain and pale skin color on left gluteal area
• Limited movements
• Weakness
VII. Patient’s Profile

Name: Ramos, Marissa Ada Age: 36 Sex: Female
Address: Naga-naga, Palo Leyte
Religion: Catholic Occupation: Fish vendor
Date of birth: 10-27-70 Birthplace: Borongan
Mother: Delia Ada Father: Bonifacio Baydin
Date Admission: 9-05-07 Time of Admission: 9:30 AM
Diagnosis: Ductal Breast Carcinoma, Right inflammatory, Cardiomegaly with
Pulmonary
Congestion, Bibasal Pneumonia
VIII. History
This is a case Ramos, Marissa 36 y.o, female residing at Naga-naga, Palo Leyte was
admitted for the first time at EVRMC as a referral from Schistosomiasis Center and Research
Hospital for further evaluation and management of the client’s condition.
According to the client the development of her disease condition started a year ago when
her breast was accidentally strongly hit by the head of her child while she was bathing him. Pain
was noted right after the incident but no other manifestations were seen, after one month the
patient noticed a small mass about the size of a mongo bean was growing in her right breast,
however no consultation was done. After 3 months her right breast became painful and the masses
grew bigger, this prompted her to seek consultation to a “tambalan”. She was given virgin coconut
oil to be taken everyday. There was a slight decrease in size of the breast mass noted but not
totally. Since there was no full abatement of the condition of the patient, she tried to seek consult to
another “tambalan”, medication was given to her but could not remember the name, after which she
noticed that the mass just grew bigger. Everyday it grew, got bigger, and increased in number. This
now prompted her to seek consult at their rural health unit and there she was given Cefalexin.
However, the mass still remained to grow in size.
5 months prior to current admission, the patient sought consult at EVRMC and had a
biopsy of her breast mass done. The result revealed cellular features consistent with intraductal
carcinoma, Right breast. The patient was advised to undergo surgery but due to financial
constraints, she wasn’t able to comply. The mass continued to grow in size until it became
ulcerated and necrotic. 3 months prior to current admission the patient sought medical consultation
at Schistosomiasis Center and Research Hospital and subsequently followed up at the OPD. She
was then referred to EVRMC to further evaluate and manage her condition. The patient prompted
consult and was then admitted.
IX. Past History:

The patient had no other previous hospitalization due to serious medical illness before, but
she recalled that when she was still a child she experienced a minor vehicular accident
which gave her a scar on her left toe, however the accident that she experienced was not
that serious enough to cause her fractures and hospitalization. She also stated that she did
not experience having previous history of hypertension, diabetes mellitus, asthma, past
operation, and transfusion. She has also no known allergy to food, drugs, and animals.
With regards to her childhood illness, she recalled having chickenpox when she was little,
but not mumps and measles. The client cannot recall if she received complete doses of her
immunizations when she was still a child.
X. Lifestyle:
The patient was a former smoker, and started at the age of 22, she usually is able to
consume more or less 1 pack per day, three times a week; however she stopped when
she started having manifestations of her present disease condition. She is also an
occasional alcoholic beverage drinker prior to illness.
With regards to her daily food intake, she said that previously she usually eats anything
that is served. She has no diet restrictions and has good appetite. At present, because of
her disease condition she said that she is not able to eat very well, she usually has no
good appetite for eating. When asked about her fluid intake, she stated that she is able to
consume about 6 glasses of water as day. She has no vitamins and supplements being
taken. Regarding her elimination pattern, she said that previously and even until present
she moves her bowel every morning of everyday to a formed and brown stool, with no
difficulty. She also stated that she voids more or less 6 times a day to a yellow colored
urine about 1 full glass in amount for every time she voids.
The patient has does not perform any exercise regimen in the past. With regards to her
sleeping pattern, she said that she usually sleeps at 7 PM and wakes up at 6AM, but at
present she stated that she is not able to sleep well at night due to the pain of her breast.
XI. Family History:

a. Both of the patient’s mother and father are apparently well but are separated a long time
ago. When asked about her family history of diseases. She said that both her
grandmother and grandfather had hypertension and arthritis; however other diseases such
as heart disease, cancer, diabetes, asthma, and bleeding disorders are not present in their
family.
XII. Social Data
i. The patient has a husband; however they are not yet legally married. They also have 2
children both are boys but are not already living with them. The patient is a high school
graduate. She formerly works as a fish vendor.
GG. General Health: patient is cooperative, easy to talk with, responds when asked but with poor eye
contact. Patient appears weak and distressed
HH. Vital Signs:
II. Head: Inspection: normocephalic and symmetrical
Palpation: No tenderness or mass, absence of nodules.
JJ. Hair: Inspection: short, black, unwashed hair, evenly distributed, scalp has no infection or
infestation;
Palpation: thin, resilient hair
KK. Nails: Inspection: Convex curvature, capillary bed is pale in color
Palpation: smooth texture, delay in return of capillary refill (about 4 seconds; normal is less
than 3 seconds)
LL. Skin: Inspection: light brown in color, with presence of edema on right arm on metacarpal area, is
painful and reddened; pallor is noted
Palpation: skin is warm to touch, dry, with good skin turgor
MM.Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no
discharges and no discoloration, and sclera appears white and clear, pupils are equally round and
reactive to light and accommodation
Palpation: pale palpebral conjunctiva, no periorbital edema, no tenderness over lacrimal
gland.
NN. Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, has no difficulty in
hearing normal voice tones
Palpation: auricles are mobile, firm and not tender
OO. Nose: Inspection: no discharges, with nasal flaring noted
PP. Mouth: Inspection: lips pink in color, moist and pinkish buccal membrane, no dentures, tongue
moves freely, with good set of teeth, no presence of mouth sores
Palpation: soft mucus membrane and smooth texture
QQ. Neck: Inspection: able to flex, hyperextend and rotate head, thyroid gland not visible, no neck vein
distention, no visible pulsations
Palpation: no palpable lymph nodes (no cervical lymphadenopathy)
RR. Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact, symmetric chest
expansion, use of accessory muscles, no marked retractions, difficulty in breathing, rapid shallow
respiration noted, productive cough noted with whitish sputum, with pulmonary congestion
Palpation: no tenderness and no masses,
Auscultation: with crackles
SS. Breast: Inspection: grossly enlarged right breast, with areas of ulceration and presence of yellowish
purulent discharges, skin dimpling and nipple retraction noted, breast looks like an orange peel
Palpation: tenderness with great severity of right breast, palpable hard mass
TT. Cardiovascular: Inspection: with no abnormal pulsations
Palpation: not easily palpable radial pulse
Auscultation: no abnormal heart sound, no murmurs, heartbeat is regular and
synchronous
UU. Abdomen: Inspection: flat and rounded, no evidence of enlargement of liver
Palpation: soft, no tenderness
Auscultation: 14 bowel sounds/min
VV. Musculoskeletal: Inspection: no contractures, no tremors, limited ROM, with poor left leg muscle
strength and tone
Palpation: tenderness of left groin area, joint pain, normal skin temperature
WW.Extremities: Inspection: fat and flabby, unable to raise left leg, no active lesions noted
Palpation: no tenderness, with full and equal pulses
XX. Mental Status: Oriented to time, place and person, responsive, with no discrepancies with past
memory.
REVIEW OF SYSTEMS:
MM.General Health: patient is restless, appears frail, acutely ill. Distress noted through facial
expression of pain and guarding behavior. Patient verbalized of not being able to perform self-care
activities due to pain.
NN. Skin: pain and edema on right arm at metacarpal area
OO. Head: verbalization of nausea, no headache
PP. Face: facial grimacing due to pain
QQ. Eyes: no blurring of vision, no visual disturbances, no pain around the eyes
RR. Ears: no tinnitus and vertigo of ears, no tenderness
SS. Nose: no change in sense of smell, no colds, no bleeding, difficulty of breathing
TT. Mouth: no hoarseness and sore throat, no bleeding gums, no difficulty in swallowing and chewing
of food, poor appetite
UU. Respiratory: with orthopnea, dyspnea, and shortness of breath
VV. Cardiovascular: no complaints of chest pain, no syncope, no abnormal palpitations
WW.Breast: throbbing pain on right breast with the scale of 8
XX. Gastrointestinal: no pain on the stomach
YY. Genitourinary: voided more than 6 times during the whole shift with no pain and discomfort during
urination
ZZ. Musculoskeletal: easy fatigability, decreased muscle strength, limited ROM of extremities
(especially the right leg), unable to move about, with difficulty in changing position like turning and
sitting and still needs assistance in performing self-care activities
LABORATORY EXAMS
Date Lab Exam Result Normal Value Significance

09-14- Clinical Na: 140.3 135-148 >Normal
07 Chemistry mmol/L
K: 4.63 3.5-5.3 mmol/L >Normal
Cl: 95.5 98-107 mmol/L >Decreased in pneumonia
08-21- Glucose: 4.1 mmol/L 4.2-6.4 >Low but not that significant
07
Creatinine: 62.3 umol/L 53-97 >Normal
08-13- Hematology Hct: 0.40 0.36-0.47 >Normal
07
WBC: 6.55x 10~9/L 4.5-10.0 >Normal
Differential count:
Segmenter: 0.54 0.55-0.60 >slightly decreased but not that
significant
Eosiniphil: 0.09 0.01-0.04 >Increased with neoplasms and
skin diseases
Lymphocyte: 0.29 0.200-0.350 >Normal
Monocyte: 0.08 0.020-0.060 >Decreased with infection
07-27- Clotting time: 3 mins 15 7 sec-2 min >Increased in coagulation
07 sec problems
Bleeding time: 1 min 1-9 min >Normal
RBC: 4.04 x 10~12/L F: 4.2-5.4 >Normal
WBC: 7.30 x 10~9/L 4.5-10.0 >Normal
Granulocytes: 0.63 0.500-0.750 >Normal
Lymphocyte: 0.33 0.200-0.350 >Normal
Monocyte: 0.04 0.020-0.060 >Normal
MCV: 86.00 fl 80-96 >Normal
MCH: 35.10 pg 27-31 >Increased which indicates
macrocytic cells
MCHC: 408 320-360 >Increased which indicated
oversized cells
08-13- Urinalysis Color: Light yellow Yellow >Normal
07
Transparency: Slt. Clear >Due to increased epithelial cells
Turbid
Sp. Gr: 1.010 1.002-1.035 >Normal
Albumin & Sugar: (-) Negative >Normal
Epith. Cells: many Rare-few
pH: 6 4.5-8.0 >Normal
I. ECG- 09-15-07
b. Result: Incomplete Right Bungle branch block
II. Chest X-ray

A. 09-13-07
 Result: Radiographic exam of the chest shows homogenous opacity in the right lower lung
obscuring the right cardiac border and right diaphragm, intact left hemidiaphragm, trachea
at midline. Thoracic cage and soft tissues are unremarkable.
 Impression: Pleural Effusion Right
B.
 Result: Radiographic exam shows enlarged heart and shadow with perivascular blurring of
hilar vascular markings as well as presence of kerly B lines at the periphery of both lower
lobes suggestive of intestinal edema. There is bibasal haziness. Superior mediastinum is
not widened. Thracheal air column is seen at midline intact diaphragmatic leaflets and
sulci. Other chest structures are not unusual.
 Impression: Cardiomegaly with pulmonary congestion coexisting bibasal pneumonia
III. Gross and Microscopic Description:

 Gross: The mass is firm, approximately 6.0 cm located at the upper aspect of right breast.
Skin retraction and nipple ulceration are also noted.
 Microscopic: The smears show clusters of ductal cells having increased N:C ration, fine to
coarse chromatin, and some having prominent nucleoli. Many isolated tumor cells show
marked anisonucleosis. The background is bloody.
VII. Patients Profile:

Name: Alcantara, Consuelo Chua Age: 71 y.o Sex: F Civil Status: Married
Religion: Catholic Date of Birth: 12-03-35
Birthplace: Borongan E. Samar Citizenship: Filipino
Address: Brgy. Mabini, Laping Northern Samar
Physician: Del Pilar, Jose Carlo, MD
Chief Complaint: Cough
Diagnosis: CAP (Community Acquired Pneumonia)
VIII. History of Present Illness

>The condition of the patient started 2 weeks prior to admission where she experienced
chest pain and productive cough with thick whitish to yellow sputum, not associated with
dyspnea and fever. When patient was asked about what caused the occurrence of her
condition, she stated that this condition of hers has been a recurrent one; she even had
her previous hospitalization with the same chief complaint. Patient tried to relieve the
symptoms by taking an antibiotic; however this measure did not totally alleviate the
condition. Morning prior to admission the symptoms persisted thus prompted consult and
admission.
IX. Past History

>The patient had her immunizations during childhood but can’t recall if she had completed
them for according to the patient “diri pa man sugad kauso an mga bakuna hadto, diri
parehas yana”. With regards to the patient’s previous hospitalizations, she claimed that
just last May 2007 she was admitted at EVRMC for the same chief complaint. Other
hospitalizations of the patient she can’t recall anymore. The patient did not suffer any
accidental injuries and fractures in the past. Other illnesses that the patient currently
has are asthma, arthritis and heart problem (Heart failure), in association with these
illnesses she stated that she takes her maintenance medications such as Diclofenac for
her arthritis and take this only when her joints become inflamed and painful and Captopril
for her heart problem. She has a known history of hypertension but no history of DM,
has no known allergies to any food and drugs, and has not had any blood transfusions in
the past. According to the patient her asthma is the main cause of her present condition
and this was aggravated because of her heart problem.
X. Lifestyle
>The patient is a non-smoker and non-alcoholic beverage drinker. She no difficulty in
eating and swallowing but she stated that at present she isn’t able to eat as much food as
she wants for she has some diet restrictions. According to her she doesn’t eat foods that
are “makatol”, those high in fat, and vegetables with seeds. She does not take any
supplements. With regards to her fluid intake, she claimed that she drinks a lot of water.
In fact she is even able to consume more or less 20 glass of water per day, though at
present because of her condition she isn’t able to drink that much because she was told
that she must be able to consume at least only about 1L of water a day. Today the patient
has no bowel movement, and according to her that this is only normal because her normal
BM pattern is every 2 or 3 days interval. With regards to her urinary elimination, at
present she voided twice this morning and once this afternoon with no difficulty or
discomforts.
The patient stated that she don’t usually perform exercise, whenever she has
nothing else to do, during her leisure times she just usually sit down, do nothing and
sometimes sleeps, though oftentimes she also walks around their house. With regards to
her sleep pattern, according to her she has no sleep onset problems, but at present
because of her productive cough and difficulty of breathing she isn’t able to sleep well a
night. In performing self care activities, she said that she still needs assistance in lying
down and getting up from bed, in going to the bathroom and in dressing, however in eating
and in standing from sitting position, she is able to do it by herself.
XI. Family history

>The patient has a family history of hypertension. But she does not have any family
history of DM, heart diseases, arthritis, epilepsy, cancer and psychosis.
XII. Social Data

>The patient is married to Vivencio Alcantara and has 10 children. She is a plain housewife
while her husband was a formerly a farmer before but at present he also has no work, he
stopped because he said he is already old and weak. She and her husband live with their
daughter Eufemia Alcantara together with her own family. Financially, they just ask for
help and support from their daughter. In case of stressful situations and problems, she
said she usually just prays and ask for a divine intervention, and sometimes talk to her
husband and seek support.
YY. General Health: Patient is a 71 y.o female adult, awake, cooperative, answers to questions and
is easy to talk with, but appear fatigued.
ZZ. Vital Signs:
AAA.Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass, absence
of nodules.
BBB.Hair: Inspection: white with some strands of black hair, evenly distributed, scalp has no
infection or infestation; Palpation: thick, resilient hair
CCC.Nails: Inspection: Convex curvature, capillary bed is pale-light pink in color; Palpation: smooth
texture, delay in return of capillary refill (about 5 seconds; normal= less than 4 seconds)
DDD.Skin: Inspection: light brown in color with visible age spots, is saggy and wrinkled, with slight
non-pitting edema on lower extremities (left leg). Palpation: skin is moderately warm to touch,
dry, with poor senile skin turgor.
EEE.Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no
FFF.Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, unable to hear
GGG.Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions
HHH.Mouth: Inspection: uniform light pink in color, able to purse lips, not complete set of teeth
on lower teeth with brown to black discoloration of the enamel of the remaining teeth, pinkish
III. Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible; Palpation: no
palpable lymph nodes
JJJ.Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact, with
shallow respiration, use of accessory muscles, no retractions, with some effort in respiration,
with productive cough; Palpation: with moderate chest pain and no masses, Auscultation: with
crackles
KKK.Cardiovascular: Inspection: precordium no abnormal pulsations; Palpation: small weak radial
pulse
LLL. Abdomen: Inspection: flabby and rounded. Palpation: soft, no evidence of enlargement of liver
MMM.Musculoskeletal: Inspection: no contractures, no tremors, with slight weakness of muscles
of the body; Palpation: no tenderness or swelling, with good handgrip,
NNN.Mental Status: Oriented to time, place and person, drowsy but responsive, unable to recall
some past memories, fatigued, restless at times, no difficulty in walking, able to balance.
REVIEW OF SYSTEMS:
AAA.General Health: No weight loss, no fever and chills, not diaphoretic

BBB.Skin: no pruritus, no itchiness
CCC.Head: no headache, no dizziness, not nauseated
DDD.Eyes: no blurring of vision, no visual difficulties, no use of eyeglasses
EEE.Ears: no ringing of ears, no tenderness, with some difficulty in hearing but does not use any
hearing aid.
FFF.Nose: no change in sense of smell, no colds, no bleeding
GGG.Mouth: no bleeding gums, no difficulty in swallowing and chewing of food
HHH.Respiratory: has productive cough with thick, difficult to expectorate whitish sputum
dyspneic, has difficulty in breathing, shortness of breath
III. Cardiovascular: with chest pain, no syncope,
JJJ.Gastrointestinal: no tenderness, has no bowel movement, with good appetite, not nauseated
KKK.Genitourinary: voided 3 times from morning to afternoon with, no pain and discomfort during
urination
LLL. Musculoskeletal: slight weakness of body, still needs assistance in some of self care activities
MMM.Neurologic: with feeling of body weakness, no paralysis of any body part, no numbness, no
tremors.
LABORATORY EXAMS

Value
06-19- Urinalysis Color: yellow Pale yellow- >Normal
07 deep amber
Transparency: Slight Clear >Increased in concentration of
Turbid urine
pH: 6.0 5.5-6.5 >Normal
Specific Gravity: 1.015 1.002-1.035 >Normal
Protein: (-) Negative >Normal
Sugar: (-) Negative >Normal
Red cells: none <3/hpf >Normal
Epith. Cells: few Rare-few >Normal
Mucus threads: rare Rare-few >Normal
A. Urates/phosphates: Rare-few >Normal
few
Bacteria: rare None >Normal
K: 4.99 mmol/L 3.50-5.30 >Normal
CREA-B: 132.6 umol/L 53.0-115.0 >Increased in renal failure
06-19- Special TSH:0.07 0.25-5.0 >Decreased in secondary
07 Chemistry uU/mol hypothyroidism; high doses of
dopamine
FT3: 6.66 4.0-8.3 >Normal
pmol/L
FT4: 19.16 9-20 pmol/L >Normal
06-19- Prothrombin Test: 109.6%
07 Time
12.5 sec 9.5-12 sec >slightly increased by deficiency
of factors I, II, V, VII, and X
INR: 1.021 1.0
Control: 100%
13.7 sec
INR: 1.16
06-19- Hematology Hgb: 106 g/L F: 120-160 >Decreased in all anemias and
07 excessive fluid intake, but in the
case of the patient since she has
heart failure, this is a way to
compensate to reduce the fluid
volume in the body.
Hct: 0.32 F: 0.36-0.46 >Decreased in severe anemias and
acute massive blood loss
WBC: 5.7 x 10~9/L 4.5-11.3 >Normal
Differential Ct.:
Neutrophils: 0.6 0.45-0.65 >Normal
Lymphocytes: 0.28 0.20-0.35 >Normal
Monocytes: 0.05 0.02-0.06 >Normal
Eosinophils: 0.05 0.02-0.04 >Increased in allergy, parasitic
disease, and subacute infections
Stabs: 0.02 0.02-0.04 >Normal
Value
06- Heamatology Platelet Count: 245 x 140-440 >Normal
20-07 10~9/L
Reticulocyte ct: 0.8% 0.5-1.5% >Normal
Clinical Lab GLUC-b: 6.78 mmol/L 3.90-6.40 >Increased in Diabetes Mellitus
and Nephritis
CHON-E: 5.2 mmol/L 3.9-6.7 >Normal
TRIG-E: 1.07 mmol/L 0.46-1.88 >Normal
HDL-BM: 1.79 mmol/L 0.80-1.68 >Increased
LDL: 3.0mmol/L
Test HbAIC Test: 4.8% 4.5-6.3% >Normal
III. Test: Gram’s & AFB

Specimen: sputum
A. Gram: Few organisms are seen consisting of gram (+) cocci in pairs of gram (-) bacilli.
Few leukocytes are present
B. AFB: Negative
IV. Test: Peripheral smear

Specimen: Blood
Result: The red cell are normocytic and normochromic. There are no abnormal leukocytes,
the platelets are adequate.
XIII. Patient’s Profile

Name: Llanza, Jay Cuňa Age: 17 y.o Sex: Male
Address: Hiagsam, Jaro Leyte
Religion: Roman Catholic Occupation: Student
Mother: Natividad Cuňa Father: Buenaventura Llanza
Date Admission: 7/01/07 Time of Admission: 7:05 AM
Chief complaint: Fever
Physician: Dr. Jaime R. Borrinaga
XIV. History
a. This is a case of Llanza Jay, 17 y.o. a resident of Jaro , Leyte who was admitted for
the first time with a chief complaint of fever and body weakness. The condition of
the patient started last June 27, Wednesday morning, 4 days prior to admission as
onset of low grade fever after he has done washing his clothes. On Thursday morning
the patient claimed that he vomited to about a half full glass in quantity, yellowish in
color, and watery in consistency. The patient decided to self medicate with
paracetamol 500 mg three times a day, and this provided him temporary relief of
fever but recurred after a few hours. Morning of Friday, June 29, 1 day prior to
admission the symptom still persisted and this time it was accompanied with epistaxis
two times that day. The patient tried relieving the epistaxis by placing an ice pack on
his forehead and this somehow stopped the bleeding. On June 30, Saturday
afternoon, the patient still had fever and generalized body weakness so he decided
to seek consult at the EVRMC ER. His platelet and CBC was taken and was found out
to be decreased, so he was advised for admission.
XV. Past History:

i. The patient has had complete immunizations when he was still a child. He has not had
chicken pox, mumps, and measles during his childhood.
ii. This is the patient’s first hospitalization.
iii. Patient experienced a minor injury when he was still a child. He claimed that he fell
from their balcony and broke his left arm but did not sought consult to a doctor
instead his parents brought him to a “hilot” .
iv. Patient has had an allergy to sunlight. He claimed that whenever he would stay long
under the sun he would develop rashes and itching all over his arms. He said he had this
when he was 12 years old and disappeared when he aged 14. Patient has no known allergy
to any drugs, animals, and food.
v. Patient has no history of serious illness or infection in the past.
vi. He did not have any blood transfusions in the past.
XVI. Lifestyle:
i. The patient is a non-smoker and a non alcoholic beverage drinker.
ii. Patient eats anything and usually has a good appetite, but when was hospitalized he said
that he had difficulty in swallowing. When he was 3 years old until 11 years old he used
to take vitamins as supplement. With regards to his fluid intake, he said he is able to
consume 6 glasses of water a day. He also drinks milk during morning three times a
week. The patient usually has his bowel movement every other day, and at present he
has no BM yet. With regards to his urinary elimination, the patient voided 4 times this
day. Patient has no difficulty in urinating and defecating.
iii. The patient claimed that he does exercise every morning and the usual types of
exercises he performs are jogging and karate. During his spare time he keeps himself
busy and fit by playing basketball with his friends.
iv. With regards to patient’s self care, at present he is able to go to the toilet by himself.
He also able to feed and dress all by himself without any assistance.
v. With regards to the patient’s sleep pattern, he said that he has no sleep onset
problems. His usual sleeping time is 11 PM and his waking time is 3:30 AM.
XVII. Family History:

i. The patient has no family history of hypertension, Diabetes, heart disease, cancer and
tuberculosis. His mother has arthritis and his youngest sister had asthma when she was
in her school-age years.
XVIII. Social Data

i. The patient is a 1st year college student taking up criminology at LC and is currently
boarding here in Tacloban city but he usually go home to Jaro every weekends to his
family.
ii. His father works as a farmer while his mother is a plain housewife.
iii. In cases of problems, it is his family who helps and supports him emotionally. He claims
that he has many sets of friends and he is able to get along well with them.
iv. Financially, he still depends on his parents and his half sister who is currently working
in a company in Manila, for his schooling and his other needs.
v. He is a Roman Catholic and gives value and importance to his faith.
vi. With regards to the patient’s environmental condition, he claimed that at their
boarding house where he is currently residing at there is a nearby swamp.
vii. In his hometown in Jaro, their source of water is from the“burabod”. Here in Tacloban
they get their water from the faucet, he said that sometimes he boil the water before
drinking if he has time.
OOO.General Health: patient is a 33 y.o male adult. He is cooperative, easy to talk with, but
restless at times. He has a good posture and good body built.
PPP. Vital Signs:
QQQ.Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass,
absence of nodules.
RRR.Hair: Inspection: Evenly distributed, scalp has no infection or infestation; Palpation:
moderately thick, resilient hair
SSS.Nails: Inspection: Convex curvature, capillary bed is pale-light pink in color; Palpation: smooth
texture, slight delay in return of capillary refill (about 5 seconds; normal is less than 4
seconds)
TTT.Skin: Inspection: light brown in color, no presence of edema, there is some scars on patient’s
feet as a result of the lesions he got from his previous allergic reaction; Palpation: skin is
moderately warm to touch, has good skin turgor.
UUU.Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no
conjunctiva, no periorbital edema, no tenderness over lacrimal gland..
VVV.Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, able to hear
with normal voice tones; Palpation: auricles are mobile, firm and not tender
WWW.Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions
XXX.Mouth: Inspection: uniform light pink in color, able to purse lips, good set of teeth, pinkish
YYY.Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible; Palpation:
no palpable lymph nodes
ZZZ.Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact,
symmetric chest expansion, no use of accessory muscles, no retractions, quiet, effortless
respiration; Palpation: no tenderness and no masses, Auscultation: no wheeze or crackles
AAAA.Cardiovascular: Inspection: precordium no abnormal pulsations; Palpation: palpable radial
pulse; Auscultation: no abnormal heart sound, no murmurs
BBBB.Abdomen: Inspection: flat and rounded, no evidence of enlargement of liver; abdominal
guarding. Palpation: soft, slight tenderness
CCCC.Musculoskeletal: Inspection: no contractures, no tremors, with slight weakness of muscles of
the body; Palpation: no tenderness or swelling, with good handgrip,
DDDD.Mental Status: Oriented to time, place and person, alert and responsive, with intact
memory, restlessness at times
REVIEW OF SYSTEMS:
NNN.General Health: No weight loss, no fever and chills, not diaphoretic, no colds
OOO.Skin: no pruritus, no itchiness
PPP. Head: no headache, no dizziness, not nauseated
QQQ.Eyes: no blurring of vision, no visual difficulties
RRR.Ears: no ringing of ears, no tenderness
SSS.Nose: no change in sense of smell, no colds, no bleeding
TTT.Mouth: no bleeding gums, no difficulty in swallowing and chewing of food
UUU.Respiratory: not dyspneic, not out of breath when moving, no difficulty breathing when
supine
VVV.Cardiovascular: no chest pain, no syncope
WWW.Gastrointestinal: moderate pain on abdomen, 5 episodes of bowel movement with slightly
formed semisolid stool in moderate amount
XXX.Genitourinary: voided 10 times fro more than 1L in amount, no pain and discomfort during
urination
YYY.Musculoskeletal: slight weakness of body, still needs assistance in some of self care activities
XIX. Patient’s Profile

Name: Del Socorro, Andrew Olang Age: 17 y.o Sex: Male
Address: Cabulihan, Ormoc city
Birthdate: 11-1-89 Birthplace: Ormoc city
Religion: Roman Catholic Occupation: Student
Mother: Elizabeth Olang Father: Alejandro Del Socorro
Date Admission: 6/30/07 Time of Admission: 3:40 PM
Chief complaint: Fever
Physician: Dr. Jaime R. Borrinaga
XX. History
a. This is a case of Del Socorro, Andrew, 17 y.o., a resident of Ormoc city who was
admitted for the first time as a referral from Palompon District Hospital for
further evaluation and management as dengue suspect. The condition of the patient
started June 24, Sunday 1 week prior to admission as onset of moderate fever by
touch. It was associated with abdominal pain on epigastric area. There were no other
symptoms noted and no consultation was done. Monday, June 25, 5 days prior to
admission the patient’s condition persisted and claimed to have had high grade fever
at about 38-39˚C and abdominal pain, because of this they decided to bring the
patient at Palompon District Hospital and was admitted. During his stay at the
hospital, the patient claimed that he experienced loose, watery stools, non-mucoid
and non-bloody, several bowls in quantity with associated vomiting noted, 5 times
more than three glasses and watery in consistency, but the symptoms was relieved
the following night. He was given medications during his stay at Palompon Hospital
such as Ranitidine, Ceftriaxone, and Paracetamol. Evening of June 29, a night prior to
admission, the patient experienced flashing with petechiae all over the body. The
platelet ct of the patient was taken and was found out to drop to 50 x 10~9/L.
because of this, the hospital decided to refer the patient at EVRMC, hence patient
was admitted.
XXI. Past History:
i. The patient had complete immunizations when he was still a child. He had chicken pox
but has not yet experienced having mumps and measles during his childhood. He
experienced having diarrhea when he was 12 years old but was not admitted to the
hospital instead he was only given oral hydration which relieved the symptoms.
ii. This is the patient’s first hospitalization.
iii. Patient did not experience any injury or accidents in the past.
iv. Patient has no known allergy to any food, animals, and drugs.
v. Patient has no history of serious illness or infection in the past.
vi. He did not have any blood transfusions in the past.
XXII. Lifestyle:
i. The patient is a non-smoker but an occasional alcoholic beverage drinker.
ii. Currently the patient is on full heme free diet. Normally, patient has adequate food
intake, has no difficulty in swallowing and has no diet restrictions. Patient takes
vitamins as his daily supplement. With regards to his fluid intake, he said he is able to
consume 2-3 glasses of water a day. The patient usually has his bowel movement every
other day with normal in consistency. However, at present he has not eliminated yet.
With regards to his urinary elimination, the patient voided three times this day to
yellowish colored urine. Patient has no difficulty in urinating and defecating.
iii. The patient claimed that he is not used in exercising every morning, however the
patient stated that he usually spends his leisure time playing basketball with his
friends and this keeps him fit and active.
iv. With regards to the patient’s self care, at present he still needs a company in going to
the toilet, and in dressing. He urinates on a basin at bedside.
v. With regards to the patient’s sleep pattern, he said that he has no difficulty in going
to sleep. His usual sleeping time is 9-10 PM and his waking time is 6-7 AM.
XXIII. Family History:
i. The patient has no family history of hypertension, Diabetes, heart disease, cancer,
asthma, arthritis and tuberculosis. He lives with his parents and he has one younger
sister who is studying in high school at Ormoc.
XXIV. Social Data

i. The patient is a 1st year college student taking up Marine Engineering at Palompon and is
staying in a boarding house near their school.
ii. His father works as a farmer while his mother is a plain housewife.
iii. In cases of problems, it is his family who helps and supports him emotionally. He said
that he has many sets of friends and he is able to get along well with them.
iv. Financially, he depends on his parent’s support for his other needs but at the same time
he also works a part time job in a fast food chain.
v. He is a Roman Catholic and gives value and importance to his faith.
vi. With regards to the patient’s environmental condition, he claimed that at their
boarding house where he resides there is nearby seawater which usually rises during
rainy days.
EEEE.General Health: patient is a 33 y.o male adult. He is cooperative, easy to talk with, but
FFFF.Vital Signs:
GGGG.Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass,
absence of nodules.
HHHH.Hair: Inspection: Evenly distributed, scalp has no infection or infestation; Palpation:
IIII.Nails: Inspection: Convex curvature, capillary bed is pale-light pink in color; Palpation: smooth
seconds)
JJJJ.Skin: Inspection: light brown in color, no presence of edema, there is some scars on
patient’s feet as a result of the lesions he got from his previous allergic reaction; Palpation:
skin is moderately warm to touch, has good skin turgor.
KKKK.Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no
LLLL.Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, able to hear
MMMM.Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions
NNNN.Mouth: Inspection: uniform light pink in color, able to purse lips, good set of teeth, pinkish
OOOO.Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible;
PPPP.Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact,
QQQQ.Cardiovascular: Inspection: precordium no abnormal pulsations; Palpation: palpable radial
RRRR.Abdomen: Inspection: flat and rounded, no evidence of enlargement of liver; abdominal
SSSS.Musculoskeletal: Inspection: no contractures, no tremors, with slight weakness of muscles
TTTT.Mental Status: Oriented to time, place and person, alert and responsive, with intact
REVIEW OF SYSTEMS:
ZZZ.General Health: No weight loss, no fever and chills, not diaphoretic, no colds
AAAA.Skin: no pruritus, no itchiness
BBBB.Head: no headache, no dizziness, not nauseated
CCCC.Eyes: no blurring of vision, no visual difficulties
DDDD.Ears: no ringing of ears, no tenderness
EEEE.Nose: no change in sense of smell, no colds, no bleeding
FFFF.Mouth: no bleeding gums, no difficulty in swallowing and chewing of food
GGGG.Respiratory: not dyspneic, not out of breath when moving, no difficulty breathing when
supine
HHHH.Cardiovascular: no chest pain, no syncope
IIII.Gastrointestinal: moderate pain on abdomen, 5 episodes of bowel movement with slightly
JJJJ.Genitourinary: voided 10 times fro more than 1L in amount, no pain and discomfort during
urination
KKKK.Musculoskeletal: slight weakness of body, still needs assistance in some of self care
activities such as toileting and dressing.
DIAGNOSTIC EXAMS:
Name: Llanza, Jay Cuňa
Date of Admission: 07/01/01

Age: 17 y.o.
Time of Admission: 7:05 AM

Sex: Male
Physician: Jaime R. Borrinaga, FPCP

Chief Complaint: Fever
Diagnosis: DHF II

Values
6-30-07 Hematology Hct= 0.41 M: 0.42-0.47 >slightly
decreased
Plt=130 150-450 x >Decreased
10~9/L
WBC= 7.9 5-10 x >Normal
10~10/L
Hgb=148 M:140-180 >Normal
g/L
Hct=0.44 M: 0.42-0.47 >Normal
Plt= 180 150-450 x >Normal
10~9/L
Segmenters=0.54 0.45-0.65 >Normal
Lymphocyte=0.46 0.20-0.35 >Increased
7-01-07 Hematology Hct=0.43 M: 0.42-0.47 >Normal
6 AM:
10~9/L
Hct=0.40 M: 0.42-0.47 >Decreased
12 NN:
10~9/L
Hct=0.44 M: 0.42-0.47 >Normal
6 PM:
10~9/L
Urinalysis Macroscopic:
Color=yellow Pale yellow- >Normal
deep amber
Transparency=clear Clear >Normal
Spc. Gr.= 1.015
pH=6.0
Glucose, Albumin, Negative >Normal
Blood= (-)
Microscopic:
Pus=0-2
RBC=0-1
Epith.
Cell=occasional
Bacteria=some
M. threads=some
10~9/L
Hct=0.48 M: 0.42-0.47 >slightly
12 MN: increased
10~9/L
10~9/L
DIAGNOSTIC EXAMS
Name: Del Socorro, Andrew Olang
Date of Admission: 06/30/07

Age: 17 y.o.
Time of Admission: 3:40 PM

Sex: Male
Physician: Jaime R. Borrinaga, FPCP

Chief Complaint: Fever
Diagnosis: DHF II

Values
6-30-07 Hematology APTT=53.3 sec
Control=35.4 sec 31.2-39.8 >Normal
sec
Miscellaneous:
Specimen-Plasma
Exam Desired- Test= >120 sec
PROTIME
Control= 12.0 sec
Hematology Hct= 0.44 M: 0.42- >Normal
12 MN: 0.47
Plt= 34 150-450 x >Decreased
10~9/L
Hgb=146 g/L Male: 140-175 >Normal
Hct=0.44 M: 0.42- >Normal
0.47
WBC=5.60 x 10~9/L 4.5-11.3 >Normal
Differential Ct:
Segmenter=0.19 0.45-0.65 >Decreased
Lymphocyte=0.77 0.20-0.35 >Increased
Monocyte=0.03 0.02-0.06 >Normal
Eosinophil=0.01
Basophil=0.01
Plt=50 x 10~9/L 150-450 x
10~9/L
Bld type- O; RH(+)
7-01-07 Hematology Hct=0.43 M: 0.42- >Normal
6 AM: 0.47
10~9/L
Hct=0.43 M: 0.42- >Normal
6 PM 0.47
10~9/L
7-02-07 Hematology Hct=0.42 M: 0.42- >Normal
0.47
10~9/L
7-03-07 Hct=0.38 M: 0.42- >Decreased
0.47
10~9/L
XXV. Patient’s Profile

Name: Purog, Ramil Apurillo Age: 33 y.o Sex: Male
Address: Blk 9, Lot 31, Ilang-ilang St. V&G Tac. City
Religion: Catholic Occupation: Teacher
Date of birth: 04-18-74 Birthplace: Cebu city
Mother: Fe April Purog Father: Jose Purog
Chief coplaint: LBM
Physician: Dr. C. Baligod
XXVI. History
>Morning prior to admission, the patient experienced severe abdominal pain on
the umbilical and hypogastric region, he had more than 3 episodes of LBM and passed out watery,
pus bloody and non-mucoid stool, scanty in amount associated with scarring abdominal pain. Other
symptoms he experienced were numbness, cold clammy, and diaphoresis. No vomiting was noted.
When asked about what may have caused the illness, patient stated that he ate food which he
bought and mixed it with some vegetables which probably precipitated his condition. Medications
taken during the onset of the disease were metronidazole, ofloxacin, hydrite and vitamins,
however these medications did not relieved the condition of the patient. His LBM persisted for
about 9 episodes which prompted consult and admission.
XXVII. Past History:

>The patient has had complete immunizations when he was still a child.
>Patients had many hospitalizations a few of them which he can still remember
are back when he was in high school when he was bitten by a dog, another was when he was
operated because of abscess on his lower head, and the most recent was last September 6, 2006
because of amoebiasis.
>Patient did not experienced any serious accidents that lead to fractures and
major injuries, though he claimed that he had a very minor accident when he was playing with his
bicycle and accidentally fell.
>Patient has allergies in foods with MSG, especially junk foods and “dagmay”. He
said whenever he eats these foods he would develop a lesion which heals poorly.
>Patient claimed that he had a history of asthma when he was a child, and a
pulmonary infection when he aged 23 and the patient said that the cause probably was because of
chalk dust that irritated his lungs.
>He did not have any blood transfusions in the past.
XXVIII.Lifestyle:
>The patient experienced smoking back when he was in his high school years but
claimed that he only tried few times only because of peer pressure but did not continue on this
vice because he knew that it would be bad for his health. The patient at present is an occasional
alcoholic beverage drinker but he revealed that when he was in his 4th year high school he drank
alcohol almost weekly with his friends and it was only during 1st yr college that he stopped drinking
too much.
>Patient is a vegetarian, he takes supplements such as multivitamins and vitamin C
(Cecon); he is able to consume 8 glasses of water per day and drinks juice every meal. He has good
appetite but he complained of experiencing nausea last night. Today the patient had 5 bowel
movements and passed out a slightly watery semisolid stool. With regards to his urinary
elimination, the patient voided 10 times this day with an amount of more than 1L as stated by the
patient. Patient has no difficulty in urinating and defecating.
>The patient claimed that he does exercise every morning and the usual types of
exercises he performs are the non-strenuous ones such as jogging and swimming. During his spare
time he keeps himself busy by doing some leisure activities such as going to the beach, playing
basketball and gardening (planting vegetables).
>With regards to patient’s self care, at present the patient stated that he needs
assistance in going to the bathroom and in dressing, however in eating he is able to feed himself.
Patient is mobile and ambulatory.
>With regards to the patient’s sleep pattern, he said that he has no sleep onset
problems though sometimes he sleeps late, at present he usually has early awakenings because of
the need to go to the bathroom to urinate. He also stated that he isn’t able to sleep well because
he is not that comfortable with his room.
XXIX. Family History:

>The patient has a family history of hypertension specifically on his paternal
side. But he does not have any family history of DM, heart diseases, arthritis, epilepsy, cancer
and psychosis.
XXX. Social Data

>The patient is single and currently lives with his parents at V&G subdivision. He
works as a high school economics teacher.
>In cases of problems, it is his family who helps him a lot and supports him
emotionally. He claims that he has many sets of friends and he is able to get along well with
others.
>Financially, he is able to support himself and able to provide his own needs with
his own income.
>He is a religious person, and values his spiritual faith a lot.
UUUU.General Health: patient is a 33 y.o male adult. He is cooperative, easy to talk with, but
VVVV.Vital Signs:
WWWW.Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass,
absence of nodules.
XXXX.Hair: Inspection: Evenly distributed, scalp has no infection or infestation; Palpation:
YYYY.Nails: Inspection: Convex curvature, capillary bed is pale-light pink in color; Palpation:
smooth texture, slight delay in return of capillary refill (about 5 seconds; normal is less than
4 seconds)
ZZZZ.Skin: Inspection: light brown in color, no presence of edema, there is some scars on
patient’s feet as a result of the lesions he got from his previous allergic reaction; Palpation:
skin is moderately warm to touch, has good skin turgor.
AAAAA.Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no
BBBBB.Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, able to hear
CCCCC.Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions
DDDDD.Mouth: Inspection: uniform light pink in color, able to purse lips, good set of teeth,
pinkish gums, no dentures, tongue moves freely; Palpation: soft, moderately dry and smooth
texture
EEEEE.Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible; Palpation:
no palpable lymph nodes
FFFFF.Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact,
GGGGG.Cardiovascular: Inspection: precordium no abnormal pulsations; Palpation: palpable radial
HHHHH.Abdomen: Inspection: flat and rounded, no evidence of enlargement of liver; abdominal
IIIII.Musculoskeletal: Inspection: no contractures, no tremors, with slight weakness of muscles
JJJJJ.Mental Status: Oriented to time, place and person, alert and responsive, with intact
REVIEW OF SYSTEMS:
LLLL.General Health: No weight loss, no fever and chills, not diaphoretic, no colds
MMMM.Skin: no pruritus, no itchiness
NNNN.Head: no headache, no dizziness, not nauseated
OOOO.Eyes: no blurring of vision, no visual difficulties
PPPP.Ears: no ringing of ears, no tenderness
QQQQ.Nose: no change in sense of smell, no colds, no bleeding
RRRR.Mouth: no bleeding gums, no difficulty in swallowing and chewing of food
SSSS.Respiratory: not dyspneic, not out of breath when moving, no difficulty breathing when supine
TTTT.Cardiovascular: no chest pain, no syncope
UUUU.Gastrointestinal: moderate pain on abdomen, 5 episodes of bowel movement with slightly
VVVV.Genitourinary: voided 10 times fro more than 1L in amount, no pain and discomfort during
urination
WWWW.Musculoskeletal: slight weakness of body, still needs assistance in some of self care
activities such as toileting and dressing.
XXXI. Patient’s Profile

Name: Lopez, Mechele Aguinalde Age: 22 y.o. Sex: Female
Address: Rizal Dulag, Leyte Religion: Catholic Civil Stat: Single
Date of birth: 07-18-85 Birthplace: Dulag, Leyte
Mother: Carmen Aguinalde Father: Melchor R. Lopez
Occupation: Student, GM- Sangguniang Brgy.
Physician: Dr. Lesiguez/Dr. Omega
Chief complaint: Vaginal Bleeding
Admitting Diagnosis: Abortion, Incomplete, 10 5/7 weeks AOG, Spontaneous,
non-septic, G1P0
XXXII. History
a. This is a case of Lopez, Michele, 22 years old, female residing at Dulag, Leyte
who was admitted for the first time in this institution with a chief complaint of
vaginal bleeding. The condition of the patient started several hours prior to
admission as sudden onset of vaginal bleeding, painless and profuse with
passing of meaty tissues. No other symptoms were associated. Patient claimed
of having a fall 1 day prior to admission, she said she accidentally slipped on
their CR. After the incident, pain was noted on her left posterior trunk, she just
tried to rest and lie down to relieve the pain. No consult and no medications were
taken. The next day when she woke up she just suddenly experienced heavy
vaginal bleeding and this continued for many hours. This prompted her to seek
consult, hence present admission. Before the incident happened, she was
positive of being 2 ½ months pregnant. But no prenatal visits were taken.
XXXIII. Past History:

 The patient had complete immunizations when he was still a child. She had
chicken pox, measles, and mumps during her childhood.
 She has a history of chronic UTI before pregnancy.
 The patient had other previous hospitalization in the past and this was last 2005
for the reason of falling from her bicycle. She was admitted at Burauen District
Hopsital. No fractures or injuries were noted.
 The patient has no known allergy to any food, drug, or animals.
 Patient has no history of abortion, asthma, Diabetes Mellitus and other serious
medical illnesses in the past.
 She did not have any blood transfusions in the past.
XXXIV. Lifestyle:
a. The patient is a non-smoker and an occasional alcoholic beverage drinker.
b. When it comes to her daily food intake, the patient said that she is able to eat just
enough, and eats whatever is served. The patient has no difficulty in eating and
usually has good appetite. She does not take any vitamins and other
supplements. With regards to her fluid intake, she said that she is able to
consume about 1 L of water per day.
c. Regarding patient’s elimination pattern, she said that she usually bowel
eliminates every after 2 days, with a formed stool; brownish in color, With regards
to her urinary elimination, she said he usually voids many times a day with no
difficulty and pain.
d. The patient seldom performs an exercise, if ever she gets the chance to do so
she only usually does the stretching in the morning upon awakening.
e. With regards to the patient’s sleep pattern, she said she doesn’t have any
difficulty in getting asleep.
XXXV. Family History:

a. The patient has 2 other siblings. 1 elder brother and 1 younger brother. She is
the second child and the only girl of the family. The patient’s parents are Mr.
Melchor Lopez and Mrs. Carmen Aguinalde. The patient has a family history of
hypertension (Fatherside); other illnesses such as TB, Rheumatic heart disease,
kidney disease, asthma, cancer, arthritis, Diabetes, and bleeding tendencies are
not present in their family.
XXXVI. Social Data
i. The patient is single and lives with her parents. She was formerly studying as a 4th
year commerce student at St. Paul’s Business School but stopped when she found
out that she was pregnant.
XXXVII. Obstetrical Record

 Chief complaint: vaginal bleeding
 First day of last menstruation: June 27, 2007
 Duration of pregnancy: 2 ½ months
 Age of Gestation: 10 5/7
 Expected date of confinement: April 3, 2008
 Prenatal care: None
XXXVIII.Menstrual History
 Menarche: 14 y.o.
 Cycle: 20 days
 Amount: 12 napkins/ 4 days duration
 Duration: 4 days
 Pain: positive during the first day
 Previous menstrual period: May 2007
KKKKK.General Health: patient is a 22 y.o. female adult. Shee is cooperative, easy to talk
with, calm and, responds when asked. Body weakness is noted.
LLLLL.Vital Signs:
MMMMM.Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or
mass, absence of nodules.
NNNNN.Hair: Inspection: With black strands of hair, evenly distributed, scalp has no infection
or infestation; Palpation: thick, resilient hair
OOOOO.Nails: Inspection: Convex curvature, capillary bed is slightly pale in color; Palpation:
smooth texture, there slight delay in return of capillary refill (about 4 seconds; normal is
less than 3 seconds)
PPPPP.Skin: Inspection: light brown in color with no presence of edema and active lesions;
Palpation: has normal skin temperature, has good skin turgor.
QQQQQ.Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids
have no discharges and no discoloration, and sclera appears white and anicteric, pupils
are equally round and reactive to light and accommodation; Palpation: pale palpebral
RRRRR.Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, has no
difficulty in hearing normal voice tones; Palpation: auricles are mobile, firm and not tender
SSSSS.Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions
TTTTT.Mouth: Inspection: slightly pale in color, able to purse lips, with good set of teeth, no
dentures, tongue moves freely; Palpation: soft, moderately dry and smooth texture
UUUUU.Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible, no
neck vein distention; Palpation: no palpable lymph nodes
VVVVV.Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact,
respiration; Palpation: no tenderness and no masses, Auscultation: no wheeze or
crackles
WWWWW.Breast: symmetrical, nipples are everted
XXXXX.Cardiovascular: Inspection: precordium no abnormal pulsations; Palpation: palpable
radial pulse; Auscultation: no abnormal heart sound, no murmurs
YYYYY.Abdomen: Inspection: flat and rounded, no evidence of enlargement of liver;
Palpation: soft, no tenderness
ZZZZZ.Musculoskeletal: Inspection: no contractures, no tremors, with slight weakness of
muscles of the body; Palpation: no tenderness or swelling.
AAAAAA.Extremities: palms of the hands are pale; no edema, no varicosities, no defects
BBBBBB.Mental Status: Oriented to time, place and person, and responsive
CCCCCC.Genitourinary: positive for vaginal bleeding, with passing out of meaty tissues
DDDDDD.Pelvic exam: Uterus not enlarge; nullipara
REVIEW OF SYSTEMS:
XXXX.General Health: No weight loss, no fever and chills, slighlty diaphoretic, no colds
YYYY.Skin: no pruritus, no itchiness
ZZZZ.Head: no headache, not nauseated
AAAAA.Eyes: no blurring of vision, no visual disturbances
BBBBB.Ears: no ringing of ears, no tenderness
CCCCC.Nose: no change in sense of smell, no colds, no bleeding, no difficulty in breathing
DDDDD.Mouth: no bleeding gums, no difficulty in swallowing and chewing of food
EEEEE.Respiratory: no reports of dyspnea, not out of breath when moving.
FFFFF.Cardiovascular: no complaints of abnormal pulsations, no syncope
GGGGG.Gastrointestinal: no tenderness, has not yet bowel eliminated,
HHHHH.Genitourinary: voided 3 times, no pain and discomfort during urination
IIIII. Musculoskeletal: slight weakness of body, easy fatigability
Upon Internal Examination:

 Result: admits 1 finger to internal right, with palpable meaty tissues and
blood clots.
 Positive history of passing of meaty tissues and fetus 2 hrs. PTA
XXXIX. Patient’s Profile

Name: Badeo, Marlon Espiritu Age: 27 Sex: Male
Address: Brgy. Rizal, Dagami Leyte
Religion: Catholic Occupation: Pedicab Driver
Date of birth: 5-30-80 Birthplace: Dagami, Leyte
Mother: Shirley Espiritu Father: Alfredo Badeo
XL. History
a. This is a case of Badeo, Marlon, 27 years old, male residing at Brgy Rizal Dagami Leyte
who was admitted for the second time at EVRMC with a chief complaint of sudden pain on
both legs and inability to walk. The condition of the patient started last August 30,
Thursday morning , few hours prior to admission as sudden onset of acute pain of his post
surgical wound on left upper leg, which later progressed to involve the right leg. Severe
and intolerable pain on both legs was noted. The patient claimed that he was not able to
move his both legs and was not able to walk. Other associated manifestation noted on the
patient was pain on the stomach. He tried to rest but this measure did not alleviate the
pain. Maintenance medications that were previously prescribed to him were given and
taken by the patient such as Cefalexin and Diclofenac, pain was decreased after taking
the said medicines however the pain recurred again. This prompted him to seek consult,
hence he was admitted.
XLI. Past History:

 The patient has incomplete childhood immunization particularly the Measles vaccine.
 The patient had 2 other previous hospitalizations in the past. The first was last November
2006 at Burauen hospital with the chief complaint of acute pain and swelling of left upper
leg, medical treatment was given and pain was alleviated. However, last January 2007 the
condition of the patient recurred, this time he sought consult and was admitted at EVRMC
surgical ward. Operation was done on his left leg which involved removal of pus that
caused the swelling. A small incision was made.
 The patient did not experience any accidents or injuries in the past.
 Patient has no history of asthma, Diabetes Mellitus, and other serious medical condition
 He did not have any blood transfusions in the past.
XLII. Lifestyle:
a. The patient is a non-smoker and an occasional alcoholic beverage drinker.
b. When it comes to his daily food intake, the patient said that he is able to eat just enough,
and he eats whatever it is that is served but at present he is unable to eat well because of
the pain. He has poor appetite and is nauseated at times. He also claimed that he loss his
weight. Previously, he takes some Vitamins and Clusivol as his supplement. With regards
to his fluid intake, he said that he is able to consume more than a liter of water per day.
c. Regarding patient’s elimination pattern, he said that usually he has a regular daily bowel
movement with formed stool, but at preset he has not yet bowel eliminated for about two
weeks now. With regards to his urinary elimination, he said he usually voids many times a
day. At present, he voided more than 5 times since this morning to yellow colored urine,
moderate in quantity with no difficulty and incontinence.
d. The patient has no particular exercise pattern that he performs. During his leisure time
when he was not yet ill he said he used to play basketball with his friends.
e. With regards to the patient’s sleep pattern, at present he is not able to sleep well because
of the pain.
XLIII. Family History:

a. The patient has a family history of heart disease on his paternal side (Grandmother); but
has no known family history of hypertension, Diabetes, arthritis, and other degenerative
bone diseases.
XLIV. Social Data

i. The patient is single and currently lives with his parents at Dagami together with his other 4
brothers and sisters. He was formerly working as a pedicab driver.
EEEEEE.General Health: patient is a 27 y.o male adult. He is cooperative, easy to talk with, calm,
responds when asked but a little drowsy.
FFFFFF.Vital Signs:
GGGGGG.Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass,
absence of nodules.
HHHHHH.Hair: Inspection: black, unwashed hair, evenly distributed, scalp has no infection or
infestation; Palpation: thin, resilient hair
IIIIII.Nails: Inspection: Convex curvature, capillary bed is pale in color; Palpation: smooth texture, delay
in return of capillary refill (about 4 seconds; normal is less than 3 seconds)
JJJJJJ.Skin: Inspection: light brown in color, with presence of pressure sore at the buttocks due to
immobility; Palpation: skin is warm to touch, moist, has good skin turgor, pale
KKKKKK.Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no
discharges and no discoloration, and sclera appears slightly yellowish, pale conjunctiva, pupils are
equally round and reactive to light and accommodation, does not use eyeglasses, no visual
problems; Palpation: light pink palpebral conjunctiva, no periorbital edema, no tenderness over
lacrimal gland.
LLLLLL.Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, has no difficulty in
hearing normal voice tones; Palpation: auricles are mobile, firm and not tender
MMMMMM.Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions
NNNNNN.Mouth: Inspection: with dry lips but moist, pinkish buccal membrane, no dentures, tongue
moves freely; Palpation: soft mucus membrane and smooth texture
OOOOOO.Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible, no neck vein
distention, visible pulsation; Palpation: no palpable lymph nodes
PPPPPP.Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact, symmetric
chest expansion, no use of accessory muscles, no retractions, quiet, effortless respiration;
Palpation: no tenderness and no masses, Auscultation: no wheeze or crackles
QQQQQQ.Cardiovascular: Inspection: with abnormal pulsations; Palpation: palpable radial pulse;
Auscultation: no abnormal heart sound, no murmurs
RRRRRR.Abdomen: Inspection: flat and rounded, no evidence of enlargement of liver; Palpation: soft,
no tenderness
SSSSSS.Musculoskeletal: Inspection: no contractures, no tremors, with generalized body weakness;
with poor leg muscle strength and tone; Palpation: with pain on left upper leg, swelling of the
previous open surgical wound oozing with a yellowish colored fluid.
TTTTTT.Extremities: Inspection: decreased subcutaneous tissue, thin, unable to move both legs
UUUUUU.Mental Status: Oriented to time, place and person, responsive, with no discrepancies with
past memory.
REVIEW OF SYSTEMS:
JJJJJ.General Health: verbalization of weight loss, febrile and diaphoretic, no cough and colds.
KKKKK.Skin: pain on left sole of feet and of the open wound on the left upper leg
LLLLL.Head: no headache but nauseated at times
MMMMM.Face: facial grimacing due to pain
NNNNN.Eyes: no blurring of vision, no visual disturbances
OOOOO.Ears: no ringing of ears, no tenderness
PPPPP.Nose: no change in sense of smell, no colds, no bleeding, no difficulty in breathing
QQQQQ.Mouth: no bleeding gums, no difficulty in swallowing and chewing of food, poor appetite
RRRRR.Respiratory: no orthopnea, dyspnea, and shortness of breath
SSSSS.Cardiovascular: no complaints of chest pain, no syncope
TTTTT.Gastrointestinal: pain on the stomach every after eating, has no bowel elimination for 2 weeks
now
UUUUU.Genitourinary: voided more than 5 times since morning, no pain and discomfort during
urination
VVVVV.Musculoskeletal: easy fatigability, decreased muscle strength
I. Patient’s Profile
Name: Grejalde, Marlon Age: 54 y.o Sex: Male

Address: Brgy. Songco, Borongan E. Samar
Religion: Catholic Occupation: MCH driver
Date of birth: Jan. 16, 1953 Birthplace: Misamis Oriental
Mother: Deceased Father: Deceased
Chief Complaint: VA
Diagnosis: Fracture, open Tibia-Fibula, Right; Fracture, closed M/3rd, Femur Left
II. History
a. This is a case of Grejalde, Marlon 54 years old, male residing at Brgy. Songco, Borongan
E. Samar who was admitted for the first time at EVRMC with a chief complaint of vehicular
accident. The incident happened last August 13 2007, Monday at Borongan E. Samar at
exactly 11:00 AM. The patient was riding his single motorcycle and was about to live their
when he suddenly lose control in driving and accidentally crashed and broke his both legs
with some abrasion- contusion on his right forehead. The patient was immediately brought
to Borongan provincial hospital. Cast was applied on both legs. On August 14, 2007 the
patient was referred to EVRMC for further medical and surgical management. Hence
present admission.
III. Past History:

 The patient had complete immunizations when he was still a child.
 The patient has only one previous hospitalization in the past (1986) with a chief complaint
of fever.
 When asked if he experienced any other accidents or injury in the past, he said that this is
the first time he had an accident.
 Patient has no history of asthma, Diabetes Mellitus, arthritis, hypetensin and other serious
medical condition in the past,
IV. Lifestyle:
a. The patient used to smoke before and said that he was able to consume 1 pack of
cigarette per day but quitted just last 2006. He is an occasional alcoholic beverage drinker
and stated that he is able to consume about 10 glasses of alcoholic drink. He drinks both
hard and light alcoholic beverages.
b. Regarding his daily food intake, the patient said that previously he used to have a good
appetite but at present he is unable to eat much because of pain. He does not take any
vitamins and other supplements. With regards to his fluid intake, he said he is able to
consume about 20 glasses of water per day.
c. Regarding patient’s elimination pattern, he said that usually he has a daily bowel
movement with formed stool, at present since he can’t move about and go to the
bathroom he use an adult diaper. He has no problem in bowel elimination and stated that
he has just bowel eliminated to a color brown, formed stool. With regards to his urinary
elimination, he said he voids many times a day. At present, he voided 6-8 times since
morning. with no difficulty and incontinence.
d. According to the patient, his usual type of exercise that he performs is walking and he
does this every morning around their house.
e. With regards to the patient’s sleep pattern, he said that he doesn’t get enough sleep and
whenever he is able to close his eyes and sleep he can only do this for just an hour and
will wake up again.
V. Family History:
 The patient’s parents are both deceased. His mother died of a heart disease and his
father was hypertensive. Other diseases such as diabetes mellitus, arthritis, asthma,
cancer, and bone diseases are not present in their family.
VI. Social Data

 The patient is married, and has 3 children who are still living with the. The patient is the
breadwinner of the family and works as a tricycle driver at their place.
1. General Health: patient is a 54 y.o male adult. He is cooperative, easy to talk with, calm and,
responds when asked.
2. Vital Signs:
3. Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass, absence of
nodules.
4. Hair: Inspection: black hair and evenly distributed, scalp has no infection or infestation; Palpation:
thick, resilient hair
5. Nails: Inspection: Convex curvature, capillary bed is pale in color; Palpation: smooth texture, delay
in return of capillary refill (about 5 seconds; normal is less than 3 seconds)
6. Skin: Inspection: light brown in color with visible age spots, wrinkled and saggy, no presence of
active lesions; Palpation: skin is slightly warm to touch, has senile skin turgor.
7. Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no
discharges and no discoloration, and sclera appears white and anicteric, pupils are equally round
and reactive to light and accommodation; Palpation: pink palpebral conjunctiva, no periorbital
edema, no tenderness over lacrimal gland.
8. Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, has some difficulty in
hearing normal voice tones; Palpation: auricles are mobile, firm and not tender
9. Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions
10. Mouth: Inspection: slightly dry lips, moist buccal membrane, able to purse lips, tongue moves
freely; Palpation: soft and smooth texture
11. Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible, no neck vein
distention; Palpation: no palpable lymph nodes
12. Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact, symmetric chest
expansion, use of accessory muscles, no retractions, with deep respiration; Palpation: no
tenderness and no masses, Auscultation: crackles positive
13. Cardiovascular: Inspection: precordium no abnormal pulsations; Palpation: palpable radial pulse;
Auscultation: no abnormal heart sound, no murmurs
14. Abdomen: Inspection: flat and rounded, no evidence of enlargement of liver; Palpation: soft, no
tenderness
15. Musculoskeletal: Inspection: no contractures, no tremors, weakness of muscles of the body;
Palpation: with tenderness of the fractured extremities ( Right Tibia-Fibula, Left Femur)
16. Extremities: presence of cast on both legs,
17. Mental Status: Oriented to time, place and person, responsive, with some discrepancies with past
memory.
REVIEW OF SYSTEMS:
WWWWW.General Health: No weight loss, slightly febrile, not diaphoretic, no cough and colds
XXXXX.Skin: no pruritus, no itchiness, no cold clammy
YYYYY.Head: no headache, not nauseated, experiences orthostatic hypotension when changing
position from lying to sitting
ZZZZZ.Eyes: no blurring of vision, no visual disturbances, uses reading glasses
AAAAAA.Ears: no ringing of ears, no tenderness
BBBBBB.Nose: no change in sense of smell, no colds, no bleeding, with difficulty in breathing
CCCCCC.Mouth: no bleeding gums, no difficulty in swallowing and chewing of food, poor appetite
DDDDDD.Respiratory: with nonproductive cough, no orthopnea, dyspneic at times, visible deep
respirations
EEEEEE.Cardiovascular: with no complaints of chest pain
FFFFFF.Gastrointestinal: no tenderness, has bowel eliminated and uses adult diaper, not constipated
GGGGGG.Genitourinary: voided 6-8 times since morning, no pain and discomfort during urination
HHHHHH.Musculoskeletal: generalized body weakness, fatigability, poor muscle tone and strength
especially lower extremities, restricted movements, limited range of motion
XLV. Patient’s Profile

Name: Verano, Clarito Regaňon Age: 63 y.o Sex: Male
Address: 44 Quarry District Tacloban City
Religion: Catholic Occupation: None
Date of birth: 01-22-44 Birthplace: Sta. Margarita Samar
Mother: Deceased Father: Deceased
Date Admission: 07-01-07 Time of Admission: 8:00 AM
Chief Complaint: Chesty Heaviness
XLVI. History
a. This is a case of Verano, Clarito, 63 years old, male residing at Quarry District who
was admitted for the third time with a chief complaint of chest heaviness. The
condition of the patient started last June 30, Saturday, 1 day prior to admission as
sudden onset of chest heaviness, mild and tolerable. No other symptoms were
associated. No medications were taken; he tried to rest however the condition was
still not relieved. This prompted him to seek consult, hence he was admitted.
XLVII. Past History:

 The patient had complete immunizations when he was still a child. He had his chicken
pox, measles, and mumps during his childhood.
 The patient had 2 other previous hospitalizations in the past with the same chief
complaint. His first admission was last 2006l due to chest heaviness, however his
diagnosis was not determined, The second was last May 11-15, 2007 with the same
chief complaint, he was diagnosed with unstable angina and he was admitted at the
CICU. He was also given medications during his 2nd hospitalization and these were: (1)
Fraxiparine 3,800 “IU” SQ, (2) ASA 80 mg OD, (3) Clopridagril 75 mg OD if
fraxipatine is NA, (4) Enalapril 5 mg OD, (5) Metoprolol 50 mg BID, and (6) ISDN 10
mg TID. He had previous elevation of his blood pressure for about a year now and he
is positive for recurrent chest pains.
 When asked if he experienced any accidents or injury in the past, he said he had
several accidents but he can only recall 3 of those accidents he had experienced.
First accident that he can remember was a vehicular accident, he was a college
student then, he suffered some minor injuries from that accident. The second was
during his 30’s, this time he was hit by a jeepney while he was crossing the street,
however he did not suffer any serious injury and fractures, no operation was done.
He was only hospitalized. The third he recalled was during his 50’s, again he was hit
by a vehicle, but according still he did not suffer any serious injury.
 Patient has no history of asthma and Diabetes Mellitus in the past.
XLVIII.Lifestyle:
a. The patient was a smoker. He started during his first year high school and claimed
that he was able to consume about 1 pack per day. It is only 2 years ago that he
stopped smoking. He is also an occasional alcoholic beverage drinker and stated that
he drinks “tuba”.
b. When it comes to his daily food intake, the patient said that he is able to eat just
enough, and he eats whatever it is that is served, and he also claimed that he loves to
eat meat. In the past the patient has no difficulty in eating and usually has good
appetite. He does not take any vitamins and other supplements. With regards to his
fluid intake, he said that during his usual days he is able to consume about 1 L of
water per day.
c. Regarding patient’s elimination pattern, he said that usually he has a daily bowel
movement with formed stool, but at preset he has not yet bowel eliminated. He also
does not frequently experience constipation. With regards to his urinary elimination,
he said he usually voids many times a day. At present, he voided twice this afternoon
to yellow colored urine, moderate in quantity with no difficulty and incontinence.
d. According to the patient, his usual type of exercise that he performs is walking and
he does this every morning around their house.
e. With regards to the patient’s sleep pattern, he said he doesn’t have any difficulty in
getting asleep, and at present he usually sleeps many times during the day.
XLIX. Family History:

a. The patient has 3 other siblings. 1 elder brother and 2 sisters, but according to him
it is only he who has this kind of illness. The patient’s parents are both deceased. His
father according to him died when he was still a child, he was shot and killed while he
was on his duty in the army. His mother on the other hand died after the delivery of
her 4th child. The patient has no family history of asthma, DM, arthritis, TB, and
hypertension.
L. Social Data
i. The patient is married, and has 4 children. 2 girls and 2 boys, but it is only his 1st
daughter who lives with him together with his grandchildren. He formerly worked in a
printing business but after he had his illness he stopped, his wife on the other hand
works as a Brgy. kagawad at their place.
ii. The patient is a graduate of AB Pol. Sci. at Leyte Colleges.
iii. In cases of problems, it is his family who helps him a lot and supports him emotionally.
VVVVVV.General Health: patient is a 63 y.o male adult. He is cooperative, easy to talk with, calm
and, responds when asked.
WWWWWW.Vital Signs:
XXXXXX.Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass,
absence of nodules.
YYYYYY.Hair: Inspection: With white strands of hair, evenly distributed, scalp has no infection or
infestation; Palpation: thin, resilient hair
ZZZZZZ.Nails: Inspection: Convex curvature, capillary bed is pale in color; Palpation: smooth
seconds)
AAAAAAA.Skin: Inspection: light brown in color with visible age spots, wrinkled and saggy, no
presence of edema and active lesions; Palpation: has normal skin temperature, has senile skin
turgor. Cold clammy skin, pallor
BBBBBBB.Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no
discharges and no discoloration, and sclera appears white and anicteric, pupils are equally
round and reactive to light and accommodation, uses eyeglasses; Palpation: light pink palpebral
CCCCCCC.Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, has some
difficulty in hearing normal voice tones; Palpation: auricles are mobile, firm and not tender
DDDDDDD.Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions
EEEEEEE.Mouth: Inspection: uniform slight pale, able to purse lips, with some teeth missing and
with brown to black discoloration of the enamel of the remaining teeth, no dentures, tongue
moves freely; Palpation: soft, moderately dry and smooth texture
FFFFFFF.Neck: Inspection: able to flex, hyperextend and rotate, thyroid gland not visible, neck
vein distention; Palpation: no palpable lymph nodes
GGGGGGG.Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact,
HHHHHHH.Cardiovascular: Inspection: precordium no abnormal pulsations; Palpation: palpable
radial pulse; Auscultation: no abnormal heart sound, no murmurs
IIIIIII.Abdomen: Inspection: flat and rounded, no evidence of enlargement of liver; Palpation:
soft, no tenderness
JJJJJJJ.Musculoskeletal: Inspection: no contractures, no tremors, with slight weakness of
muscles of the body; Palpation: no tenderness or swelling, with good handgrip,
KKKKKKK.Mental Status: Oriented to time, place and person, responsive, with some discrepancies
with past memory.
REVIEW OF SYSTEMS:
IIIIII.General Health: No weight loss, no fever and chills, not diaphoretic, no colds
JJJJJJ.Skin: no pruritus, no itchiness, cool and pale
KKKKKK.Head: no headache, not nauseated, dizzy at times
LLLLLL.Eyes: no blurring of vision, no visual disturbances
MMMMMM.Ears: no ringing of ears, no tenderness
NNNNNN.Nose: no change in sense of smell, no colds, no bleeding, difficulty in breathing
OOOOOO.Mouth: no bleeding gums, no difficulty in swallowing and chewing of food
PPPPPP.Respiratory: with reports of orthopnea, with report of dyspnea at times, not out of breath
when moving.
QQQQQQ.Cardiovascular: with some complaints of mild chest heaviness, no syncope
RRRRRR.Gastrointestinal: no tenderness, has not yet bowel eliminated,
SSSSSS.Genitourinary: voided 2 times the whole shift, no pain and discomfort during urination
TTTTTT.Musculoskeletal: slight weakness of body, easy fatigability
XIII. Patients Profile:
Name: Matacero, Arvin Benerez Age: 19 y.o Sex: M Civil Status: Single
Religion: Catholic Date of Birth: Oct. 21, 1988
Birthplace: Capoocan Citizenship: Filipino
Address: Capoocan, Leyte
Diagnosis: CKD stage 5 from CGN T/C hyperthyroidism
XIV. History of Present Illness

b. This is a case of Matacero, Arvin, 19 years old, male residing at Capoocan, Leyte who
was admitted for the first time as a referral from a private MD with a chief
complaint of dyspnea. The condition of the patient started 1 month prior to
admission. The patient was noted with increasing pallor associated with occasional
nausea. Other symptoms associated were occasional puffiness of the face especially
upon awakening in the morning and bipedal edema which resolves spontaneously. No
consult was done and no medications were taken. The patient just tolerated the
condition. 2 weeks prior to admission, the patient experienced occasional vomiting of
previously ingested food, moderate in quantity and this was associated with headache
and dizziness. According to the patient he had less than 1 L/day of urine output. The
patient still did sought consult. The symptoms of the patient persisted and now
associated with slight dyspnea. This prompted the patient to seek consult of a
private MD. The serum creatinine of the patient was taken and was found out to be
markedly elevated to 2,069 umol/L. He was given medications to take such as
Thiamine mononitrite, ciprofloxacin, Ranitidine, MV + Iron, and Glipizide, he was then
referred to EVRMC for further evaluation and management.
XV. Past History

c. The patient had complete immunizations during his childhood. He aslo recalled having
chicken pox, measles and mumps when he was still a child.
d. The patient has no other previous hospitalizations; however the patient stated that
he experienced an accident when he was 14 years old. He said that he fell from the
coconut tree and wounded his left leg. No hospitalization was done; he only treated
the wound with an ointment. He did not suffer any fractures, he only obtain a scar
from the wound that he had.
e. The patient has no history of asthma, Rheumatic heart disease, GI disorders and any
serious illness in the past.
f. The patient also has no known allergy to any food, drug, or animals.
g. He also did not experience having blood transfusions in the past.
XVI. Lifestyle
h. The patient is a non-smoker and a non alcoholic beverage drinker. With regards to his
food intake, the patient stated that on usual days he is able to eat a lot and usually
has a good appetite. He also does not experience any difficulty in eating and
swallowing. At present the patient is not able to eat much because he usually vomits
and complains of not having a good appetite. The patient also stated that he is fond
of eating junk foods twice daily, and drinking soft drinks two times a day before
when he was not yet admitted. With regards to his water intake, he said that he is
only able to consume 3 half full glass of water per day.
i. With regards to the patient’s elimination pattern, he stated that his usual bowel
movement is every other day. He also said that he frequently experience being
constipated. At present the patient has not yet bowel eliminated. Regarding his urine
output, the patient said that he voided twice during the whole shift and still has a
decrease amount of urine. No difficulty or pain was noted during urination.
j. During patient’s free time, he usually plays basketball with his friends, and this is
only the form of exercise he engages into.
k. According to the patient, before he was hospitalized he usually is able to sleep right
away continuously, however at present the patient complains of not being able to
sleep well at night. He said that it is only around 4 AM that he is able to sleep.
XVII. Family history

l. The patient has 10 other siblings and all of them are in good physical condition.
However, he stated that the 5th child of their family has asthma, and his
grandmother has diabetes and hypertension which makes him at risk of acquiring
these diseases. On the other hand, he also claimed that he has no family histoey of
arthritis, heart disease, and mental illness.
XVIII. Social Data

m. The patient is 19 years old, single and is currently living with his parents together
with his other 3 siblings. He stopped schooling and worked as a waiter. His father
works as a farmer while his mother works as a laundry washer.
n. When problem arises, he usually seeks help from his friends and parents.
1. General Health: Patient is a 19 y.o male adolescent, awake, cooperative, answers to questions
and is easy to talk with, but appear fatigued.
2. Vital Signs:
3. Head: Inspection: normocephalic and symmetrical; Palpation: No tenderness or mass, absence
of nodules.
4. Hair: Inspection: black hair, evenly distributed, scalp has no infection or infestation;
Palpation: thick, resilient hair
5. Nails: Inspection: Convex curvature, capillary bed is pale in color; Palpation: smooth texture,
delay in return of capillary refill (about 6 seconds; normal= less than 4 seconds)
6. Skin: Inspection: light brown in color, with pallor of the palms of both hands, diaphoresis;
Palpation: with cold clammy and dry skin, with slightly poor skin turgor.
7. Eyes: Inspection: eyebrows symmetrically aligned with equal movement, eyelids have no
conjunctiva, with periorbital edema, no tenderness over lacrimal gland.
8. Ears: Inspection: symmetrical, auricle aligned with outer canthus of the eye, able to hear
9. Nose: Inspection: no discharge or flaring, Palpation: Not tender, no lesions
10. Mouth: Inspection: pallor, dry mucus membrane, able to purse lips, complete set of teeth, no
dentures, tongue moves freely; Palpation: soft, moderately dry and smooth texture
11. Neck: Inspection: able to flex, hyperextend and rotate; Palpation: no palpable lymph nodes
12. Thorax: Inspection: Anteroposterior to transverse diameter is 1:2, chest wall intact, no
retractions, with non-productive cough; Palpation: with burning chest pain at xiphoid area, no
masses, Auscultation: no crackles and wheeze
13. Cardiovascular: Inspection: with heaves; Palpation: with palpitations, full bounding pulse
14. Abdomen: Inspection: flat and rounded. Palpation: soft, no evidence of enlargement of liver,
no tenderness, episodes of vomiting (watery in consistency, yellowish in color, moderate in
amount)
15. GUT: hematuria, decreased urine putput
16. Musculoskeletal: Inspection: no contractures, no tremors, with slight weak muscle tone;
Palpation: no tenderness or swelling, with good handgrip,
17. Mental Status: Oriented to time, place and person, drowsy but responsive, able to recall past
memories, fatigued, no difficulty in walking, able to balance.
REVIEW OF SYSTEMS:
UUUUUU.General Health: no fever and chills, not diaphoretic
VVVVVV.Skin: no pruritus, no itchiness; heat intolerance (diaphoretic)
WWWWWW.Head: no headache, no dizziness, not nauseated
XXXXXX.Eyes: no blurring of vision, no visual difficulties, no use of eyeglasses
YYYYYY.Ears: no ringing of ears, no tenderness, no difficulty in hearing
ZZZZZZ.Nose: no change in sense of smell, no colds, no bleeding
AAAAAAA.Mouth: no bleeding gums, no difficulty in swallowing and chewing of food, with poor
appetite
BBBBBBB.Respiratory: not dyspneic, with non-productive cough, has no difficulty in breathing,
Cardiovascular: no syncope, with burning pain on chest at xiphoid area
CCCCCCC.Gastrointestinal: no tenderness, has no bowel movement yet, with poor appetite, with
nausea, vomited to a yellow colored vomitus, water in consistency, moderate in amount.
DDDDDDD.Genitourinary: voided 2 times this afternoon with still dercreased amount of urine, no
pain and discomfort during urination was noted.
EEEEEEE.Musculoskeletal: slight weakness of body, body malaise,
FFFFFFF.Neurologic: with feeling of body weakness, no paralysis of any body part, no numbness,
no tremors.
DIAGNOSTIC EXAMS
Name of Patient: Verano, Clarito Regaňon.
Date Admitted: 7-1-07

Age: 63 y.o
Time admitted: 8:00 AM

Sex: Male
C/C: Chest Heaviness
Diagnosis: Acute Myocardial Infarction
Date Lab Exam Result Normal Values Significance

7-01-07 Hematology Hct= 0.38 0.40-0.54 >Decreased in anemia
WBC= 6.6 x 10~9/L 4.5-11.3 >Normal
Differential Ct.: >Increased in tissue necrosis
Segmenter= 0.83 0.45-0.65 (Myocardial Infarction)
Lymphocyte= 0.16 0.20-0.35 >Decreased in immunosuppression
and corticosteroid therapy
Monocyte= 0.01 0.02-0.06 >Decreased by drug therapy
Clinical Troponin I= (-) Negative >Normal
Chemistry

7-03-07 Hematology Hgb= 107 g/L M: 135-170 >Decreased in anemia
Hct= 0.31 M: 0.40-0.54 >Decreased in anemia
Erythrocyte= 3.84 x M: 4.6-6.2 >Decreased in anemia
10~12/L
Leukocyte= 5.70 x 4.5-10 >Normal
10~9/L
Granulocyte= 0.75 0.500-0.750 >Normal
Lymphocyte= 0.20 0.200-0.350 >Normal
Monocyte= 0.05 0.020-0.060 >Normal
MCV= 80 fl 80-96 >Normal
MCH= 27.80 pg 27-31 >Normal
MCHC= 350 320-360 >Normal
Urinalysis Color= pale yellow Pale yellow-deep >Normal
amber
Transparency= slight Clear
turbid
Spc. Gr.= 1.010 1.002-1.035 >Normal
pH= 6.0 4.5-8.0 >Normal
Gluc/Albu/Blood= (-) Negative >Normal
Pus cells= 0-2/hpf
RBC= 0-2/hpf <3/hpf >Normal
Epith. Cells= some
Bacteria= few Negative
M. threads= some
A. Urates= few
Blood Glucose= 4.6 mmol/L 4.2-6.4 >Normal
Chemistry
(Serum)
Creatinine= 230.5 53-97 >Increased in cardiac disorder
umol/L that adversely affect renal
circulation
Cholesterol= 4.8 < or = 5.7 >Normal
mmol/L
Triglyceride= 0.7 0-1.71 >Normal
mmol/L
7-04-07 PROTIME Test= 12.6 sec 9.5-12 sec >Slightly prolonged with low levels
or deficiencies of fibrinogen,
clotting factors 11, V, Vii, & X
Control= 12.0 sec
INR= 1.1
DIAGNOSTIC EXAMS
Name of Patient: Matacero, Arvin Benerez
Date Admitted: 7-03--07

Age: 19 y.o
Time admitted: 3:15 PM

Sex: Male
Diagnosis: CKD stage 5 from CGN
T/C hyperthyroidism

7-02-07 Blood Chemistry Creatinine= 2,069 53-97 >Increased in nephritis &
umol/L chronic renal disease
Urinalysis Color= Yellow Pale yellow-deep >Normal
amber
Transparency= hazy Clear
Sp. Gr.= 1.030 1.002-1.035 >Normal
pH= 5.0 4.5-8.0 >Normal
Albumin= +++ (-) >Increased in glomerular disease
and nephropathy
RBC= 1-2/hpf <3/hpf >Normal
Sugar= (-) (-) >Normal
WBC= 6-8/hpf 0-5/hpf >Increased in infection
Epith. Cells= many
M. threads= many
Bacteria= moderate none >UTI
Miscellaneous FBS= 8.36 mmol/L 4.2-6.4 >Increased in nephritis

7-03-07 Hematology Hgb= 34 g/L M: 135-170 >Decreased in anemia
Hct= 0.17 M: 0.40-0.54 >Decreased in anemia
WBC= 5.35 x 10~9/L 4.5-11.3 >Normal
Sementer= 0.74 0.45-0.65 >Increased in inflammatory
disease or bacterial infection
Blood type “A” RH(+)

7-04-07 Urinalysis Color= Light yellow Pale yellow-deep >Normal
amber
Transparency= Clear Clear >Normal
Sp. Gr.= 1.025 1.002-1.035 >Normal
pH= 5.0 4.5-8.0 >Normal
Pus cells= 1-4/hpf
RBC= 4-6/hpf <3/hpf >Increased in IgA nephropathy,
infection, renal artey thrombosis
Epith. Cells=
Occasional
Bacteria= Some None >Present in UTI
A. Urates= Moderate
Glucose= (+) (-)
Albumin= ++++ (-) >Increased in nephritis and
glomerular disease
Blood= ++ (-) >Increased in nephropathy
Coarse granular 0-4/hpf >Normal
casts= 0-1/hpf
Others: No
dysmorphic RBC seen
Clinical Urea (BUN)= 11.3 2.5-7.5 >Increased in renal failure
Chemistry mmol/L
Creatinine= 2332.6 53-97 >Increased in Nephritic and
umol/L chronic renal disease
Hematology Hgb= 36 g/L 135-170 >Decreased in anemia
Hct= 0.10 M: 0.40-0.54 Decreased in anemia
Erythrocyte= 1044x M: 4.6-6.2 Decreased in severe anemia
10~12/L
Leukocyte= 4.80 x 4.5-10 >Normal
10~9/L
Granulocyte= 073 0.500-0.750 >Normal
Monocyte= 0.07 0.020-0.060 >Normal
MCV= 70 fl 80-96 >Decreased in microcytic anemia
MCH= 25.30 pg 27-31 >Decreased in hemoglobin
deficiency, hypochromic anemia
MCHC= 364 320-360 >Increased when cells are
oversized (fewer cells can be
packed together within 1 dl)
I. PATIENTS PROFILE
Name: Glenn Raphael Dolina Case No: 030883

Age: 1 month old Sex: Male Civil status: Single
Address: Brgy. Buri, Palo, Leyte
Birthday: Decmber 13, 2007 Birthplace: EVRMC Tacloban City
Date of Admission: January 28, 2008 Time: 11:07 AM
Mother: Cheryl Dolina Occupation: Receptionist
Attending Consultant: Dr. Monterde/ Dr. Almaden
Chief Complaint: “ Parang nahihirapan siyang huminga at parang merong sound yung
paghinga niya” as verbalized by the mother
Diagnosis: R/O Hyaline Membrane Disease

This is a case of Glenn Raphael Dolina, a 1-month old baby, male, infant, Roman
Catholic, Filipino and currently residing at Brgy. Buri Palo, Leyte. He is admitted for the
first time at our center.
Patient was born last December 13, 2007 at EVRMC at 34 weeks AOG via C/S
delivery. After birth, the patient was noted to have grunting and disrupted feeding,
nasal flaring, and jaundice. So they patient underwent blood transfusion of about 250 cc
of blood. After, the patient was discharged along with his mother.
The above symptoms (except for jaundice) persisted and so mother brought the
patient to this center for consult, hence admission.
III. Past History

The patient has no past hospitalization, operation and has no allergy to any food,
drug and plants. He has not experienced any childhood diseases such as measles,
chicken pox or mumps. After he was born, he was immunized with Hepatitis B one
dose, BCG, DPT one dose, OPV one dose. This is his first time to be hospitalized since
he was born. After birth, the patient had fever as a normal reaction to the immunization
so mother gave Paracetamol.
IV. Family History

According to his mother, the only heredofamilial disease they have is diabetes
milletus from his grandparents.
The patient’s mother originally lives in Metro Manila. Last month, she came to
Tacloban for a vacation.
VI. Birth History

A. Pre-natal- During her 2nd month pregnancy, Ms. Dolina had a urinary tract infection.
According to her she took some medications as per consult with a doctor but was
unable to recall. She takes vitamins everyday. She did not experience any vaginal
bleeding and the duration of her pregnancy is only 34 weeks.
B. Natal- Baby Glenn was born via C/S delivery to a G1P1 26 years old mother. Her
birthweight was 3.7 kg.
C. Neonatal- The patient had jaundice after he was born and underwent blood
transfusion of about 250 cc of whole blood.
VII. Feeding History

Patient is bottlefed since birth. After birth her milk formula was Bona but mother
switched to S26 formula (5-6X/ day at 4 ounce each).
LABORATORY EXAMINATIONS
I. January 28, 2008- Chest APL

Haziness in the inner lung zones. Heart is not enlarged. Thoracic cage diaphragm
and costophrenic sulci are unremarkable.
Impression: bronchopneumonia
II. January 28, 2008- Urinalysis
yellow
Transparency Clear Clear Normal
pH 6.0 5.0-7.0 Normal
Epithelial cells Rare No significance Normal
III. January 28, 2008- Fecalysis

Color: Yellow
Character: Soft
- No significant finding
IV. January 29, 2008- Hematology

Remarks: Blood type “A”; Rh (+)

Hemoglobin 110 g/L Male: 140-175g/L Decreased in
overload), anemia,
recent hemorrhage
and acute massive
blood loss.
WBC 7.75 5-10x109/L Normal
Platelets 432 150-450X10 g/L Normal
Neutrophils 0.26 0.57-0.65 Decreased in viral
diseases. Leukemias,
agranulocytoss and
aplastic anemia.
Eosinophils 0.68 0.25-0.35 Increased in
tissue necrosis,
anemia, allergic
reactions.
Lymphocytes 0.02 0.04-0.08 Decreased in renal
failure, aplastic
anemia and leukemia.
REVIEW OF SYSTEMS
General: No weight loss, fever and chills, fatigue

Skin: No rashes, pruritus, bruising, change in color
Head: No headaches, injury, tenderness, dizziness
Eyes: No change in visual field, glasses, contact lenses
Ears: No Change in hearing, tinnitus, pain, discharge, dizziness
Nose: No Allergies, sinus problem, obstruction, polyps, loss of sense of smell, sneezing,
epistaxis with nasal flaring
Throat: No toothaches, loose teeth, bleeding gums, mouth sores
Respiratory: Subcostal retractions, occasional crackles
Cardiovascular: no Chest pain, pressure/ tightness, palpitations
GIT: No dysphagia, heartburn, ulcer, indigestion, diarrhea, constipation, abdominal
pain, GUT: No urgency, frequency, nocturia, dysuria, hematuria, UTI, incontinence
Endocrine: No Heat/cold intolerance, weight change, fatigue
Musculoskeletal: No weakness.
Vital Signs
Pulse Rate: 145 bpm
Temperature: 37°C
Weight: 3.7 kilograms
General Survey: Conscious, cuddled by mother with an IVF of D5 0.3 NaCl at 12

ugtts/min per soluset.
Integument:
Inspection: Pinkish in complexion, uniform in color through out body
Nails:
Inspection: smooth, nail plate-convex curvature
Palpation: Thin, capillary refill = 3 seconds.
Head:
Inspection: Normocephalic skull with thin hair
Eyes:
Inspection: Symmetrical, pinkish palpebral conjunctiva, pupils equally round
and reactive to light.
Ears:
Inspection: Symmetrical, auricles aligned with the outer canthus of the eye
Nose:
Inspection: Symmetrical at midline
Palpation: Non tender sinus
Throat and Mouth:

Inspection: Moist oral mucosa
Chest & Lungs:

Inspection: Symmetrical chest, irregular respiratory rhythm, tachypnea
(RR=35cpm), subcostal retractions
Auscultation: Crackles
Heart:
I. PATIENTS PROFILE
Name: Alegar Montallana Moralles Case No: 72902-2008

Address: Brgy. Pangudtan, Oras Eastern Samar Occupation: Student (4th Year HS)
Birthday: 6/17/1991 Birthplace: Oras Eastern Samar
Date of Admission: February 7, 2008 Time: 3:46 PM
Father: Olegario Moralles Age: 49 Occupation: “Nagsasabong”
Mother: Almira Moralles Age: 42 Occupation: Housewife
Attending Consultant: Dr. Francisco Caboboy
Chief Complaint: “Mabanhod an akon kamot tas masakit hiya labi na kun nakikiwa.”As
verbalized by the patient.
Diagnosis: Fracture, closed, displaced, distal 3rd radius-ulnar
Operation Performed: Open reduction Plating, radius-ulna right

This is a case of Alegar Moralles, 16 years old, male, roman catholic, Filipno, a 4 th year
high school student, residing at Brgy. Pangudtan Oras Eastern Samar, who is admitted for the
first time in this center due to fracture of his right arm.
2 days PTA, patient was playing basketball in their school. After doing a lay up, he fell
badly on the ground and broke his 3rd distal radius-ulnar on the right arm. Patient immediately
complained of pain and so his classmates brought him home. Parents decided to bring him to the
hilot and the affected area was massaged. And advised them to have an x ray of his arm. Parentst
decided to give the patient Amoxicillin and Mefenamic Acid.
A day PTA, patient complained of swelling, pain, redness and deformity. So parents
decided to sought consult at this center.
III. Past History

Patient has no previous trauma, surgery and accidents. He had measles, chicken pox and
mumps during his childhood. His mother verbalized that he had complete immunizations. He has
no allergies to any food, plant and animals. This is the first time he was hospitalized. And he has
no maintenance medications.
IV. Family History

Patient has a family history of hypertension, cardiomegaly and asthma on his paternal
side.
V. Lifestyle
Patient drinks Beer about 2 grande but only during occasion. He does not smoke. His
usual ADL is going to school, attending his classes, playing basketball, doing his homework,
watching TV and going out with his barkada. He loves to eat meat but also eats fish and
vegetables especially mongos. He has no problems or difficulty with his sleeping. He usually
sleeps at around 9PM and wakes up at around 5 AM. Her hobbies includes going out with his
friends and playing basketball.
VI. Social Data

The patient has 4 siblings and he is the youngest. He has good relationship with his
family. He is currently a 4th year high school student. He lives in a house made of cement with 2
rooms. Their house is about 50 meters from the main road with electricity and water supply from
deep well.
LABORATORY EXAMINATION:
February 7, 2008 Chest PA View

• Impression: Dextroscoliosis, thoracic spine otherwise normal chest study.
February 7, 2008 Urinalysis

yellow
Transparency Turbid Clear Due to presence of
pus cells
pH 6.0 4.6-8.0 Normal
Protein Negative Negative Normal
Red blood cells None 2-4/hpf Normal
Epithelial cells None Rare/Few/None Normal
A.urates Many Rare/Few/None
Mucus threads Few Rare/Few/None Normal
February 7, 2008 Hematology

Hemoglobin 154 Male: 140-175g/L Normal
Female: 120-160g/L
Female: 0.36-0.46
WBC 8.6 4.5-11.3x109/L Normal
Neutrophils 0.71 0.45-0.65 Increased in acute
infections, inflammatory
disease and tissue
damage
February 11, 2008 Right Forearm APL

Follow-up study to an outside film now shows metallic plates and screws transfixing the
fractures on the radius and ulna.
REVIEW OF SYSTEMS:
General: No weight loss, fever and chills, fatigue

Skin: No rashes, pruritus, bruising, no change in color
Nose: No Allergies, sinus problem, obstruction, polyps, loss of sense of smell, sneezing,
epistaxis with nasal flaring
Respiratory: No cough, no crackles or rales
Cardiovascular: no Chest pain, pressure/ tightness, palpitations
GIT: No dysphagia, heartburn, ulcer, indigestion, diarrhea, constipation, abdominal pain, GUT:
No urgency, frequency, nocturia, dysuria, hematuria, UTI, incontinence
Endocrine: No Heat/cold intolerance, weight change, fatigue
Date of Examination: February 10, 2008
General Survey:
Symmetrical body, with no attached IVF, with cast on right arm and lying on bed asleep.
Vital signs:
HR= 65 bpm Temperature= 37°C
Integument:
Inspection: Brown in complexion, uniform in color through out body, dry and pallor
Nails:
Inspection: Trimmed clean fingernails, smooth, nail plate-convex curvature
Head:
Inspection: Normocephalic skull, Blackevenly distributed hair, no infestation
Eyes:
Inspection: Symmetrical, pinkish palpebral conjunctiva, pupils equally round and reactive
to light; pupils dilatation: 3-4mm, can read newsprint.
Ears:
Inspection: Symmetrical, auricles aligned with the outer canthus of the eye, cannot hear
normal voice tone.
Nose:
Throat and Mouth:

Inspection: Moist oral mucosa, able to purse lips, Pinkish tongue, moves freely, reddened
Neck:
Chest & Lungs:

Anterior:
Inspection: Symmetrical chest, regular respiratory rhyth
Posterior:
Heart:
Abdomen:
Extremities:
Upper:
Lower:
• With reflexes
I. PATIENTS PROFILE
Name: Gregoria Patris Casil Case No: 72954-2008

Address: Brgy. Cabungaan BayBay Leyte Occupation: Housewife
Birthday: 11/11/1955 Birthplace: BayBay Leyte
Husband: Jose Casil Age: 56 Occupation: Farmer
Attending Consultant: Dr. Blas
Chief Complaint: Ningsakit man ang akong tiyan ug likod.” As verbalized by the patient.
Diagnosis: Acute prelonephritis with nephrolithiasis

This is a case of Gregoria casil, 52 years, married, a Roman Catholic, Filipino, residing at Baybay Leyte is
admitted for the first time in this institution due to abdominal pain.
1 week PTA, patient had colicky pain on the right lower quadrant. It was intermittent accompanied by
dysuria, frequency,and hematuria. Patient took Mefenamic acid to relieve the pain and went to the hilot and was
given herbal medications.
But the above symptoms persisted hence prompted the patient to sought consult in this institution.
III. Past History

The patient has no previous trauma, injury nor accidents. She remembered to have had chicken pox,
measles and mumps. She has allergies to shrimps. She was hospitalized for three times already. And she has a
maintenance medication of centrum.
IV. Family History

Patient’s family has a history of hypertension, and asthma.
V. Lifestyle
Patient drinks tuba and coffee occasionally but unable to count up to how many glasses. She does not
smoke. Her usual ADL is cleaning the house, cooking, washing clothes and other household chores because she is a
housewife and she loves doing these chores for her children and husband. She usually do some morning walking
about 30 minutes. She loves to eat vegetables. She usually sleeps at around 8Pm and wakes up at 3 AM and does not
complain of any difficulties with sleeping.
VI. Social Data

The patient has 8 children. She is a high school graduate. She sometimes helps his husband in doing some
chores in the farm.
2/4/08 Ultrasound
Conclusion:
 Nephrolithiasis right associated with grade IV hydronephrosis
 Normal sonographic evaluation of the left kidney and urinary bladder.
2/7/08 X-ray
Impression: Fibrocalcific density as described likely due to previous healed pulmonary infection.
2/8/08 ECG
Sinus rhythm and non-specific P wave.
2/7/08 Hematology

Hemoglobin 127 Male: 140-175g/L Normal
Female: 120-160g/L
Female: 0.36-0.46
WBC 5.5 4.5-11.3x109/L Normal
2/7/08 Clinical Chemistry

Creatinine 71.12 Male: 71-115 umol/L Normal
Female: 53-106 umol/L

Sodium 146.2 135-148mmol/L Normal
Potassium 3.53 3.5-5.3mmol/L Normal
Uric-E 0.19 0.17-035mmol/L Normal
Gluc-D 5.47 3.90-6.40mmol/L Normal
Chol-E 6.5 3.9-6.7mmol/L Normal
Trig-E 0.56 0.46-1.88mmol/L Normal
HDL 1.23 0.00-1.68mmol/L Normal
LDL 5.0
2/8/08 Hematology

Bleeding Time 2 mins. 15 sec. 1-4 mins. Normal
Clotting Time 3 mins 2-6 mins. Normal
2/10/08 Urinalysis

Color Straw Colorless to dark yellow Normal
Transparency Clear Clear Normal
pH 6.0 4.6-8.0 Normal
Epithelial cells Few Rare/Few/None Normal
A.urates Few Rare/Few/None Normal
2/11/08 Miscellaneous
TSH 1.30 0.25-5.0 IU/mL Decreased in secondary
hypothyroidism and high
level of dopamine
FT3 4.42 4.0-8.3pmol/L Normal
FT4 19.86 9-20pmol/L Normal
2/11/08 Protime and APTT

Exam Result
Protime 12.9 sec
121.6%
0.89 INR
Control 15.6 sec

88%
1.14 INR
APTT with mixing Test: 43.5 sec
Control: 37.7 sec
REVIEW OF SYSTEMS:
General: weight loss, fatigue, with no fever and chills

Head: headaches and no injury, tenderness, dizziness
Nose: With Allergies to shrimp, No sinus problem, obstruction, polyps, loss of sense of smell, sneezing, epistaxis
with nasal flaring
Throat: No toothaches, loose teeth, bleeding gums, mouth sores, polyps on the vocal folds
Respiratory: No cough, no crackles or rales, dyspneic
Cardiovascular: Chest pain, pressure/ tightness
GIT: No dysphagia, heartburn, ulcer, indigestion, diarrhea, constipation, but with abdominal pain.
GUT: urgency, frequency, dysuria, hematuria.
Endocrine: weight change, fatigue
Musculoskeletal: slight weakness.
General Survey:
Symmetrical body, with an IVF of D5MM 1 liter newly hooked at 20 gtts/min.
Vital signs:
HR= 69 bpm Temperature= 36.5°C
Integument:
Nails:
Head:
Inspection: Normocephalic skull, grayish evenly distributed hair, no infestation
Eyes:
Inspection: Symmetrical, pinkish palpebral conjunctiva, pupils equally round and reactive to light; pupils
dilatation: 3-4mm, can read newsprint.
Ears:
Nose:
Throat and Mouth:

Inspection: Moist oral mucosa, able to purse lips, Pinkish tongue, moves freely, reddened uvula, non-
inflamed tonsils, no dysphagia., with polyps on the vocal folds.
Neck:
Chest & Lungs:

Anterior:
Inspection: Symmetrical chest, irregular respiratory rhythm (RR=28 cpm)
Posterior:
Heart:
Abdomen:
Extremities:
Upper:
Lower:
• With reflexes
I. PATIENTS PROFILE
Name: Fernando Oria Case No: 73509-2008

Address: Brgy. Rawis, Arteche E. Samar Occupation: Farmer
Birthday: 5/15/1928 Birthplace: Arteche Eastern Samar
Wife: Dela Paz Oria Occupation: Housewife
Attending Consultant: Dr. Jose Carlo Del Pilar
Chief Complaint: “Inatake man ini hiya tas natumba” as verbalized by SO.
Diagnosis: Right hemipharesis secondary to cerebral insufficiency probably left MCA
thrombosis HPN II Essential COPD.

This is a case of Fernando Oria, 79 years old, male, married, Filipino, a Roman Catholic
and residing in Brgy. Rawis Arteche Eastern Samar, admitted for the first time due to right body
weakness.
1 week PTA, patient was riding on a small boat to his farm along with nephew, when
suddenly he fell on the boat. SO immediately brought him to a hospital in Arteche Eastern
Samar. According to the SO, patient did not feel any discomforts or problems with his health.
What happened was just sudden. During his stay in Arteche, patient was treated as a case for
CVA. And after 4 days was discharged. Patient stayed at home for a day then SO decided to
bring patient to this institution for further evaluation and management.
III. Past History
Patient has no previous trauma, surgery and accidents. He had measles, chicken pox and
mumps during his childhood. SO was unable to recall any immunization of the patient since it
was a long time ago. He has no allergies to any food, drug or plants. He has no maintenance
medications previously.
IV. Family History

Patient has a family history of hypertension and asthma.
V. Lifestyle
According to So, patient drinks alcoholic beverage but on moderation and occasionally.
He does not smoke. He loves to eat fish and other salty foods but denies esting meat too much.
He usual do a morning exercise about 30 minutes on the seashore everyday. He has no sleeping
difficulties.
VI. Social Data

The patient was not able to go to school. He can write but unable to read. He has 9
children and most of them has their own families and are already professionals. Patient has no
problems with his neighborhood.

• Impression: APL is suggested for further evaluation.
• Cardiomega;y
2/8/08 ECG
Sinus rhythm, LVH
2/9/08 Cranial CT scan

• Acute cerebral infarction, left temporo-parietal lobes
• Cerebral atrophy

Gluc-D 10.33 3.90-6.40mmol/L Increased in DM and
nephritis

HgbA1C 4.1% 4.5-5.3 Decreased in anemia

Crea-B 124.2 53-115 umol/L Increased in CHF
Gluc-D 7.13 3.90-6.40mmol/L Increased in DM
Chol-E 3.0 3.9-6.7mmol/L Decreased in
starvation and
malabsorption
LDL 2.1

Calcium 1.92 2.15-2.57 mmol/L Decreased in
malabsorption of
Calcium from the GIT
2/11/08 Urinalysis

Color Dark yellow Colorless to dark Normal
yellow
Transparency Turbid Clear Due to pus cells
pH 6.0 4.6-8.0 Normal
Protein Positive Negative Proteinuria; cardiac
disease
Pus cells Many 3-5/hpf
Red blood cells Loaded 2-4/hpf Renal disease
Epithelial cells Some Rare/Few/None Normal
Bacteria Some Rare/Few/None Normal
A.urates ++ Rare/Few/None
Mucus threads +++ Rare/Few/None
REVIEW OF SYSTEMS
General: Weight loss; fever, no chills, no night sweats.

Skin: pruritus, no bruising, no changes in color.
Head: no Headache, no injury, no tenderness.
Eyes: Unable to read or concentrate
Ears: Change in hearing.
Nose: Clear nasal discharges, sneezing, no epistaxis, no loss of sense of smell.
Throat and Mouth: pale and dry mucosa, cannot speak
Respiratory: no non productive cough, no chest pain, dyspnea, crackles
Cardiovascular: No chest pain, no palpitations, no shortness of breath.
Gastrointestinal: no indigestion, no food intolerances, no diarrhea, and no abdominal pain,
dysphagia
Genitourinary: Hematuria.
Musculoskeletal: edema on right hand, right hemipharesis.
Vital Signs
Heart Rate: 65 bpm
Temperature: 36°C
Blood Pressure: 120/70 mm Hg
General Survey: Fairly groomed, drowsy and sleeps most of the time, with an ongoing IVF of
PNSS 1 liter at 20 gtts/min, with o2 inhalation at 5 liters/min, with NGT intact and in place.
Integument:
Inspection: Brown in complexion, uniform in color through out body, brown “age spots”
on exposed body areas, dry and pallor.
Nails:
Head:
Inspection: Normocephalic skull, grayish evenly distributed hair, no infestation
Eyes:
Inspection: Symmetrical, cannot read newsprint.
Ears:
Inspection: Symmetrical, auricles aligned with the outer canthus of the eye, cannot hear
normal voice tone.
Nose:
Inspection: Symmetrical at midline with clear discharges.
Throat and Mouth:

Inspection: Pale oral mucosa, smooth yellow tooth enamel, dysphagia, cannot move
tongue freely. Unable to speak.
Neck:
Inspection: thyroid gland not visible.
Chest & Lungs:

Inspection: Barrel chest, irregular respiratory rhythm, tachypnea (RR=32cpm)
Palpation: Non-tender, not symmetric chest expansion, no nodules nor mass.
Percussion: Adventitious breath sounds
Auscultation: fine crackles
Heart:
Auscultation: irregular heart rhythm.
Abdomen:
Inspection: Uniform color.
Auscultation: irregular bowel sound
Extremities:
Neurologic System:
Not oriented to place and time, oriented to person, affect not appropriate to situation,
irritable at times and confusion, right hemipharesis
I. PATIENTS PROFILE
Name: Angeles Orbaneja Raagas Case No: 22103-2005

Age: 84 years old Sex: Female Civil status: Widow
Address: Brgy. San Vicente Dulag Leyte Occupation: Houseewife
Birthday: 5/10/1923 Birthplace: Marabut Eastern Samar
Date of Admission: February 22, 2008 Time: 9:26 AM
Attending Consultant: Dr. Felicisimo Abuyabor
Chief Complaint: Din inubo ako hin usa na ka simana tapos din hirantan gihap.” As verbalized by the patient.
Diagnosis: CAP R/O UTI

This is a case of Angeles Raagas, 84 years old, female, a widow, Filipino, Roman Catholic, a resident of
Brgy. San Vicente Dulag Leyte, is admitted in this institution due to fever, cough and chills.
A day PTA, patient had onset of fever associated with chills. This was accompanied by occasional cough
and chest and abdominal pain. Patient took medications at home but unable to recall the name.
Few hours PTA, patient’s symptoms persisted, hence prompted consult at this institution.
III. Past History

Patient has previous accidents but unable to recall. She also cant remember her childhood illness and
immunizations since it was along time ago. She has no allergies to food, drugs or plants. She has been hospitalized
before.
IV. Family History

Patient has a family history of Diabetes mellitus and heart disease.
V. Lifestyle
Patient is a non-alcoholic drinker and non-smoker since she was young. She loves to eat salty foods. Her
usual diet consists of fish, rice and vegetables. She has no sleeping difficulties. When she got married, she was a
plain housewife. She has no exercise regimen and does not love to drink coffee.
VI. Social Data

The patient has 6 children and a widow. Some of his children is not living with her anymore since they
have their won family. She now relies on her children for financial support. She has good communication and
relationship with her family and neighborhood.

Hazy infiltrates are seen in right lower lung field. The heart is slightly enlarged. The rest of the visualized
chest structures are unremarkable.
• Impression: Right basal interstitial pneumonia
• Cardiomegaly
February 22, 2008 Urinalysis

Color Light yellow Colorless to dark yellow Normal
Transparency Slight turbid Clear Due to presence of pus
cells
pH 6.0 4.6-8.0 Normal
Pus cells 35-48/hpf 3-5/hpf Increased
Epithelial cells Some Rare/Few/None Normal
Bacteria Rare Rare/Few/None Normal
A.urates Some Rare/Few/None None
February 2, 2008 Hematology

Hemoglobin 100 Male: 140-175g/L Decreased in Anemia
Female: 120-160g/L
Hematocrit 0.30 Male: 0.42-0.50 Decreased in anemia
Female: 0.36-0.46
WBC 5.0 4.5-11.3x109/L Normal
Neutrophils 0.92 0.45-0.65 Increased in acute infections
Lymphocytes 0.06 0.20-0.35 Decreased renal failure and
anemia
Platelets 269 140-440 Normal
February 22, 2008 ECG

Ventricular rate: 100
Normal ECG
February 22, 2008 Clinical Chemistry

Potassium 5.40 3.5-5.3mmol/L Increased in acute renal
failure
Chloride 108.4 98-107 mmol/L Increased in kidney
dysfunction
February 23, 2008 Clinical Chemistry

Uric-E 0.65 0.17-0.35mmol/L Increased in renal failure
Crea-B 674.5 53-115 umol/L Increased in acute renal
failure
Gluc-D 7.46 3.90-6.40mmol/L Increased in DM
Chol-E 2.6 3.9-6.7mmol/L Decreased in starvation
and malabsorption
LDL 1.7 <2.6 mmol/L Normal
REVIEW OF SYSTEMS:
General: No weight loss, with fever and chills, fatigue

Nose: No Allergies, sinus problem, obstruction, polyps, loss of sense of smell, sneezing, epistaxis with nasal flaring
Respiratory: with cough and rales but no wheeze.
Cardiovascular: With Chest pain, no pressure/ tightness, palpitations
GIT: No dysphagia, heartburn, ulcer, indigestion, diarrhea, constipation, but with abdominal pain,
GUT: No urgency, frequency, nocturia, dysuria, hematuria
Endocrine: No Heat/cold intolerance, weight change.
General Survey:
Fairly groomed with IVF of D5LR at 12gtts/min.
Vital signs:
HR= 83 bpm Temperature= 38.5°C
Integument:
Nails:
Head:
Inspection: Normocephalic skull, Black not evenly distributed hair, no infestation
Eyes:
Inspection: Symmetrical, pinkish palpebral conjunctiva, pupils equally round and reactive to light.
Ears:
Nose:
Throat and Mouth:

Inspection: Moist oral mucosa, able to purse lips, Pinkish tongue, moves freely, reddened uvula, non-
inflamed tonsils, no dysphagia.
Neck:
Chest & Lungs:

Inspection: Symmetrical chest, regular respiratory rhythm
Palpation: tender, symmetric chest expansion, no nodules nor mass.
Auscultation: rales
Heart:
Abdomen:
Extremities:
Upper:
Lower:
• With reflexes
I. PATIENTS PROFILE
Name: Albert Padul Case No: 371272

Address: Sta.Rosa Balangiga Eastern Samar Occupation: Pupil
Birthday: February 5, 1995 Birthplace: Olongapo City
Date of Admission: February 28, 2008 Time: 5PM
Father: Nicandro Padul Mother: Ma. Teresa Padul
Chief Complaint: “ Meada man nagawas ha iya talinga ngan nareklamo hiya hin kasakit.” As verbalized by the SO.
Diagnosis: T/C Brain Abscess, Chronic otitis media, AS

This is a case of Albert Padul, 13 years old, male, child, Roman Catholic, Filipino, a resident of Sta.Rosa
Balangiga Eastern Samar, was admitted for the first time in this institution due to HA and ear pain.
2 years PTA when the condition started. Patient had onset of local swelling with yellowish ear discharge
from the right ear. There was no pain, fever or any other associated symptoms. So no consult was done nor meds
taken.
2 months PTA, the above symptoms now associated with low grade fever, HA and ear pain. Patient took
Paracetamol 1 tab was given but no consult was done. Still the medicine given temporarily relieved the fever.
34 days PTA, there was increase in the swelling of the right ear which prompted the parents to sought
consult at the nearest hospital, which was the Balangiga District Hospital. Patient was admitted and stayed there for
8 days. He was given medicines but so was unable to recall. Then patient was discharged in an improved condition,
with no ear discharge, ear pain nor HA and fever.
3 days PTA, fever recurred now associated with HA. No consult done but was given Paracetamol 500mg 1
tab every 6 hours which temporary relieve the fever.
2 days PTA, at the height of the fever, patient had seizure attack. This was characterized with upward
rolling of the eyeballs and flexion and extension of both the upward and downward extremities lasted for 3 minutes.
This was associated with ptosis of the left eyelid but still no consult was done.
With the persistence of the above symptoms, sought consult at Balangiga Eastern Samar and was referred
to this institution for further evaluation and management.
III. Past History

Patient was previously hospitalized at Balangiga District Hospital in Eastern Samar due to the present
illness. He has no allergies to food or drugs. And has a positive history for cough and colds.
IV. Family History

Patient and family negates having a heredofamilial history of diseases like asthma, hypertension, diabetes
milletus and etc.
V. Maternal History
Born to a G6P6 mother with regular prenatal check up at the Barangay Health Center. With intake of
Multivitamins and FeSO4. Negated presence of illness during entire course of pregnancy.
Delivered full term, cephalic via NSVD at home. This was assisted by the hilot. There was no difficulty in
delivery with good suck and eating after birth. There was no jaundice, no cyanosis noted.
Breastfeeding was from birth until 1 year old. Then at 6 months, was given lugaw, and at 1 year old given
with rice, fish and fruits and vegetables.
With complete immunization and growth and development at par with age.
VI. Psychosocial Data

Patient and family lives in a house made of light materials with electricity and water sealed toilet located
outside the house. Source of daily water is from the public faucet abd not boiled. Garbage are disposed through
burning.
REVIEW OF SYSTEMS
General: Complains of fever, chills, fatigue but negates weight loss.

Skin: Negates rashes, pruritus, bruising and active lesion but with dryness
Head: Negates headaches, injury, tenderness, dizziness
Eyes: Negates change in visual field, glasses, contact lenses, diplopia, pain, excessive discharge, dry eyes.
Ears: Negates Change in hearing, tinnitus and dizziness. With foul smelling discharge on the right ear with
tenderness and swelling behind the ear.
Nose: Negates allergies, sinus problem, obstruction, polyps, loss of sense of smell, sneezing, epistaxis.
Throat: Negates toothaches, loose teeth, bleeding gums, mouth sores, hoarseness, dysphagia, ulcerations, lesions.
Respiratory: Negates chest pain, dyspnea, cough, hemoptysis
Cardiovascular: Negates Chest pain, pressure/ tightness, and palpitations.
GIT: Negates dysphagia, heartburn, ulcer, indigestion, diarrhea, and constipation.
GUT: Negates urgency, frequency, nocturia, dysuria, hematuria, UTI, incontinence.
Endocrine: Negates heat/cold intolerance, weight change.
Pulse Rate: 90 bpm
Temperature: 38°C
Blood Pressure: 90/50mmHg
General Survey: Fairly groomed lying on bed.
Integument:
Nails:
Inspection: Trimmed fingernails, smooth, nail plate-convex curvature
Head:
Inspection: Normocephalic skull, black evenly distributed hair, no infestation
Eyes:
Inspection: Symmetrical, glossy, pinkish palpebral conjunctiva.
Ears:
Inspection: Symmetrical, auricles aligned with the outer canthus of the eye, with foul smelling discharge at
right ear.
Palpation: with tenderness and swelling on right ear.
Nose:
Throat and Mouth:

Inspection: Moist oral mucosa, able to purse lips, whitish tongue, moves freely, reddened uvula, non-
inflamed tonsils, no dysphagia.
Neck:
Chest & Lungs:

Inspection: Symmetrical chest, regular respiratory rhythm
Heart:
Abdomen:
Inspection: Uniform color, round in shape, flat
Neurologic:
CNI: No anosmia
CN II, III: (+) papilledema, (+)ptosis of the left eyelid
CN III,IV,VI: Full EOM
CN V: (+) blink reflex
CN VII: (-) focal asymmetry
CN VIII: able to hear loud conversation

CN IX,X: (+) gag reflex
CN XI: able to shrug shoulder
CN XII: tongue at midline
(+) Brudzinki’s sign and nuchal rigidity

History..a Lot

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History..a Lot

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I.

Name: Alfredo Ortiz Perida Case No: 336059

II. History Present Illness

III. Past History

IV. Family History

VI. Social Data

I. Ultrasound Report (April 26, 2007)

Impressions: Normal chest findings.

II. Urinalysis (April 26, 2007)

Exam Result Normal Findings Significance

Exam Result Normal Values Significance

IV. Clinical Chemistry (April 26, 2007)

Exam Result Normal Values Significance

V. Hematology (April 26, 2007)

Exam Result Normal Values Significance

Name: Bernabe Rañin Petallana Sr. Case No: 336375

II. History Present Illness

III. Past History

IV. Family History

VI. Social Data

I. Urinalysis (April 30, 2007)

Exam Result Normal Findings Significance

II. Hematology (April 30 2007)

Exam Result Normal Values Significance

Name: Kimuel Carit Yobia Case No: 337033

II. History Present Illness

III. Past History

I. Ultrasound Report (May 11, 2007)

II. Abdominal Ultrasound (May 11, 2007)

III. Ultrasound Report (May 13, 2007)

IV. Urinalysis (May 10, 2007)

Exam Result Normal Findings Significance

V. Clinical Chemistry (April 26, 2007)

Exam Result Normal Values Significance

VI. Hematology (May 10, 2007)

Exam Result Normal Values Significance

VII. Hematology (May 13, 2007)

Exam Result Normal Values Significance

VIII. Hematology (May10,2007)

Exam Result Normal Values Significance

IX. Fecalysis (May 10,2007)

Exam Result Normal Values Significance

III. Past History:

VI. Social Data

Name: Menchie Militante Miranda Case No: 51527-2007

II. History Present Illness

IV. Family History

VI. Social Data

I. Ultrasound Report (June 18, 2007)

II. Urinalysis (June 18, 2007)

Exam Result Normal Findings Significance

III. Clinical Chemistry (April 26, 2007)

Exam Result Normal Values Significance

IV. Hematology (April 26, 2007)

Exam Result Normal Values Significance

II. History of Present Illness

III. Past History

VI. Social Data

M. General Health: No weight loss, no fever and chills, not diaphoretic

Date Lab Exam Result Normal Significance

I. Test: Gram’s & AFB

II. Test: Peripheral smear

Name: Ernesto Abocejo Abarientos Case No: 345123