LORMA COLLEGES

INITIAL EVALUATON

General Information:
Pts Name: C.R.W
Age: 20y/o
Sex: M
Address: Gov. Lucero St. City of San Fernando, La Union
Civil Status: Single
Handedness: Right
Occupation: N/A, Student
Referring Unit: OPD
Referring MD: Dr. C.P
Rehab MD: N/A
Date of Consultation: 10-31-16
Date of Referral: N/A
Date of IE: 11-4-16
Diagnosis: Community Acquired Pneumonia

S:
c/c: nakaka-choke yung ubo ko, tas yung lalamunan ko makati pag tuloy tuloy

yung

ubo per pt.s verbatim

PT translation: Pt. c/o choking cough & sore throat during continuous coughing.
HPI: Present condition started 12 days PTIE when Pt. experienced continuous cough.
He assumed that it is just a normal cough d/t lack of rest & stress in preparing for
their schools cheer dance competition. Pt. took Solmux 500mg capsule q 8 hrs. &
continued medication for 5 days s medical advice.
Pt. noticed severity of condition, stated that, it occurs q morning until daytime, he is
experiencing continuous cough & felt itchiness on his throat. Pt.s condition is
aggravated when exposed to sun or in too cold temperature, when in stress & doing
school academic activities such as to over analyze questions during examinations &
doing laboratory activities or experiments. After ~10min. of continuous coughing he
is experiencing SOB. Pt. drinks water to prevent coughing & stated that it took long
time to reoccur. At night, pt.s condition is less severe. He sleeps in a R sidelying
position as his comfortable position & refrains from sleeping in a supine position
because he felt difficulty on breathing.

Pt.s mother is worried on his condition

which prompted the pt. to ask for a medical advice @LMC c Dr. C.P & was
recommended to have an x-ray (see AP) c medical prescriptions given (see Present
Medication)
Pt. has min. difficulty on performing ADLs such as doing household chores d/t
irritability and easy to feel tiredness.
ANCILLARY PROCEDURES:

PROCEDURE
X-Ray (Chest PA)

DATE/PLACE
LMC/ 10-31-16

FINDINGS
(+) Bilateral Pneumonia

PRESENT MEDICATION
Name of Medicine
Azithromycin 500 mg

Indication
Anti-infectives

Dosage
1 tab once a day X 5

Sandoz
Cefixime 200 mgTercef
Zykast 5mg

Anti-bacterial
Anti-histamine

days
1 tab 2x a day x 1 wk
1 tab p dinner for 30

Fluimucil 600mg

Mucolytic

days
1 tab to glass of water

Zambon

p dinner for 7 days

PMHx: Pt. has (+) asthma,however, doesnt have any previous hx of hospitalization or
surgical intervention.
FMHx:
Pathology
HTN
DM
Heart Dse
Asthma
CA

Mother
(+)
(-)
(-)
(+)
(-)

Father
(+)
(+)
(-)
(-)
(-)

PSHx: Pt. has an active lifestyle. Pt. has no hx of any substance abuse, a non-alcoholic
beverage drinker and a non-smoker. He plays table tennis occasionally
and an

active student leader.

Pt.s condition moderately affects his psychosocial aspects such as his duty as
student leader & studies because he felt sudden tiredness, irritability

when

preparing for a school event & pt. was advised to rest early, and to refrain

from

sleeping late & to avoid stress of any kind.

Goal: Sana mawala na yung ubo ko per pts verbatim