UNIVERSITY OF PERPETUAL HELP-DR. JOSE G.

TAMAYO MEDICAL CENTER

Sto Nino, Binan City, Laguna

DEPARTMENT OF INTERNAL MEDICINE

24 Hour History
GENERAL DATA:
This is a case of Jamela Edgardo, 55 year old, male , Filipino, Currently residing in
Blk 69,lot 52 PH 1, SU5A, Brgy. Lang Kiwa,Binan,Laguna, admitted in our institution on 23
September, 2017.

CHIEF COMPLAINT:
Left sided weakness.

HISTORY OF PRESENT ILLNESS

1.5 hours prior to consult, patient was watching TV with his wife while lying down in his
sofa. Patient suddenly stopped talking and sat down and had hard time talking. The
relatives tried giving water to the patient but the patient couldn't able to drink the water.
Left sided body weakness was noted and patient was taken to the hospital and while on
transport, patient allegedly had a seizure with the stiffening of the right side of body and
drooling of saliva for 30 mins. Patient was taken in our institute for further evaluation and
management.

PAST MEDICAL HISTORY:

(-) HPN
(-) DM
(-) Bronchial asthma
(-) COPD
(-) Allergy
(-) Childhood diseases
Others:
FAMILY HISTORY
(-) PTB (-) diabetes mellitus
(+) hypertension:mother (-) CVD
(-) cancer (-) Kidney disease
(-) bronchial asthma (-) heart disease

PERSONAL AND SOCIAL HISTORY

Patient is a non-smoker and non alcoholic drinker, with no history of allergy to food and
drugs.

REVIEW OF SYSTEM
CNS: (-) loss of consciousness (-) headache (-) dizziness
INTEGUMENTARY: (-) pruritus
RESPIRATORY: (-) hemoptysis, (-) dyspnea, (-) DOB
CVS: (-) chest pain/discomfort, (-) palpitations, (-) orthopnea, (-) paroxysmal nocturnal
dyspnea
GIT: (-) heart burn, (-) decrease appetite, (-) nausea, (-) vomiting, (-) bowel movement, (-
) change in bowel habits, (-) melena, (-) change in color of stool,
GUT: (-) polyuria, (-) oliguria (-) nocturia, (-) urgency, (+) dysuria, (-) hematuria, (-)
incontinence
MUSCULOSKELETAL: (-) limitation in movement
HEMATOLOGIC: (-) easy bruising, (-) bleeding of the hemangioma
PHYSICAL EXAMINATION:
General Survey: conscious, coherent, not in cardiorespiratory distress
Vital Signs:
BP: 110/70 mmHg PR: 67bpm RR: 22cpm Temp: 36.10C
Skin: Warm to touch, senile skin turgor, (-) rashes, (-) Active dermatomes
HEENT: No deformities, no masses, no facial edema, anicteric sclera, pink palpebral
conjunctivae, no nasoaural discharge, no tonsillopharyngeal congestion, no cervical
lymphadenopathy,
Chest/Lungs: Symmetrical chest expansion, no retraction, (+)crackles
Heart: Adynamic precordium, no thrills, no heaves, normal rate, regular rhythm, no murmur
Abdomen: Flabby, normoactive bowel sound, (-) abdominal tenderness
Extremities: No gross deformities, full and equal pulses, (-) cyanosis, (-) edema
Neurologic Exam:
Cerebrum: oriented to time place and person
CN I – not assessed
CN II – 2-3 mm reactive to light stimulation
CN III, IV, VI – intact extraocular muscle
CN V – can clench teeth
CN VII – no facial asymmetry
CN VIII – can hear
CN IX, X – can swallow
CN XI – can shrug shoulder
CN XII – tongue at the midline

Admitting diagnosis: Community Acquired Pneumonia -Moderate Risk,

Hypertension,HCVD

ASSESSMENT:
PLAN
➢ Diet: low salt,low fat,renal diet with high biologic value protein
➢ IVF: PNSS 1L×40 CC/hour
MEDICATIONS:
Ceftriaxone 1 gm IV Quh
Paracetamol 500 mg 1 tab Quh
Azithromycin 500 mg 1 tab OD for 3 days
N-Acetyl Cysteine 600 mg/200 mg in 75 ml water
Ipratropium+Fenoterol(Berodual)nebulizer 2 inhalations QID
Telmisartan 80mg/tab ,1 tab OD
Verapmil 240 mg/tab,1 tab OD
Clopidogrel 75 mg/tab,1 tab OD

JI HAKKAPAKKI SANGEETHA
IM CLERK IN CHARGE