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Date of Interview: November 5, 2010

Time of Interview: 1:40pm


Source of Information: Patient
Reliabilit: !0"
Referral: none
IDENTIFYING DATA:
RP, 22 ear# ol$, male, #in%le, farmer, Roman &at'olic, currentl re#i$in% at Sta( Rita,
Samar, a$mitte$ for t'e 2
n$
time at )*R+& la#t ,ctober 2!, 2010 at 10:55am(
&-I). &,+P/0INT: &ou%' an$ $#pnea
-IST,R1 ,. PR)S)NT I//N)SS:
1 mont' PT0, patient e2perience$ on an$ off low %ra$e fever, w'ic' u#uall occur# late
in t'e afternoon( T'i# i# accompanie$ b a non pro$uctive cou%', tri%%ere$ b 'eav wor3, an$
relieve$ b re#t( No p'le%m, no epi#ta2i#, no 'emopt#i#, no $ifficult of breat'in%, no c'ill#, no
c'e#t pain, no bo$ malai#e( No con#ultation $one, no me$ication# ta3en(
1 wee3 PT0, above #mptom# %ra$uall wor#en#, wit' a 'i%' %ra$e fever occurrin%
antime of t'e $a, an$ 'a# ta3en Paracetamol 500 m%, 1 tab PRN for fever, w'ic' provi$e$
'im temporar relief( -e al#o 'a# pro$uctive cou%', an$ e2pectorate$ about 142 t#p of w'iti#'
p'le%m per cou%'in% epi#o$e, no me$ication# ta3en to relieve cou%', but 'e claim# t'at re#tin%
relieve# it( T'i# i# not accompanie$ b epi#ta2i#, no 'empt#i#, no c'ill#, no c'e#t pain, no bo$
malai#e, no $#pnea, no ort'opnea, no cano#i#( Still,no con#ultation $one(
5 $a# PT0, con$itione$ wor#en#, wit' increa#e cou%'in% epi#o$e, w'ic' u#uall
e2acerbate# late in t'e afternoon, wit' bloo$ tin%e$ e2pectorate, #till amountin% to 142 t#p(
.ever #till per#i#t#, w'ic' wa# relieve$ b Paracetamol( -e al#o complain# of $ifficult #leepin%
at ni%'t $ue to $#pnea, an$ 'a# to u#e 245 pillow#( -e al#o e2perience$ c'e#t pain #peciall
$urin% cou%'in% epi#o$e#, an$ i# relieve$ b re#t( No me$ication# ta3en for relief of cou%' an$
c'e#t pain( No bo$ malai#e, no cano#i#, an$ no con#ultation $one(
1 $a PT0, $ue to per#i#tence of above #mptom#, 'e #ee3 con#ult# at ,P Department
of )*R+&, w'ere 'e wa# a$vi#e$ to $o a c'e#t 2ra( -e eventuall %ot 'i# c'e#t 2rae$ at St(
Paul# -o#pital(
-our# PT0, upon pre#entation of c'e#t 2ra re#ult at t'e )*R+& ,PD, 'e wa# t'en
a$vi#e$ for a$mi##ion, 'ence a$mitte$(
P0ST +)DI&0/ -IST,R1
&'il$'oo$ illne##: no immuni6ation, 'a$ mump# at ! ear# ol$, an$ mea#le# at 10 ear# ol$, no
c'ic3en po2, no primar comple2, no polio, no ot'er #i%nificant illne## $urin% c'il$'oo$(
+e$ical: 1
#t
'o#pitali6ation at )*R+& $ue to pneumonia, at unrecalle$ a%e, time, an$ ear
'o#pitali6ation(
Sur%ical: no #ur%ical proce$ure $one
P#c'iatric: none
No 3nown aller%ie#
.0+I/1 -IST,R1:
Patient i# t'e oun%e#t of t'e broo$ of 10
0ll #iblin%# are alive an$ apparentl well
Patient# mot'er, 72 ear# ol$, i# apparentl well
Patient# fat'er, 75 ear# ol$, complain# of occa#ional bac3 pain, an$ mu#cle pain
Patient# %ran$parent# 'a# a famil 'i#tor of ulcer#(
No 'i#tor of 'perten#ion, no $iabete#, no e2po#ure to T8, no p#c'iatric $i#or$er#, no
neopla#m#, no car$iac an$ pulmonar problem#, no 'epatic problem#(
PS1&-,S,&I0/ -IST,R1:
Patient wa# born an$ rai#e$ in Sta( Rita, Samar( -e fini#'e$ 5
r$
ear 'i%' #c'ool( -e i#
currentl re#i$in% in a 2 roome$ bamboo 'ou#e, wit' 5 ot'er people( -e $e#cribe$ t'i# a#
a$e9uatel #pace$ for all of t'em( T'e 'ave t'eir own electric connection, an$ a $eep well
w'ic' #erve# a# t'eir primar water #ource( T'e u#e woo$ an$ c'arcoal in coo3in%( T'e $on:t
'ave t'eir own comfort room, t'e $i#po#e t'eir wa#te anw'ere(
-er u#ual $iet inclu$e# rice, fi#' an$ ve%etable# an$ t'ere i# no e2ce##ive inta3e
of fatt foo$#( S'e u#uall con#ume# about !410 %la##e# of water per $a an$ u#e$ to
$rin3 coffee $urin% brea3fa#t( T'ere i# no re%ular e2erci#e an$ con#i$er# 'ou#e'ol$
c'ore# a# 'er $ail e2erci#e(
-e #tart# #mo3in% at t'e a%e of 15 ear# ol$, an$ u#uall con#ume# a pac3 a ci%arette
per $a( -e al#o $rin3# occa#ionall wit' frien$#(
-e i# not a member of an or%ani6ation# in t'eir place( -e $oe# not u#uall atten$ ma##
on Sun$a#(
REVIEW OF SYSTEMS
General Survey: 'e lo#t aroun$ 7 3ilo# from 'i# u#ual wei%'t of 57 3ilo# to 50 3ilo#, no
wea3ne##, no fati%ue, febrile
Skin: no noticeable c'an%e in #3in color, no lump#, no #ore#, no itc'in%, no $rne##,
no c'an%e# in 'air or nail#
Head: no 'ea$ac'e, no $i66ine##, no li%'t'ea$e$ne##
Eyes: no pain, no itc'in%, no re$ne##, no e2ce##ive tearin%, no blurr of vi#ion, no
$iplopia
Ears: no tinnitu#, no verti%o, no earac'e, no 'earin% impairment, no ear $i#c'ar%e#
Nose: no col$#, no na#al con%e#tion, no na#al #tuffine##, no itc'in%, no epi#ta2i#
Troa! and Mou!: complete #et of teet', no $enture#, no blee$in% %um#, no cavitie#
nor toot'ac'e, no #ore ton%ue, no $r mout', no #ore t'roat, no 'oar#ene## of voice
Ne"k: no lump#, no pain, no #tiffne##, no limitation of movement
#reas!: no lump#, no pain or $i#comfort, no $i#c'ar%e#
Res$ira!ory: wit' cou%', ort'opneic wit' 5 pillow#, wit' $#pnea, no w'ee6in%, wit'
'emopt#i#
%ardiovas"ular: no 'perten#ion, no 'eartburn#, wit' ort'opnea, wit' c'e#t pain, no
palpitation#, no paro2#mal nocturnal $#pnea
Gas!roin!es!inal: no lo## of appetite, no nau#ea an$ vomitin%, no $#p'a%ia, no
'emateme#i#, no in$i%e#tion, no 'eartburn#, no colic, $efecate# once a $a to a forme$
ellow #tool, no con#tipation, no $iarr'ea, no rectal blee$in%, , no melena,no
'ematoc'e6ia, no pa##in% of %a#
&rinary: urine output about 1 cup per urination 4 time# a $a, no poluria, no ur%enc,
no $ribblin%, no 'e#itanc, no nocturia, no incontinence, no burnin% or pain on urination,
no 'ematuria, no flan3 pain
Geni!al: no itc'in%, no $i#comfort, no penile $i#c'ar%e
'eri$eral Vas"ular: no le% cramp#, no intermittent clau$ication, no color c'an%e in
fin%er tip# an$ toe#
Mus"uloskele!al: no wea3ne##, no fati%abilit, no art'ral%ia, no mal%ia, no #tiffne##,
no art'riti#, no %out, no bac3ac'e, no limitation of motion
'sy"ia!ri": no $epre##ion, no moo$ #win%#, no ten#ion, no nervou#ne##, no #leep
wal3in%, no #leep tal3in%
Neurolo(i": no memor lap#e#, no $i66ine##, no verti%o, wit' faintin%, no blac3out#,
no tin%lin% #en#ation, no tremor# or ot'er involuntar movement#, no motor an$ #en#or
lo##
He)a!olo(i": no ea# brui#in%, no blee$in% %um#, no epi#ta2i#, wit' 'emopt#i#, no
'emateme#i#, no melena, no 'ematoc'e6ia, no pallor
Endo"rine: no t'roi$ trouble, no pol$ip#ia, no polp'a%ia, no poluria, no col$
intolerance, no 'eat intolerance, no e2ce##ive t'ir#t, no fine 'an$ tremor
'HYSI%A* E+AMINATION
General Survey
0$mitte$ a con#ciou#, co'erent an$ ambulator patient, ae#t'enic, an$ well
$evelope$( ;it' normal wa3in% %ait, afebrile, not in re#pirator $i#tre##an$ 'a# t'e
followin% vital #i%n#:
T< 5! P< =0 bpm R< 2! bpm 8P< 120>?0 mm-%, 'ei%'t < 5:4:: wei%'t< 50 3ilo#
In!e(u)en!
S3in: warm #3in, wit' %oo$ #3in tur%or, wit' ab#ence of le#ion# an$ ra#'e#(
Nail#: Nail# are t'ic3, no cano#i#, wit' capillar refill of 5 #econ$# on blanc' te#t( T'ere
i# no clubbin%, no #poonin%, no brea3#, an$ no ri$%e# of t'e nail#(
-air: Dr, t'ic3, evenl $i#tribute$ 'air(
Head
Scalp: T'ere i# no le#ion#, no no$ule#, no #eborr'eic $ermatiti#, no vein en%or%ement,
an$ no ten$erne##(
S3ull: normocep'alic wit' #mmetric an$ #moot' #3ull contour#( T'ere i# ab#ence of
no$ule# or ma##e#(
Eyes
Sclera i# anicteric, wit' pale con@unctiva, pupil# e9uall roun$ an$ reactive to li%'t an$
accommo$ation, wit' #mmetrical eebrow#, e9ual in movement an$ no le#ion, eeli$
'a# no $i#c'ar%e# an$ $i#coloration, li$# clo#e #mmetricall, no li$ la%, no #t, no
pto#i#, no ectropion, no intropionA cornea 'a# no opacitie# an$ 'emorr'a%eA wit' ),+
intact an$ full movement
Ears
)ar# are #mmetrical an$ t'e auricle are ali%ne$ wit' t'e outer cant'u# of t'e ee#(
0c9uit of 'earin% i# %oo$ to normal voice(
Nose
No#e are #mmetrical an$ #trai%'t wit' t'e #eptum intact an$ at t'e mi$line( T'ere i# no
$i#c'ar%e#, flarin%, ten$erne##, an$ le#ion#( Na#al muco#a i# pale pin3 an$ na#al
#inu#e# are non4ten$er(
Mou! and !roa!
no pallor, no cano#i#, no w'ite patc'e#, no $rne##, no e2ce##ive blee$in%, no
%in%iviti#, no inflame$ ton#il#, wit' uvula at t'e mi$lineA no le#ion#A wit' complete #et of
teet'(
Ne"k
no unilateral #wellin%, no #car#, no #tiffne##, wit' no limitation of movement, no
$i#comfort,
-ea$ movement i# coor$inate$, #moot', wit' no $i#comfort( Trac'ea locate$ in t'e
mi$line( Nec3 i# #uppleA t'roi$ i#t'mu# palpable, lobe# not felt(
*y)$ nodes
/mp' no$e# not enlar%e$( Small, #oft, nonten$er, an$ mobile ton#illar an$ po#terior
cervical no$e# bilaterall(
Tora, and lun(s
&'e#t are #mmetric( Spine i# verticall ali%ne$( Re#piration i# 9uiet, an$
effortle## wit'out t'e u#e of acce##or mu#cle#( &'e#t wall i# intact wit' no ten$erne##
an$ no ma##e#( .ull an$ #mmetric c'e#t e2pan#ion( 8ilateral #mmetr of tactile
fremitu#( 8reat' #oun$# are ve#icular wit' ab#ence of crac3le#, r'onc'i, w'ee6e# rale#,
an$ pleural friction rub(
;it' e%op'on on t'e leftlowe un% firle#$
&v: