• Case No. 2
General Data:
• G.E., 53 year old, Female, Married, Employed, Filipino, Roman Catholic, Born
on February 11, 1963 at Romblon, Currently residing at ALL 85 Blk 4 Gk Sitio
Pajo, Baesa, Quezon City, Consulted for the first time in our institution last
April, 18, 2017
Chief Complaint:
• Chest Pain
Family History
• (+) Asthma (maternal side)
• No other family history of heredofamilial diseases such as hypertension,
diabetes, goiter, or malignancies
• No family history of communicable diseases such as PTB or pneumonia
OB-Gyne History
• Menarche: 16 years old
• Interval: regular (28-30 days)
• Duration: 3 days
• Amount: 4 pads a day (moderately soaked)
• Symptoms: Dysmenorrhea
• Menopause: 46 years old
Obstetrical Score
• G4P4
– G1: 1990 – NSD (Jose Reyes Hospital)
– G2: 1992 – NSD (house delivery)
– G3: 1994 – NSD (house delivery)
– G4: 1996 – NSD (house delivery)
Review of Systems
• General
o No weight loss, no weight gain, no fever, no chills, no fatigue, no
insomnia, no loss of appetite, no night sweats
• Skin
o No color changes, no sores, no rashes, no itching, no scaling, no
bleeding
• Head
o No headache, no trauma, no stiffness
• Eyes
o No eye pain, no diplopia, no itch, with blurring of vision, no dryness,
no redness
• Ears
o No ear pain, no tinnitus
• Nose
o No colds, no nasal bleeding, no dryness, no nasal discharge, no nasal
pain, no sneezing
• Mouth
o No bleeding gums, no soreness, no ulcers, no hoarseness
• Cardiovascular
o No chest pain, no dyspnea, no PND, no orthopnea, no palpitations
• Gastrointestinal
o No anorexia, no dysphagia, no hematemesis, no nausea, no vomiting,
no hematochezia, no melena, no diarrhea
• Genitourinary
o No dysuria, no hematuria, no nocturia, no retention, no incontinence,
no frequency, no urgency, no discharge
• Musculoskeletal
o No pain, no weakness, no tenderness, no cramps, no trauma, no joint
pain, no backache, no stiffness
• Endocrine
o No polyuria, no polydipsia, no polyphagia, no cold intolerance, no heat
intolerance
• Hematologic
o No pallor, no easy bruising
• Nervous
o No syncope, no seizures, no dizziness, no tremor
Physical Examination
• Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress
• Vital signs:
o BP: 140/80 mmHg
o PR: 90 bpm
o RR: 20 cpm
o T: 36.8 C
• SKIN: Brown, no lesions, no masses, soft, warm to the touch
• HEENT: Anicteric sclera, pink palpebral conjunctiva, no nasoaural discharge,
no tonsillopharyngeal congestion, no cervical lymphadenopathy
• CHEST AND LUNGS: Symmetrical chest expansion, no retraction, no lagging,
clear breath sounds, (+) pain on right side of chest upon palpation.
• HEART: Adynamic precordium, normal rate, regular rhythm, no murmurs
• ABDOMEN: Flat abdomen, normoactive bowel sounds, soft, (+) tenderness
on the right upper quadrant
• EXTREMITIES: Grossly normal extremities, no deformities, no cyanosis, no
pallor, no edema
Clinical Impression
• T/C musculoskeletal strain;
• R/O fracture
• R/O IHD
Plan
• For Chest x-ray – PA view
• For 12L ECG
• Start
• Eperisone 50mg, 1 tablet TID for 4 days
• Celecoxib 200mg, 1 tab BID for 4 days then as needed for pain
• Vitamin B complex, 1 tablet before bedtime
• Avoid lifting heavy objects
• Proper body mechanics
• Avoid pressure manipulation
• Follow-up on 4/21/2017 with results
Subjective:
(+) chest pain
(+) shortness of breath
(+) night sweats
(-) night fever
(+) orthopnea
(+) nonproductive cough
(-) colds
(+) easy fatigability
(-) dysphagia
Patient verbalized change in voice character
Assessment:
CAP-MR
Plan:
• Start
– Azithromycin 500mg/tab, 1 tab OD for 3 days
– Co-Amoxiclav 625mg/tab, 1 tab TID for 7 days
– Erdosteine 300mg/cap, 1 cap BID for 5 days
– Multivitamins tab, 1 tab OD
• Continue
– Vitamin B complex tab, 1 tab at bedtime
• Increase oral fluid intake
• Therapeutic lifestyle changes
• To come back after 3 days
Subjective:
• (+) slight shortness of breath
• (+) loss of appetite
• (+) intermittent cough, non-productive
• (+) easy fatigability
• (-) chest pain
• (-) orthopnea
• (-) fever
Objective:
• Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress
• Vital signs:
– BP: 130/70 mmHg
– PR: 110 bpm
– RR: 25 cpm
– T: 36.6 C
– O2: 98%
• SKIN: Brown, no lesions, no masses, soft, warm to the touch
• HEENT: Anicteric sclera, pale palpebral conjunctiva, no nasoaural discharge,
no tonsillopharyngeal congestion, no cervical lymphadenopathy
• CHEST AND LUNGS: Symmetrical chest expansion, elevated mass, firm,
nontender, erythematous, on the sternal area above right sternal area,
tender, erythematous, decreased breath sounds on right posterior lung field
no retraction, no lagging,
• HEART: Adynamic precordium, tachycardic, regular rhythm, no murmurs
• ABDOMEN: Flat abdomen, normoactive bowel sounds, soft, non-tender
• EXTREMITIES: Grossly normal extremities, no deformities, no cyanosis, no
pallor, no edema
Assessment:
• CAP-MR: resolving
• Hypertension St. II
Plan
• Continue
– Co-Amoxiclav 625mg/tab, 1 tab TID for 4 more days
– Erdosteine 300mg/cap, 1 cap BID for 2 more days
– Multivitamins tab, 1 tab OD
– Vitamin B complex tab, 1 tab OD
• Shift
– Amlodipine 5mg/tab, 1 tab OD to metoprolol 50mg/tab, 1 tab OD
• Daily BP measuring
• Increase oral fluid intake
• Therapeutic lifestyle changes
• To come back after 3 days (April 27, 2017)
Subjective:
• (+) shortness of breath (improved)
• (+) appetite improvement
• (+) cough, non-productive
• (-) chest pain
• (-) orthopnea
• (-) fever
• (+) PND – 2 nights
Objective:
• Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress
• Vital signs:
– BP: 120/70 mmHg
– PR: 112 bpm
– RR: 23 cpm
– T: 36.8 C
– O2: 97%
• SKIN: Brown, no lesions, no masses, soft, warm to the touch
• HEENT: Anicteric sclera, slightly pale palpebral conjunctiva, no nasoaural
discharge, no tonsillopharyngeal congestion, no cervical lymphadenopathy
• CHEST AND LUNGS: Symmetrical chest expansion, decreased breath sounds
on right posterior lung field, no retraction, no lagging,
• HEART: Adynamic precordium, tachycardic, regular rhythm, no murmurs
• ABDOMEN: Flat abdomen, normoactive bowel sounds, soft, non-tender
• EXTREMITIES: Grossly normal extremities, no deformities, no cyanosis, no
pallor, no edema, full equal pulses
Assessment:
• Hypertension St. II – controlled
• R/O IHD
• CAP-MR – resolving
• STR (soft tissue rheumatism)
Plan
• For 2D-Echo
• For creatinine, RBS, SQPT, SGOT, Sodium, potassium, lipid profile
• Continue:
– Metoprolol 50mg/tab, 1 tab OD
– Vitamin B complex tab, 1 tab OD
– Multivitamins tab, 1 tab OD
• Start:
– Celecoxib 200mg/tab 1 tab BID for pain
• Increase oral fluid intake
• Daily blood pressure monitoring
• Therapeutic lifestyle changes
• Follow up after 5 days (05/02/17) with results
Subjective:
• (+) difficulty of breathing (improved)
• (+) cough – productive, whitish
• (+) chest pain (when coughing)
• (-) orthopnea
• (-) fever
• (+) PND – 5 nights
• (+) foot pain – right side
Objective:
• Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress
• Vital signs:
– BP: 110/80 mmHg
– PR: 89 bpm
– RR: 19 cpm
– T: 36.8 C
– O2: 96%
• SKIN: Brown, no lesions, no masses, soft, warm to the touch
• HEENT: Anicteric sclera, slightly pale palpebral conjunctiva, no nasoaural
discharge, no tonsillopharyngeal congestion, no cervical lymphadenopathy
• CHEST AND LUNGS: Symmetrical chest expansion, decreased breath sounds
on right posterior lung field, no retraction, no lagging,
• HEART: Adynamic precordium, normal rate, regular rhythm, no murmurs
• ABDOMEN: Flat abdomen, normoactive bowel sounds, soft, non-tender
• EXTREMITIES: Grossly normal extremities, no deformities, no cyanosis, no
pallor, no edema, full equal pulses
Assessment
• Diabetes Mellitus type II, uncontrolled
• Hypertension Stage II, controlled
Plan
• For referral to IM-OPD for further Evaluation and management of Diabetes
Mellitus type II, uncontrolled
• Suggest insulin
• Back to FM for final disposition
Subjective:
• (+) Productive cough – whitish
• (+) Chest pain (while coughing)
• (+) Difficulty of breathing (intermittent & improved)
• (-) Fever
• (-) Back pain
Clinical Chemistry:
Parameters Results Reference
BUN 3.0 mmol/L 1.7 – 8.3
Creatinine 78 umol/L 53 – 115
HBAIC 11.8% 4.2 – 6.2%
Sodium 130.7 mmol/L 135 – 148
Potassium 4.38 mmol/L 3.50 – 5.30
Objective:
• Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress
• Vital signs:
– BP: 140/80 mmHg
– PR: 90 bpm
– RR: 20 cpm
– T: 36.6 C
• SKIN: Brown, no lesions, no masses, soft, warm to the touch
• HEENT: Anicteric sclera, pink palpebral conjunctiva, no nasoaural discharge,
no tonsillopharyngeal congestion, no cervical lymphadenopathy
• CHEST AND LUNGS: Symmetrical chest expansion, decreased breath sounds
on right lung field, no retraction, no lagging,
• HEART: Adynamic precordium, normal rate, regular rhythm, no murmurs
• ABDOMEN: Flat abdomen, normoactive bowel sounds, soft, non-tender
• EXTREMITIES: Grossly normal extremities, no deformities, no cyanosis, no
pallor, no edema, full equal pulses
Assessment:
• CAP-MR
• DM Type II, uncontrolled
• Hypertension Stage II, controlled
Plan
• For chest x-ray PA view
• For observation while awaiting lab results
Assessment:
• CAP-MR
• PTB clinically diagnosed
• DM Type II, uncontrolled
• Hypertension Stage II, controlled
Plan
• Still for 2D echo
• For DSSM
• Start
– Sultamicillin 750mg/tab, 1 tab BID for 7 days
– Cefuroxime 500 mg/tab, 1 tab BID for 7 days
• Continue
– Metoprolol 50mg/tab, 1 tab OD
– Insuman 70/30 15 “u” OD before breakfast
• Increase oral fluid intake
• Respiratory etiquette
• Therapeutic lifestyle changes
• Follow up after 5 days with lab results
Subjective:
• (+) productive cough – whitish
• (-) chest pain
• (-) dyspnea
• (-) fever
• (-) back pain
Objective:
• Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress
• Vital signs:
– BP: 120/80 mmHg
– PR: 88 bpm
– RR: 18 cpm
– T: 36.9 C
• Progress Notes: 05/19/17
• SKIN: Brown, no lesions, no masses, soft, warm to the touch
• HEENT: Anicteric sclera, pale palpebral conjunctiva, no nasoaural discharge,
no tonsillopharyngeal congestion, no cervical lymphadenopathy
• CHEST AND LUNGS: Symmetrical chest expansion, decreased breath sounds
on right lung field, no retraction, no lagging, (+) crackles, right middle to base
of lung
• HEART: Adynamic precordium, normal rate, regular rhythm, no murmurs
• ABDOMEN: Flat abdomen, normoactive bowel sounds, soft, non-tender
• EXTREMITIES: Grossly normal extremities, no deformities, no cyanosis, no
pallor, no edema, full equal pulses
Assessment:
• PTB clinically diagnosed
• DM Type II
• Hypertension St. II controlled
Plan:
• Still for 2D Echo
• For repeat FBS, Creatinine
• Start:
– Clarithromycin 500mg/tab Q12 for 7 days
– Endostein 300mg/cap BID for 5 days
– Multivitamins + minerals 1 tab OD
• Continue
– Insuman 70/30 15 “u” OD before breakfast
• Therapeutic lifestyle changes
• For referral to TB DOTS for evaluation and management
• Follow up after 4 days (05/23/17)
Subjective:
• (+) productive cough – whitish
• (-) chest pain
• (-) dyspnea
• (-) abdominal pain
• (-) back pain
Objective:
• Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress
• Vital signs:
– BP: 130/80 mmHg
– PR: 94 bpm
– RR: 19 cpm
– T: 36.9 C
• SKIN: Brown, no lesions, no masses, soft, warm to the touch
• HEENT: Anicteric sclera, pale palpebral conjunctiva, no nasoaural discharge,
no tonsillopharyngeal congestion, no cervical lymphadenopathy
• CHEST AND LUNGS: Symmetrical chest expansion, decreased breath sounds
on right lung field, no retraction, no lagging,
• Progress Notes: 05/23/17
• HEART: Adynamic precordium, normal rate, regular rhythm, no murmurs
• ABDOMEN: Flat abdomen, normoactive bowel sounds, soft, non-tender
• EXTREMITIES: Grossly normal extremities, no deformities, no cyanosis, no
pallor, no edema, full equal pulses
Assessment:
• PTB clinically diagnosed
• DM Type II, uncontrolled
• Hypertension St. II - controlled
Plan:
• Still for 2D Echo
• Still for repeat FBS, Creatinine
• Continue present meds
• Still for referral to TB DOTS for evaluation and management
Salient Features
• Chief Complaint: Chest pain
• HPI
– Fever (undocumented)
– Shortness of breath/difficulty of breathing
– Headache,
– Weakness,
– Dysphagia
• Progress notes: subjective
– Night sweats
– Orthopnea
– Cough
– Easy fatigability
– PND (5 nights)
• Comorbidities
– Hypertensive (2015) – controlled
– Diabetes mellitus type II
• Family history:
– (+) Asthma (maternal side)
• Physical Examination
– Tachycardic (112bpm)
– Tachypneic (23cpm)
– Decreased breath sounds, right posterior lung field
– (+) crackles, right middle to base of lung