Patient Subjective/Objective Diagnosis Treatment Plan

M. H. E. HPI: Peridontal Clindamycin

5 year/Male/Child 4 days PTC, patient had undocumented fever and was given paracetamol 1 Abscess 75mg/5ml, 5ml QID
Brgy. Bagay, Igbaras teaspoon TID, which offered slight relief of fever. Paracetamol
1 day PTC, patient's left side of the face swelled, no medications were 250mg/5ml, 3 ml
CC: Swelling of the Left given. Swelling of face prompted consult PRN for pain and
side of face PE: fever T>37.8
>General Appearance: awake, fairly developed, fairly nourished, in pain, Refer to Dental
not in CP distress Service
>Head and Neck: closed ant fontanel, anicteric sclera, pink conjunctiva, (+) Proper Oral Hygiene
warm, tender, swelling of the left side of face, (+) dental caries (-) ear Avoid sweet food
discharge, (-) tragal tenderness, patent nasal passages, (-) Advised
tonsillopharyngeal congestion, (-) cervical lymphadenopathy
>Chest and Lungs: equal chest expansion, clear breath sounds, (-) rales,
wheezes
>Cardiovascular System: distinct heart sounds, normal rate regular rhythm,
(-) murmur
>Abdomen: protuberant, normoactive bowel sounds, nontender, (-)
hepatosplenomegaly
>Extremities: (-) edema, (-) cyanosis, (+) excoriation scars

P. N. HPI: Acute tubulo- Ciprofloxacin 500

47 year old 2 days PTC, patient had undocumented fever accompanied by chills, flank interstitial mg/tab, 1 tab BID for
/Female/Married pain, and dizziness. nephritis (ACUTE 7 days
Brgy. Tigbanaba, PYELONEPHRITIS) Paracetamol 500
Igbaras Patient took Paracetamol 500 mg tab for fever which offered relief. mg/tab, 1 tabQ4H for
PE: Fever T>37.8
CC: Fever with chills >General Appearance: awake,ambulatory, (-) cardiorespiratory distress Increase Fluid Intake
>Head and Neck: anicteric sclera, pink conjunctivae, (-) tonsillopharyngeal To come back 1 week
congestion, (-) cervical lymphadenopathy, (-) neck vein engorgement, (-) after
anterior neck mass, (-) discharge Advised
>Chest and Lungs: equal chest expansion, clear breath sounds, (-) rales, (-)
wheezes
 >Cardiovascular System: distinct heart sounds, normal rate regular rhythm,
(-) murmurs, point of maximal impulse 5th intercostal space, left
midclavicular line
>Abdomen: flabby, normoactive bowel sounds, nontender, (-)
hepatosplenomegaly (+) Goldflamm sign (Left Side Flank Tenderness)
>Extremities: pink nailbeds, (-) edema, (-) cyanosis

J. B. E. HPI: Pediatric Amoxicillin

4years/M/Child 3 days PTC, patient had productive cough accompanied by fever of 38 Community 250mg/5ml, 4ml TID
Brgy. degrees celcius and difficulty of breathing which persisted to day of consult, Acquired for 7 days
Pinaoawan,Igbaras was given Paracetamol (Tempra) q4h if with fever which provided slight Pneumonia -A Zinc syrup 5ml once a
CC: cough for 3 days relief. day
PE: Increase fluid intake
>General Appearance: awake, fairly developed, fairly nourished advised
>Head and Neck: anicteric sclera, pink conjunctiva, (-) ear discharge, (-)
tragal tenderness, patent nasal passages, (-) tonsillopharyngeal congestion,
(-) cervical lymphadenopathy (-) alar flaring
>Chest and Lungs: equal chest expansion, (+) crackles
>Cardiovascular System: distinct heart sounds, normal rate regular rhythm,
(-) murmur
>Abdomen: protuberant, normoactive bowel sounds, nontender, (-)
hepatosplenomegaly
>Extremities: (-) edema, (-) cyanosis
K. S. E. HPI: Dyspepsia Metoclopramide 10
7 year old /Male/Child 4 hours PTC, patient had projectile vomiting 3 times approximately 500ml in mg/tab 1 tab OD as
Brgy.Lutungan, Igbaras volume of previously eaten food accompanied by feeling of bloatedness need for nausea and
CC: VOMIT 3X THIS DAY and burning epigastric pain. vomiting
PE: Oral Rehydrating
>General Appearance: awake, fairly developed, fairly nourished Solution 1L to
>Head and Neck: anicteric sclera, pale conjunctiva, (-) ear discharge, (-) consume within four
tragal tenderness, patent nasal passages, (-) tonsillopharyngeal congestion, hours
(-) cervical lymphadenopathy Advised
>Chest and Lungs: equal chest expansion, clear breath sounds, (-) rales,
wheezes
 >Cardiovascular System: distinct heart sounds, normal rate regular rhythm,
(-) murmur
>Abdomen: protuberant, normoactive bowel sounds, nontender, (-)
hepatosplenomegaly
>Extremities: (-) edema, (-) cyanosis, full pulses, CRT <2 sec
L. T. HPI: OSTEOARTHRITIS Mefenamic Acid
73y/Female/Widowed 3 months PTC, patient started to have knee pains aggravated by walking 500mg/tab, 1 tab
Brgy. Jovellar, Igbaras and standing for long periods and alleviated by resting. every 8 hours for 5
CC; 1 week PTC, patient was given Paracetamol 500 mg, 1 tab OD for pain but days
pain on both knee did not provide relief of pain. Thus this consult warm compress TID
PE rest from work
>General Appearance: awake,ambulatory, (-) cardiorespiratory distress advised
>Head and Neck: anicteric sclera, pink conjunctivae, (-) tonsillopharyngeal
congestion, (-) cervical lymphadenopathy, (-) neck vein engorgement, (-)
anterior neck mass, (-) discharge
>Chest and Lungs: equal chest expansion, clear breath sounds, (-) rales, (-)
wheezes
>Cardiovascular System: distinct heart sounds, normal rate regular rhythm,
(-) murmurs, point of maximal impulse 5th intercostal space, left
midclavicular line
>Abdomen: flabby, normoactive bowel sounds, nontender, (-)
hepatosplenomegaly
>Extremities: pink nailbeds, (-) edema, (-) cyanosis, non-erythemaous, non-
tender, non-swelling knee joint
C. A. D. C. HPI: Allergic Cough Salbutamol
1year 7 2 days PTC, patient had runny nose which developed into productive cough 100mcg/inhalation
mons/male/child with whitish-yellowish in color. nebule, 1 neb TID for
Brgy.2 Poblacion, 1 day PTC, patient was given Salbutamol TID and Paracetamol BID 3 days
Igbaras PE Lagundi Leaf syrup,
>General Appearance: asleep, fairly developed, fairly nourished 2ml TID for 5 days
CC:COUGH X 3 DAYS >Head and Neck: closed ant fontanelle, anicteric sclera, pink conjunctiva, (-) Cetirizine 2.5mg/5ml,
ear discharge, (-) tragal tenderness, patent nasal passages, (-) 5ml ODHS for 3 days
tonsillopharyngeal congestion, (-) cervical lymphadenopathy Continue vitamin
supplementation
 >Chest and Lungs: equal chest expansion, clear breath sounds, (-) rales,
wheezes
>Cardiovascular System: distinct heart sounds, normal rate regular rhythm,
(-) murmur
>Abdomen: protuberant, normoactive bowel sounds, nontender, (-)
hepatosplenomegaly
>Extremities: (-) edema, (-) cyanosis
M. E. Q. HPI: Acute upper Cetirizine 2.5mg/5ml,
1year3mons/male/child 2 days PTC, patient had clear nasal cattarh which develop into respiratory 4.5 ml ODHS for 3
Brgy.Signe, Igbaras nonproductive cough was given Cetirizine 1ml ODHS for 3 days infection, days
CC:COUGH X 2 DAYS PE: unspecified Ambroxol 50mg/ml,
RUNNY NOSE >General Appearance: awake, fairly developed, fairly nourished (Acute Upper 2.5 ml BID for 5 days
>Head and Neck: anicteric sclera, pink conjunctiva, (-) ear discharge, (-) Respiratory Tract Multivitamins syrup,
tragal tenderness, patent nasal passages, (-) tonsillopharyngeal congestion, Infection, VIRAL) 5ml OD
(-) cervical lymphadenopathy Advised
>Chest and Lungs: equal chest expansion, clear breath sounds, (-) rales,
wheezes
>Cardiovascular System: distinct heart sounds, normal rate regular rhythm,
(-) murmur
>Abdomen: protuberant, normoactive bowel sounds, nontender, (-)
hepatosplenomegaly
>Extremities: (-) edema, (-) cyanosis
M. E. D. HPI: Diabetes mellitus -Diagnostics: Fasting
60 year FBS: 7.46 mmol/L due to blood after a month
old/Female/Married PE: underlying -Meds:
Brgy. 4 Poblacion, >General Appearance: awake,ambulatory, (-) cardiorespiratory distress condition Metformin 500 mg
Igbaras >Head and Neck: anicteric sclera, pink conjunctivae, (-) tonsillopharyngeal without BID after meals
congestion, (-) cervical lymphadenopathy, (-) neck vein engorgement, (-) complications Losartan 50 mg OD
CC: With Lab Result anterior neck mass, (-) discharge (E08.9) , -Non-pharma:
>Chest and Lungs: equal chest expansion, clear breath sounds, (-) rales, (-) HYPERTENSION, Exercise daily
wheezes STAGE Low fat, low
>Cardiovascular System: distinct heart sounds, normal rate regular rhythm, carbohydrate diet,
(-) murmurs, point of maximal impulse 5th intercostal space, left I (Hypertension - avoid simple sugars
midclavicular line Controlled -Advised.
 >Abdomen: flabby, normoactive bowel sounds, nontender, (-) DM Type 2 -
hepatosplenomegaly Poorly
>Extremities: pink nailbeds, (-) edema, (-) cyanosis Controlled)

K. J. B. HPI: Acute upper Lagundi 300mg/5ml

10year old/Male/child 2 days PTC, patient had nasal catarrh with clear nasal secretions which respiratory syrup 120ml, 3ml TID
Brgy. 2 Poblacion, developed into occasional productive cough with whitish-yellowish sputum infection, Cetirizine 5mg/5ml, 7
Igbaras PE: unspecified ml ODHS
>General Appearance: awake, fairly developed, fairly nourished (Acute Upper Increase Oral Fluid
CC: cough for two days >Head and Neck: anicteric sclera, pink conjunctiva, (-) ear discharge, (-) Respiratory Tract Intake
tragal tenderness, patent nasal passages, (-) tonsillopharyngeal congestion, Infection, VIRAL) Advised
(-) cervical lymphadenopathy
>Chest and Lungs: equal chest expansion, clear breath sounds, (-) rales,
wheezes
>Cardiovascular System: distinct heart sounds, normal rate regular rhythm,
(-) murmur
>Abdomen: protuberant, normoactive bowel sounds, nontender, (-)
hepatosplenomegaly
>Extremities: (-) edema, (-) cyanosis
P. A. HPI: Hypersensitivity Cetirizine 10 mg
57 year A night prior to consult, Patient developed pruritic skin lesion all over the Reaction to Food ODHS for 5 days
old/Female/Married body after eating tinapa. Intake of Tinapa Avoid triggers
Brgy. Kinagdagan, PE Watchout for
Igbaras >General Appearance: awake,ambulatory, (-) cardiorespiratory distress dyspnea, progression
>Skin: Fair complexion (+) wheal at face, neck, trunk and extremeties skin rash
CC: SKIN RASHES >Head and Neck: anicteric sclera, pink conjunctivae, (-) tonsillopharyngeal Advised
congestion, (-) cervical lymphadenopathy, (-) neck vein engorgement, (-)
anterior neck mass, (-) discharge
>Chest and Lungs: equal chest expansion, clear breath sounds, (-) rales, (-)
wheezes
>Cardiovascular System: distinct heart sounds, normal rate regular rhythm,
(-) murmurs, point of maximal impulse 5th intercostal space, left
midclavicular line
 >Abdomen: flabby, normoactive bowel sounds, nontender, (-)
hepatosplenomegaly
>Extremities: pink nailbeds, (-) edema, (-) cyanosis
R. E. P. HPI: Acute upper Lagundi 600 mg/tab,
21 year 1 week PTC, patient had itchy throat which developed into productive respiratory 1 tab TID
old/Female/Single cough with whitish-yellowish sputum infection, Drink warm
Brgy. Riro-an, Igbaras Pertinent Negative: Fever unspecified calamansi juice
PE: (Acute Upper Increase OFI
CC: COUGH FOR 1 >General Appearance: awake,ambulatory, (-) cardiorespiratory distress Respiratory Tract Advised
WEEK >Head and Neck: anicteric sclera, pink conjunctivae, (-) tonsillopharyngeal Infection, VIRAL)
congestion, (-) cervical lymphadenopathy, (-) neck vein engorgement, (-)
anterior neck mass, (-) discharge
>Chest and Lungs: equal chest expansion, clear breath sounds, (-) rales, (-)
wheezes
>Cardiovascular System: distinct heart sounds, normal rate regular rhythm,
(-) murmurs, point of
maximal impulse 5th intercostal space, left midclavicular line
>Abdomen: flabby, normoactive bowel sounds, nontender, (-)
hepatosplenomegaly
>Extremities: pink nailbeds, (-) edema, (-) cyanosis
C. E. HPI: Lacerated wound Clean and Dress
52/male/married 2 days PTC, patient accidentally lacerated his 3 fingers on the right with his at the 3 fingers Wound
Brgy. Pasong, Igbaras bolo, patient immediately washed the wound with warm water. on right hand Cloxacillin 500 mg, 1
1 day ptc, wound swelled tab QID for 7 days
CC: PE: Tetanus Toxoid 0.5ml
WOUND AT RIGHT >General Appearance: awake,ambulatory, (-) cardiorespiratory distress IM at Left Deltoid
MIDDLE FINGER >Head and Neck: anicteric sclera, pink conjunctivae, (-) tonsillopharyngeal Human Tetanus
congestion, (-) cervical lymphadenopathy, (-) neck vein engorgement, (-) Immunoglobulin
anterior neck mass, (-) discharge 0.5ml IM at Right
>Chest and Lungs: equal chest expansion, clear breath sounds, (-) rales, (-) Deltoid
wheezes Advised
>Cardiovascular System: distinct heart sounds, normal rate regular rhythm,
(-) murmurs, point of maximal impulse 5th intercostal space, left
midclavicular line
 >Abdomen: flabby, normoactive bowel sounds, nontender, (-)
hepatosplenomegaly
>Extremities: pink nailbeds, (-) edema, (-) cyanosis (+) swelling incised
wound at the right fingers
Roger Esquilarga HPI: Open Wound T/C Dressed wound and
53/m/m 30 minutes PTC patient was cutting wood and accidentally cut his left Open Fracture splint application at
Bgry. Passi, Igbaras forearm with an angle grinder Gustilo Class III left forearm
CC: PE: Referred to WVMC
Open lacerated wound >General Appearance: awake,ambulatory, (-) cardiorespiratory distress,
at Left Forearm limited ROM left forearm
>Head and Neck: anicteric sclera, pink conjunctivae, (-) tonsillopharyngeal
congestion, (-) cervical lymphadenopathy, (-) neck vein engorgement, (-)
anterior neck mass, (-) discharge
>Chest and Lungs: equal chest expansion, clear breath sounds, (-) rales, (-)
wheezes
>Cardiovascular System: distinct heart sounds, normal rate regular rhythm,
(-) murmurs, point of maximal impulse 5th intercostal space, left
midclavicular line
>Abdomen: flabby, normoactive bowel sounds, nontender, (-)
hepatosplenomegaly
>Extremities: Open Fracture Gustilo Class III, pink nailbeds, (-) edema, (-)
cyanosis, full pulses
D. R. HPI: Hypersensitivity Chlorphenamine
50y/female/married 4 days PTC, patient applied extracts of alibhon on face and extremities and Reaction to Plant 4mg/tab,1 tab TID for
Brgy. Kinagdagan, developed skin rashes took Cetirizine 10 mg OD but rash persisted to day of Extract 7 days
Igbaras consult (Sambong) Avoid allergens or
PE: HCVD - trigger
CC: skin allergy >General Appearance: awake,ambulatory, (-) cardiorespiratory distress Controlled Continue Metoprolol
>Head and Neck: anicteric sclera, pink conjunctivae, (-) tonsillopharyngeal 50 mg OD
congestion, (-) cervical lymphadenopathy, (-) neck vein engorgement, (-) Low salt intake
anterior neck mass, (-) discharge Advised
>Chest and Lungs: equal chest expansion, clear breath sounds, (-) rales, (-)
wheezes
 >Cardiovascular System: distinct heart sounds, normal rate regular rhythm,
(-) murmurs, point of maximal impulse 5th intercostal space, left
midclavicular line
>Abdomen: flabby, normoactive bowel sounds, nontender, (-)
hepatosplenomegaly
>Extremities: pink nailbeds, (-) edema, (-) cyanosis
>Skin: (+) erythematous macular pruritic rash on face and extremities
G. C. HPI: Urinary tract Requested Urinalysis
40y/female/married 2 days PTC, patient had pain in urination accompanied by hypogastric pain infection Co-amoxiclav 500 mg
Brgy. San whhich persisted to the day of consult + 125 mg TID for 7
Ambrosio,Igbaras PE: days
CC: Painful Urination >General Appearance: awake,ambulatory, (-) cardiorespiratory distress Increase OFI
>Head and Neck: anicteric sclera, pink conjunctivae, (-) tonsillopharyngeal Advised
congestion, (-) cervical lymphadenopathy, (-) neck vein engorgement, (-)
anterior neck mass, (-) discharge
>Chest and Lungs: equal chest expansion, clear breath sounds, (-) rales, (-)
wheezes
>Cardiovascular System: distinct heart sounds, normal rate regular rhythm,
(-) murmurs, point of maximal impulse 5th intercostal space, left
midclavicular line
>Abdomen: flabby, normoactive bowel sounds, nontender, (-)
hepatosplenomegaly
>Back: (+) Goldflamm at Right
>Extremities: pink nailbeds, (-) edema, (-) cyanosis
Urinalysis Result: (9/20/18)
WBC Pus Cells: 50-60/hpf
RBC: 8-12/hpf
Bacteria: Many
Squamous Cell:Many
Amorphous Urate: Many
M. G. HPI: Essentially Multivitamins tab OD
49/Female/Married 1 week PTC, patient experienced dizziness and nausea aggravated by Normal Physical Get enough sleep
Brgy. Jovellar, Igbaras exertion and relieved by rest Exam Finding daily 7-8
CC: Dizziness PE: Proper Diet
 >General Appearance: awake,ambulatory, (-) cardiorespiratory distress Advised
>Head and Neck: anicteric sclera, pink conjunctivae, (-) tonsillopharyngeal
congestion, (-) cervical lymphadenopathy, (-) neck vein engorgement, (-)
anterior neck mass, (-) discharge
>Chest and Lungs: equal chest expansion, clear breath sounds, (-) rales, (-)
wheezes
>Cardiovascular System: distinct heart sounds, normal rate regular rhythm,
(-) murmurs, point of maximal impulse 5th intercostal space, left
midclavicular line
>Abdomen: flabby, normoactive bowel sounds, nontender, (-)
hepatosplenomegaly
>Extremities: pink nailbeds, (-) edema, (-) cyanosis
Salvador Enmanuel HPI: Urinary tract Co-amoxiclav 500mg
50/m/m 2 days PTC, patient had discomfort while urinating infection + 125mg tab, 1 tab
Brgy. 3 Poblacion, 1 day PTC, urination became painful accompanied by hypogastric pain, TID for 7 days
Igabaras feeling of incomplete voiding and fever took paracetamol 500mg TID Increase OFI
CC:PAIN UPON PE: Advised
URINATION FOR 3 >General Appearance: awake,ambulatory, (-) cardiorespiratory distress
DAYS. >Head and Neck: anicteric sclera, pink conjunctivae, (-) tonsillopharyngeal
congestion, (-) cervical lymphadenopathy, (-) neck vein engorgement, (-)
anterior neck mass, (-) discharge
>Chest and Lungs: equal chest expansion, clear breath sounds, (-) rales, (-)
wheezes
>Cardiovascular System: distinct heart sounds, normal rate regular rhythm,
(-) murmurs, point of maximal impulse 5th intercostal space, left
midclavicular line
>Abdomen: flabby, normoactive bowel sounds, nontender, (-)
hepatosplenomegaly
>Extremities: pink nailbeds, (-) edema, (-) cyanosis
>Digital Rectal Exam: good sphincter tone, intact rectal vault, nontender, (-)
blood, (+) green feces on examining finger (-)prostatomegaly