5 Camus

CARILO, Bianca Criselda M. Section A

August 4, 2009 Dr. Pine

Medicine Patient Profile: NC is a 53-year old Filipino, male, El Shaddai, born April 29, 1956 at Camarines Norte and currently residing at Marikina City. He is the second among 5 siblings. He lives in a 2storey house with 2BR and 1TB with a total of 8 occupants, with 2 pet dogs. House is located near the highway and a creek. Water is provided by Maynilad and garbage is collected thrice weekly. Patient is single and has not had any intimate relationship. Patient graduated from a vocational course and works at a welding shop but stopped at the onset of his illness. Patient gets approximately 9 hours of sleep at night. He eats rice and viand thrice daily and usually prefers fatty food and vegetables. Patient is a non-smoker but occasionally drinks alcohol. Current medications include Phenytoin (Dilantin). Source and Reliability: NC and his mother graded with fair reliability Chief Complaint: Hematuria of 1 year and generalized pruritus of 3 weeks duration History of Present Illness: Past Medical Health History: Immunizations are unrecalled. At 3 years of age, patient suffered from convulsions. In 1972, patient suffered from epilepsy, was brought to a hospital, prescribed with 100mg Phenytoin (Dilantin) BID and 200mg Carbamazepine (Tegretol) OD and was sent home. Carbamazepine was discontinued after 1 year. In 2006, Phenytoin was replaced with Phenobarbital. In 2008, Phenobarbital was changed back to Phenytoin. Patient has had varicella, measles and mumps during childhood. Patient has no history of cardiac and pulmonary diseases, hypertension, DM, allergies, major physical trauma, transfusions and major surgeries. Family Health History: Patient’s father was diagnosed with hypertension and DM, and died of stroke. Age at death was unrecalled. His eldest sibling died of an aneurysm at the age of 17. His mother and 3 younger siblings have no known illnesses. Review of Systems: General: Patient has generalized weakness. No weight loss and fever. Skin: See HPI. Skin is dry and color appears to darken. No lumps and changes on hair and nails. Head: Patient has headache and dizziness. No gross lesions and injuries on the head or syncope. Eyes: Patient wears corrective lenses for reading. No pain, trauma, redness or discharge. Ears: No hearing impairment, pain, discharge or tinnitus. Nose, Throat and Mouth: Patient has toothache. No abnormalities in olfaction, horseness, sore throat, frequent coughs and colds, epistaxis, sinusitis, facial pain or neck mass. Respiratory: No cough, sputum, difficulty of breathing, PTB exposure or hemoptysis.

Cardiovascular: Patient has 1 episode of diffused chest pain and palpitations. No syncope, orthopnea, dyspnea or edema. Gastrointestinal: See HPI. Patient has dysphagia. Patient has no jaundice, indigestion, no changes in stool character and frequency or abdominal distention. Urinary: See HPI. No changes in volume and frequency. Genitoreproductive: No discharge and pain. Extremities: No wounds, cyanosis, clubbing, claudications or varicosities. Breast: No pain, discharge or lumps. Extremities: No cyanosis, varicosities, edema, clubbing, ulcers or claudication. Hematopoietic system: Patient has anemia. No excessive bruising/bleeding or pica. Nervous system: Patient has headache and dizziness. No tremors, fainting spells, seizures, vertigo, head trauma or sensory perversions. Musculoskeletal: No joint stiffness, muscle weakness, pain or swelling. Endocrine: No heat or cold intolerance, thyroid problems, DM indicators, neck surgery or irradiation. Psychiatric: No mood swings, behavioral changes, anxiety or depression. Temporal Profile: Physical Examination on Admission: General Survey: Conscious, coherent, not in cardiorespiratory distress. Vital Signs: BP: 160/90 To: 36.4 oC, axillary HEENT: AS, PPC, CTFC, CCAOS Abdomen: Flabby, protuberant, soft, no masses, (+) suprapubbic tenderness. Skin: Rashes on both upper extremities Cardiovascular: Normal rate, regular rhythm, no murmurs, S1>S2 @ apex Physical Examination: General: Patient is alert, coherent, cooperative and oriented to person, time and place. Patient is ambulatory and not in respiratory distress. Vital Signs: BP: 140/75, sitting, right arm PR: 56 bpm RR: 22 cpm T: 36.9 oC, axillary Skin: Thick and dry on both upper extremities, with numerous healed scars and hyperpigmented macules on the face, trunk and all extremities. Scaling at the right knee. No jaundice and other discolorations. Nails: Pale nail beds. Normal nail bed shape, no gross lesions, clubbing or pitting. Head: Symmetrical, rounded, with equal hair distribution and no lumps. Eyes: Anicteric sclerae and pale conjunctivae. 20/50+2 on the left and 20/40 on the right with corrective lenses, 20/400 bilaterally without corrective lenses. Full ROM bilaterally. Pupils round, reactive to light and accommodation. No visual field defects. ROR present bilaterally. No gross lesions on eyebrows, eyelashes, eyelids, cornea, iris, pupils. Ears: No discharge, gross lesions and deformity on the pinna, ear canal and tympanic membrane. No mastoid tenderness. No difficulty hearing and lateralization of sound. AC>BC on the right, BC>AC on the left. Nose: No gross lesions, deformities, tenderness, discharges and mucosal changes. Throat: No gross lesions on pharyngeal mucosa, postnasal drip, dryness and excessive salivation. Neck: Symmetrical, no gross lesions, tenderness, masses and bruits.

Lymph Nodes: No lymphadenopathy on the cervical, supraclavicular, axillary and inguinal lymph nodes. Thorax: Symmetrical chest expansion, no retractions, deformities and tenderness. Clear breath sounds, normal resonance and tactile fremitus and no rhonchi, rales or wheezes on the anterior chest. Inspiratory>expiratory, dull on percussion with adventitious sound on both middle lung fields of the posterior chest. Breast: Normal size and shape, symmetrical. No discharge, tenderness or masses. CVS: Adynamic precordium. Normal heart rate, regular rhythm. Good S1 and S2. No thrills, murmurs and gallops. PMI at 5th ICS LMCL. Abdomen: Symmetrical, rounded with visible heaves on the epigastric area. No gross lesions and deformity. Hypoactive bowel sounds, no bruit. 8 cm liver span. No tenderness, rigidity and organomegaly. Negative Goldflam test. Extremities: Weak pulses. No atrophy, edema, varicosities and clubbing. Musculoskeletal: Good muscle bulk, normal gait. No deformitiy, limitation of motion, swelling and tenderness. Neuro: Mental Status: Patient is awake, coherent, cooperative and oriented to person, time and place. Speech is consistent. Remote and memories are intact. Cognitive ability is intact. Cranial nerves: I: Able to identify 1 out of 3 stimuli. II: 20/50+2 on the left and 20/40 on the right with corrective lenses, 20/400 bilaterally without corrective lenses. Pupils round, reactive to light and accommodation. No visual field defects. ROR present bilaterally. III, IV, VI: Normal conjugate eye movements bilaterally, no nystagmus. V: Intact sensation on either side of the face. Good temporalis and masseter tone. VII: Intact muscles of facial expression. VIII: No difficulty hearing and lateralization of sound. AC>BC on the right, BC>AC on the left. IX, X: Uvula in midline, symmetrical movement of palate, intact gag reflex. XI: Good shoulder shrug, no atrophy and fasciculations. XII: Tongue in midline, no atrophy and fasciculations. Sensory: Intact sensation as to pain and light touch on all extremities. Motor Strength: Graded 5/5 on all extremities. Cerebellar: Normal gait, able to achieve finger-to-nose and heel-to-shin tests. No Romberg’s sign. Reflexes: left right

Laboratory Results: Sodium Potassium Urea nitrogen Creatinine pH pCO2 pO2

July 25, 2009 127 4.7 26.85 759 7.24 24 99

July 29, 2009

Reference Values 135-156 mmol/L 3.5-5.3 mmol/L 32-68 mmol/L 44-100 mmol/L 7.35-7.45 35-45 80-100

HCO3 BE (ecf) O2 sat Total CO2 Hemoglobin mass C MCH Hematocrit MCV MCHC RBC WBC Neutrophils Lymphocytes RBC morphology

10.80 -17.30 97% 1.2 24.3 39 74 35 2.7 6.9 73 20 Hypochromic, monocytic

Platelet July 26, 2009 Total cholesterol Free cholesterol Triglycerides Cholesterol/HDL ratio Glucose

22-26 +/− 2 90-100 % 11-30 1.4-1.6 g/L 27.5-33.5 pg 40-50 % 80-90 fL 32-37 % 4.5-5.0x1012 L 5-10x109 L

1.5 24.4 38 34 34 2.4 10.4 Hypochromic, slight anisocyosis Normal

Results 4.7 1.5 0.77 3.1 6.1

Reference Values 3.4-6.1 mmol/L 0.2-2.1 mmol/L Up to 2.4 mmol/L 0.2-0.4 mmol/L

CXR: Findings: Pulmunary TB, right lung Pneumonia, Right lung Old fracture deformities, 4th, 5th, 6th, 7th right ribs Suspicious lucency at inferior portion of left scapula US: Irregular urinary bladder solid mass, malignancy considered Bilateral moderate hydronephrosis believed to be d/t obstruction of the urethral-vesical junction by the bladder mass Diffuse renal parenchymal disease, bilateral Normal prostate gland