Date and Time: June 23, 2018, 3PM

Chief Complaint: Difficulty of breathing

History of Present Illness

The patient is a known case of bronchial asthma on for more than 10 years now and on Salbutamol inhalation and
Monteleukast 10mg tablet as maintenance medications.

Patient was apparently well until 1 week prior to admission, the patient started to experience repeated cough,
productive, yellowish in color and difficult to expectorate with associated chest tightness and undocumented fever.
The patient’s cough was aggravated by dust, tobacco smoke and physical exertion. The patient consulted at their
barangay health center since her maintenance medications were out of stock and was given Lagundi syrup taken
three times a day and Paracetamol 500mg tablet. Medications provided minimal relief. No nebulization was
administered due to unavailability of electricity as claimed by the patient. The patient did not experience colds, no
chills, no urinary symptoms no nausea or vomiting but stated abdominal pain from forceful coughing that also
awakens her from sleep.

Persistence of symptoms and the availability of vehicle prompted patient to consult at the institution, with
consequent admission.

Past Medical History

The patient was diagnosed with Bronchial Asthma for 10 years now. The patient stated that initially she had yearly
admissions due to poor control of her asthma but was controlled when Monteleukast 10mg tablet was added to her
medications. Her last attack was in 2012 and was admitted in our institution.
The patient in non hypertensive and non diabetic. No other significant comorbidities.

OB-GYNE
The patient has an OB score of G10P10 (10-0-0-7). All children were full term and home delivered by a midwife.
There were no complications reported.
The patient had her menopause at 45 years old.

Family History
The patient has a family history of asthma. No family history of DM, cancer, epilepsy, kidney disease, liver disease.

Personal and Social History

The patient works as a farmer. She finished high school in a public school in her hometown. She lives with her
husband and children in a bungalow type house with adequate space.

She does not do a formal physical exercise but considers her farming as her exercise. For her diet, she has no food
preferences and her meals usually comprises of rice, meat/fish and vegetables. She drinks 3 to 4 cups of coffee daily.
She claims to have no allergies to food or drugs. The patient is a non-smoker and non-alcoholic drinker and has no
history of illicit drug use.

Their source of drinking water and use for domestic purposes comes from a natural spring.

Review of Systems
General: (-) weight loss/gain (-) weakness/fatigue (-) fever
Skin: (-) pruritus (-) rashes, (-) changes in hair (-) changes in nail (-) color change (-) anemia (-) easy burning
Head: (-) headache (-) dizziness (-) lightheadedness
Eyes: (-) visual impairment (-) pruritus (-) discharge (-) inflammation (-) glasses
Ears: (-) hearing loss (-) tinnitus (-) discharge (-) earaches
Nose, Throat, Mouth: (-) abnormal olfaction, (-) dental carries (-) gingivitis (-) dysphagia/odynophagia (-) tonsillitis (-
) hoarseness (-) gum bleeding (-) colds (-) nasal stuffiness (-) itching (-) nosebleed
Neck: (-) goiter (-) cervical lymph node enlargement (-) mass (-) lumps (-) sore throat
Respiratory: (+) cough (+) sputum (+) difficulty of breathing (-) night sweats (-) pleuritic pain (-) hemoptysis
Breast: (-) pain (-) mass (-) tenderness, (-) discharge
Cardiovascular: (-) orthopnea (-) palpitations, (-) chest pains, (-) paroxysmal nocturnal dyspnea
Gastrointestinal: (-) decreased appetite (-) constipation, (-) nausea (-) vomiting (-) dysphagia (-) hematemesis (-)
hemorrhoids (-) diarrhea (-) heartburn (-) dysphagia (-) black /tarry stool (-) bloody stool (+) abdominal pain
Urinary: (-) polyuria (-) hesitancy (-) dribbling (-) pain, (-) urgency (-) hematuria (-) nocturia (-) hernia
Genitourinary: (-) loss of libido (-) sexual dysfunction (-) lesions, (-) discharge
Peripheral Vascular: (-) edema (-) pruritus (-) intermittent claudication (-) leg cramps (-) varicose veins (-) ulcers
Musculoskeletal: (-) muscle weakness (-) wasting/atrophy (-) pain (-) fractures (-) stiffness (-) joint pains
Hematopoietic system: (-) anemia (-) abnormal bleeding (-) easy bruising
Endocrine: (-) polyphagia (-) polydipsia (-) polyuria (-) weight loss (-) goiter (-) heat/cold intolerance
Nervous: (-) slowed movement (-) vertigo (-) falls (-) headache (-) loss of consciousness (-) syncope
Psychiatric: (-) depression (-) anxiety (-) sleep disorders (-) mood swings (-) hallucinations

Physical Examination:

General Survey:
Patient is a right handed, endomorph, conversant, cooperative and able to speak in full sentences but with
several pauses due to bouts of coughing and increased work of breathing. Patient is connected to and IV
line on her right hand and hooked to O2 inhalation at 5-6LPM via nasal cannula. Patient is in apparent
respiratory distress.
Vital Signs:
PR: 78 beats per minute, regular rate and rhythm
RR: 32 cycles per minute
BP: 110/80 mmHg left arm, sitting
Temp: 36.2oC axillary
O2 sat: 93%
Anthropometrics:
Weight: 69 kg
Height: 160 cm
BMI: 26.95 kg/m2, Obese I
Skin:
Brown complexion with noticeable wrinkling. No pallor or jaundice. Nails without clubbing or cyanosis. Skin
was warm with good skin turgor, no edema.
HEENT:
Head. Atraumatic, no scars or tenderness.
Eyes. Anicteric sclera and pink palpebral conjunctiva, no swelling or redness. Arcus senilis on both eyes.
Ears. Pinna is mobile, firm and no tragal tenderness. No discharge, with dry cerumen noted.
Nose: Patent nares, septum midline with no perforation. No facial pain and no sinus tenderness.
Neck. Neck is supple with good range of motion. No neck vein distention. Trachea was midline. Non-
palpable thyroid gland. No cervical lymphadenopathy
Throat. Oral mucosa is pink without ulcers. Tongue is midline and moist. Uvula is midline. No
tonsillopharyngeal congestion.
Thorax and Lungs:
Symmetric chest expansion, use of accessory muscles noted, with no retractions. Decreased tactile fremitus
noted bilaterally. Crackles at the right base and occasional wheezes noted. Egophony noted.
Cardiovascular:
Adynamic precordium. Distinct heart sounds, S1 and S2, normal sinus rate and rhythm. No murmurs noted.
Breasts:
 Symmetric breasts. No discharge or masses.
Abdomen:
Flabby and non-distended. No visible veins nor pulsations. Normoactive bowel sounds. No bruits heard in
the aortic, renal, and iliac vessels. Abdomen is generally tympanitic. No tenderness on light and deep
palpation. No hepatosplenomegaly noted. No costovertebral angle tenderness.
Extremities:
No gross deformities. No clubbing or cyanosis. Calves are supple and non-tender. No bipedal edema. Brisk
capillary refill time <2s.
Genitourinary and Rectal:
Not assessed.
Mental Status:
Normal.
Neurological
Cerebral:
Patient is right handed. She is conscious, alert, and coherent. She was oriented to person, place, time and
situation. GCS 15/15.
Cerebellar:
No dysmetria, no dysdiadochokinesia, no nystagmus.
Cranial Nerves
I – No anosmia.
II – Pupils equally round and reactive to light and accommodation constricting from 4 mm to 2 mm. Pupillary
reflex intact.
III, IV, VI – Extraocular movements intact and equal without ptosis.
V – Intact and equal sensation over the face. Corneal reflexes present. Masticator muscles 5/5.
VII—No facial asymmetry. Facial muscles 5/5. No dysguesia.
VIII – Good gross hearing acuity.
IX and X— With intact gag reflex. No dysarthria or dysphagia.
XI – Trapezius muscle and sternocleidomastoid muscle 5/5.
XII – No tongue deviation.
Motor: Sensory:
5/5 5/5 100% 100%

5/5 5/5
100% 100%
Reflexes and Miscellaneous:
2+ elbow, knee and ankle reflex. No Babinski or clonus noted.