Lyceum-Northwestern University

Dr. Francisco Q. Duque Medical Foundation

College of Medicine

MEDICINE II WARDWORK

Katragadda sashank sairam

GROUP No.: G

February 10, 2019

Date of interview: Febraury 4, 2019

Time of interview: 5 pm

Informant: Patient’s Neighbour

Reliability: 75%

HISTORY

General Data

This is a case of Mr S.R age 69 yrs old , male, married Filipino, roman catholic,
born in april 18 1951 in talibaew ,pangasinan. He was residing in Calasiao town and
was admitted in LMC on jan 31, 2019 at 11:20 am.

Chief Complaint

Loss of consciousness.

History of Present Illness

Few hours prior to admission patient felt dizziness during his breakfast. He asked
help from his neighbor to monitor his B.P. which was noted as 90/60 mmhg. After few
minutes patient suddenly loss his consciousness and was admitted to LMC .
Past Medical History

No known history of any other illness

Family History

No known history of illness were recalled.

Personal and Social History

Patient lives alone in the house and wife lives in the next door.

REVIEW OF SYSTEMS

General

(-) fatigablity (-) weight loss (-) fever

(-) malaise (-) chills

skin

(-) rashes (-) easy bruising (-) petechiae

(-) lumps (-) changes in hair / nails (-) wounds

(-) changes in size of moles (-)itching

Head and Neck

(-) headache (-) dizziness (-) syncope

(-) blurring of vision (-) diplopia

(-) photophobia (-) eye pain (-) decrease hearing capacity

Respiratory

(-) dyspnea (-) hemoptysis (-) cough

(-) back pain (-) orthopnea (-) trepopnea

Cardiovascular

(-) chest pain (-) palpitation (-) PND

(-) easy fatigability (+) orthopnea (+) edema

Gastro-intestinal

(-) poor appetite (-) dysphagia (-) odynophagia

(-) nausea (-) vomiting (-) hematemesis

(-) diarrhea (-) constipation (-) melena

(-) abdominal enlargement (-) abdominal pain

Genitourinary

(-) nocturia (-) anuria (+) polyuria

(-) hematuria (-) incontinence (-) dribbling

Musculoskeletal

(-) leg cramps (-) joint pain & stiffness (-) swelling

(-) bone deformity (-) weakness (-) atrophy

(-) contractures (-) restriction of motion

Neuropsychiatric

(-) insomnia (-) seizures (-) weakness/paralysis

 (-) tremor (-) loss of memory (-) depression

(-) delirium (-) hallucinations

Endocrine

(-) polyuria (-) polydypsia (-) polyphagia

(-) abnormal growth (+)polyurea

Hematologic

(-) easy bruisability (-) pallor

Physical Examination:

General survey:

The patient was lying in his bed and sleeping throughout the physical examination.He
was in cardiopulmonary distress with nasal cannula inserted and had an iv line
infusing 5% dextrose in LRS on his left dorsum of his hand.

Vital Signs:

Temperature: 38.5°C, axillary

BP: 140/80mmHg, left arm (lying)

Heart Rate: 110 beats per minute

Respiratory Rate: 25 breaths per minute

Skin:

The patient has a brown complexion, no rashes with good skin turgor, no edema,
skin is warm to touch.capillary refill time of <2 seconds

Head:

Normocephalic, symmetrical, white equal distribution of hair, no alopecia, no

mass, no tenderness, no hematoma, no abscess, no edema.
Eyes:

not assessed

Ears:

The ears are symmetrical, no mass, no tenderness, no discharge noted in the ear
canal.

Nose

Patent nares, no nasal flaring, no discharges, no sinus tenderness

Mouth and Throat:

Lips are slightly dark, dry lips, moist and pinkish buccal mucosa

Neck:

Supple, no thyromegaly, no cervical lymphadenopathies, (-) carotid bruit, trachea

on the midline

Chest and Lungs:

No chest deformities , no masses, no scars,Symmetrical chest expansion, no lag,

no retractions, resonant upon percussion, clear breath sounds

Heart:

Adynamic precordium, Apex beat at the left 5th intercostal space mid clavicular line,
normal rate, regular in rhythm, no murmurs , nothrills/ heaves

Abdomen:

Globular abdomen, no discolaration of skin, normoactive bowel sounds at 9 per min,

no bruit sounds on auscultation,non tender, tympanic on percussion

Rectal exam:

not assessed

Extremities:

No clubbing on both hands and feet, no cyanosis, no bipedal edema.

DP PT P F B R

Right ++ ++ ++ ++ ++ ++

Left ++ ++ ++ ++ ++ ++