General data: Reymundo Reynaldo, 27 years old, male, Filipino, Roman Catholic, single, part time construction worker,

born on January 30, 1984 in Novaliches Quezon City, presently residing Dawid Sapa 2 pahse 2 Brgy. Kaligayahan Valenzuela, admitted for the first time at FEU-NRMF Medical Center on Feb 24, 2011. Chief complaint: Generalized body weakness Interval history: The patient had previous admission at Valenzuela General Hospital last May 2010 with the same complaint of generalized body weakness and a diagnosis of hypokalemia. It was then corrected after two days of stay in the hospital. The history of present illness started on Jan. 27, 2011 when he felt tolerable lower extremities weakness progressing to upper extremities weakness and lasted for 2 days and no intervention or consultation done. On Feb. 23, 2011, he again felt the lower extremities weakness progressing to upper extremities weakness and prompted him to rest the whole day. On the following day, an hour PTA, the symptoms felt by the patient became more severe and intolerable and patient was immediately rushed to FEU-NRMF Medical Center and subsequently admitted. Past Medical History Had chickenpox, measles, and mumps, no known allergies in food and medication, no previous accidents or injuries and blood transfusion. He claimed that he received all the vaccinations. Family history Father- 54 years of age, Hypertensive and asthmatic diagnosed in the year 2010 Mother- 52 years of age, asthmatic since childhood but subsided 9 years ago 3 siblings- apparently well No other heredofamilial diseases Personal and Social history Single, a high school graduate and currently works as a part time construction worker. Diet is mostly meats and rice. Smoke since 15 years of age consuming 10 sticks/day with a pack year of 7.5/year and an alcohol drinker consuming 250ml of Brandy twice per week since he was 15 years of age. No regular exercise. Source of drinking water is mineral water and their source of water is Manila water. Lives in a concrete house and the vicinity of their house are far from any canals and garbage in their house is collected twice/week.

REVIEW OF SYSTEMS: Constitutional: (-) weight loss, (-) chills. (+) malaise SKIN: (-) itchiness, (-) dry, (-) sweaty HEENT: (-) headache, (-) blurring of vision, (-) double vision, (-) eye pain, (-) lacrimation, (-) photophobia, (-) ear ache, (-) deafness, (-) tinnitus, (-) ear discharge, (-) smell change, (-) nasal obstruction, (-) nose bleed, (-) taste disturbances, (-) toothache, (-) gum bleed, (-) hoarseness, (-) sore throat Neck: (-) nape pain, (-) limitation of movement CVS: (-) substernal pain, (-) palpitations, (-) orthopnea, (-) edema, (-) cyanosis, (-) syncope, (-) easy fatigability Respiratory: (-) cough, (-) orthopnea, (-) tachypnea, (-) hemoptysis, (+) dyspnea, (-) wheezing, (-) chest pain GIT: (-) diarrhea, (-) constipation, (-) hematamesis, (-) melena, (-) regurgitation, (-) hematochezia GUT: (-) dysuria, (-) frequency of urine, (-) urgency, (-) hesitance, (-) polyuria, (-) hematuria, (-) incontinence, (-) genital pruritus, (-) urethral discharge NS: (-) loss of consciousness (-) paresthesia, (-) dizziness, (-) speech disorder, (-) memory loss, (-) confusion Extremities: (+) stiffness of extremities, (-) joint pain, (+) numbness, (-) swelling of joints (-) limitation of activity Hema: (-) bleeding, (-) pallor, (-) easy bruising Endocrine: (-) heat or cold intolerance, (-) polyuria, (-) polydipsia PHYSICAL EXAMINATION: General survey: conscious, coherent, oriented to time, place and person, looks appropriate for his age, well-kempt, not in cardiorespiratory distress, with the following vital signs: BP: 110/60 mmHg CR: 73 bpm RR: 18 cpm Temp: 36.7 oC Height: 168 cm Weight: 64 kg Skin: Skin is brown, normal moisture, normal degree of elasticity, mobile, no dilated superficial blood vessels. Nails are smooth with normal folds and no lesions. He has tattoos located on the ventral aspect of the left forearm, around the umbilicus, on the dorsal aspect of the left and right hands, over the right scapula, on the deltoid area of the right arm, and across the upper region of the back in the interscapular area. Head: Hair is black, thick, coarse, dry and evenly distributed. Scalp is clean, no lesions. Head is normocephalic, symmetrical, no tenderness. Temporal arteries are not visible but palpable with equal strong pulsations, walls are not thickened. Face: Symmetrical, slightly round, no masses, nor involuntary movements, equal nasolabial folds. Eyes: Has thick, coarse, black eyebrows, evenly distributed. Eyelashes are not matted, black, and directed outward. No ptosis. Normal palpebral fissure, no lesions, no edema, normally set eyeballs, pink conjunctivae, anicteric sclerae, transparent cornea, dark brown iris, pupils equally reactive to light and

can accommodate. Fundoscopic examination revealed positive red orange reflex, AV ration 2:3, no exudates, no hemorrhage, no papilledema. Ears: Auricles symmetrical, the auditory canals patent, no discharge, no swelling or redness of the walls of canal, tympanic membrane are pearly white, intact, normal contour, cone of light visible. Nose and paranasal sinuses: Nose symmetrical, no tenderness, patent vestibule, mucosa pink, septum midline, intact, turbinates not congested, no discharge, no tenderness over the frontal and maxillary sinus, normal transillumination test. Mouth and pharynx: Lips are pale, moist, and symmetrical with no lesions. Mucosa and gums are pink, smooth, no lesions. Roof, floor and palate is pinkish, no lesion, uvula is midline, tonsils not enlarge, pharynx pink, no lesions, no exudates. Neck: Neck is symmetrical, short, no mass no deformity. Neck muscles have normal tone no tenderness, trachea is in midline position, lymph nodes are not swollen, not painful, no tenderness, thyroid gland is not enlarged, no tenderness, no nodules, smooth, normal in shape. Chest and Lungs: The skin is light brown in color with no lesions and no visibly dilated blood vessels. Large tattoo noted on the upper back area. Normal muscle development, thorax is symmetrical, elliptical, no deformities. Respiratory rate is 18 cycles per minute, inspiration is longer than expiration, breathing is effortless, with symmetrical chest expansion and no retractions. No tenderness noted on anterior, posterior and lateral areas of the chest, no palpable masses. Respiratory movement symmetrical, Tactile fremitus normal and equal anteriorly, posteriorly and laterally. Percussion of anterior, posterior and lateral chest wall is resonant. Vesicular breath sounds over the entire lung area except the manubrium sterni anteriorly and the upper two-thirds of the interscapular area posteriorly. No crackles, rales or wheezes noted. Negative for bronchophony, egophony and whispered pectoriloquy. CVS: No precordial bulging, adynamic precordium as observed from the supine position, normal rate with regular rhythm. Normal heart rate at 70 bpm. Apex beat at the 5th intercostal space approximately 2cm medial to the left mid clavicular line; Carotid pulsations are strong, equal intensity and has regular rhythm, risk, without bruits. No heaves or thrills observed. S1 sound is louder than S2 at the apex, S2 sound is louder than S1 at the base. No S3 and S4 sounds. No murmurs heard. Jugular venous pressure is approximately 7 cm H2O. Abdomen: The patient s abdomen is brown in color, flat, symmetrical, umbilicus is inverted, has no dilated blood vessels, has no bulging flanks, no masses, no visible peristalsis, no lesions or scars, has normoactive bowel sounds, without bruit on the epigastric area, all quadrants are tympanic in percussion, there is no CVA tenderness, as well as light and deep palpations, there are no superficial masses, soft, and no rigidity. On deep palpation, the liver, spleen, and kidney are not palpable. The liver has a span of 8cm.

Examination of Peripheral Pulses: Upper and lower extremities are symmetrical, no swelling, no pigmentation, no lesions, no varicosities. Nail beds are pink on both upper and lower extremities. Radial artery, brachial artery and dorsalis pedis are warm to touch, having soft walls with regular, strong and equal pulsations. NEUROLOGIC EXAM: Cerebral function: Patient is GCS 15; appearance is appropriate; oriented to time, place and person; intact immediate, recent, and remote memories Cerebellum: Can do finger-nose-finger test, rapid alternating movement, no nystagmus Cranial Nerves: Cranial Nerve I- can smell Cranial Nerve II- pupils size=2-3 mm, (+) Red orange reflex, distinct disc margin, no visual field defect, can read the smallest line of the Jaeger s chart approximately 14 inches away from the eyes. Cranial Nerve III, IV, VI- Both pupils reactive to light direct and indirectly, (+) accommodation, equal and complete opening of both eyes, can move eyes in 6 cardinal direction of gaze. Cranial Nerve V- (+) bilateral corneal reflex, equal sensation in both sides of the face, can clench teeth equally on both sides Cranial Nerve VII- can frown, and raise eyebrows, close eyes, nasolabial folds symmetrical on both sides Cranial Nerve VIII- can hear on both sides Cranial Nerve IX & X- no dysphonia, uvula at midline, equal elevation of plate on phonation, (+) Gag reflex Cranial Nerve XI- can turn head from side to side against resistance, can elevate shoulder equally Cranial Nerve XII- no atrophy, (-) fasciculation, tongue is midline, able to move from side to side Motor Function: 5/5 5/5 5/5 5/5 Sensory Function: 100% 100% 100% 100% Deep Tendon Reflex ++ ++ ++ ++