GENERAL DATA

-A.G
-60 y/o ,male
-Filipino
-catholic
-December 11, 1958 in Tarlac
-77-Q, Plata Street, Tugatog, Malabon City
-First time to be admitted at FUMC
CHIEF COMPLAINT

-Elevated Blood pressure

HISTORY OF PRESENT ILLNESS
-2 days PTA, patient felt dizzy with accompanying light headedness
-no associated neck pain, nausea, vomiting and headache
-no BP was taken
- took Losartan 100 mg tab OD which afforded no relief but did not
seek consult
- 2 hours PTA patient felt dizzy, no accompanying symptoms, patient
seek consult at a health center in Manila, BP was 200/110
- Patient was given catapres sublingual
PAST MEDICAL HISTORY
(+)HPN (2017)
(+) Psoriasis (10 years ago)
(+) CVD infarct (30 years ago )
(-) DM
(-) Asthma
(-)Blood transfusion
(-) allergy
Maintenance medication: Losartan 100 mg/tab OD
FAMILY MEDICAL HISTORY
(-) HPN
(-) DM
(-) Asthma
(-) PTB
(+) cardiovascular disease –fathers side
(-) cancer
PERSONAL AND SOCIAL
retired messenger for 37 years
Alcoholic drinker (1x a week) 50-100 ml for 50 years
No illicit drug use
ROS
PHYSICAL EXAM
General survey
Patient has medium built, well groomed, ambulatory, not in
cardiopulmonary distress

Vital Signs
BP: 160/100 PR: 84 bpm RR: 18 cpm Temp:

Integument
Skin is brown, moist, warm to touch with good skin turgor. Nails beds
are pink with capillary refill of less than two seconds. No clubbing and no
cyanosis noted
PHYSICAL EXAM
HEENT: Slightly icteric sclera, pink palpebral conjunctiva, no
tonsilopharyngeal congestion, no nasoaural discharge, no cervical
lymphadenopathy, no lymph node enlargement.

CHEST AND LUNGS: Symmetrical chest expansion, no intercostal retraction,

no narrowing or widening of the ICS, no lagging, equal tactile fremitus,
resonant pon percussion, no crackles , no wheezes

CARDIOVASCULAR: Adynamic precordium, apex beat at 5thICS MCL.No

thrills, no lifts and heaves,normal rate and regular rhythm, no murmur, no
neck vein engogement
ABDOMEN: no visible lesions, discoloration, no dilated vessels, no
visible pulsation, or peristalsis, normoactive bowel sounds, no bruit
heard, typmpanitic upon percussion, soft. Liver spleen and kidney are
not palpable.

EXTREMITIES: Grossly normal extremities, no cyanosis no edema

NUEROLOGIC EXAM
CEREBRUM: Patient is awake, cooperative, conscious, follows simple
commands, oriented to person, place and time.

CEREBELLUM: No tremor, no involuntary movement, can do alternating

movements of the hand.
CRANIAL NERVES
CNI: Patients olfactory nerve is intact,was able to identify the smell being
provided to him.
CN II and III: both reactive to direct and consensual light stimuli.
CN III, IV, VI : intact Extra ocular muscles
CN V: Patient was able to clench teeth
CN VII: no facial asymmetry, able to do facial expression
CNVIII : can hear and repeat whispered words
CN IX, X : tongue and uvula was at the midline, Patient was positive for gag
reflex
CN XI: able to shrug shoulders
CN XII: no tongue deviation
Motor

Sensory

DTR

• Special test: (-)Babinski reflex, (-) Kernigs sign, (-) Brudzinski sign, (-) Nuchal
rigidity
SALIENT FEATURES:
DIFFERENTIAL DIAGNOSIS
Course in the ward
• Upon admission, patient was admitted at the Ward. Consent was
secured for admission and management. Patient was conscious,
coherent, not in cardiorespiratory, with following vital signs of BP
180/100 mmHg, PR 61 bpm, RR 19 cpm and Temperature 36.3°C.
Patient was inserted with IVF heplock. Placed under low fat, no added
salt diet. Patient was given Losartan 100mg/tab 1 tab OD .The
following diagnostics were requested; CBC with platelet, Sodium,
Potassium, Chloride, BUN, Crea, SGPT, 12 L ECG, FBS , Lipid Profile,
Urinalysis , BUA, CBG, CXR-PA
• Betahistine 24mg/tab, 1 tab prn BID was given for dizziness. At the
same day plain cranial MRI was requested . Losartan was
discontinued, Perindopril + Alodipine10/10 tab OD was started.
Course in the ward
• On the 2nd day of admission, Patient was conscious, coherent, not in
cardiorespiratory distress with no new subjective complaints. No
Headache, no dizziness, no nausea and vomiting, no chest pain, no
edema. Vital signs were ,BP 150/90, HR of 66bpm, RR of 20 and Temp
of 36.5 °C. Upon physical examination patient has pink palpebral
conjunctiva, vesicular breath sounds. Patient was given
Triplexan 10/2.5/10 g OD. Rosuvastatin 20 mg/tab OD was also
started.
Course in the ward
• On the 3rd day of admission, patient had no new subjective findings, no
chest pain, no DOB,no palpitation, no dizziness, no numbness or
weakness.Patient had a BP : 140/80 PR:72bpm RR:20cpm Temp:36.5, (-)
for crackles, (-) for wheezing, has normal rate and regular rhythm.

• On the 4th hospital stay, patient was conscious, coherent, not in

cardiorespiratory distress. No Headache, no dizziness, no nausea and
vomiting, no dyspnea, no chest pain. Vital signs were Bp 130/90, HR of
75bpm, RR of 18 and Temp of 36.0 °C.
• Upon doing physical examination patient has vesicular breath
sounds,normal rate and regular rhythm,no murmurs heard. Patient was
advised to may-go-home anytime.
Take home medications
Triplexan 10/2.5/10 tab ,1 tab OD
Rosvastatin 20 mg/tab, 1 tab OD
Betahistine 24 mg/ tab ,1 tab BID for dizziness
Course in the ward
Perindopril,indapamine,amlodipine