West Visayas State University College of Medicine

Department of Family and Community Medicine

Clinical Clerkship Community Rotation
Rotation:
Census Date:
CC Alonsabe/ CC Araneta/ CC Atotubo/CC Aguilar
Patient
Name:
Donguines,
Leah
Address:
Dumangas,
Iloilo
Birthday:
10-21-74
Clerk in
Charge:
CC Atotubo

Age
41

Sex
F

Assessment

Impression

Chief Complaint:
Generalized skin rash,
pruritic
HPI:
2 days PTC, patient
developed generalized
pruritic rash while working
in the field. Pruritus was
noted to be aggravated by
perspiration. Patient
applied cassava starch to
the affected areas with
relief of pruritus. Patient
scratched the area with
breaks in the skin.
DOC, lesions and pruritus
persisted
PMH:
(-) previous
hospitalizations
(-) FDA, BA, HTN, DM
FHx:
unremarkable
PSHx:
NANS, farmer
Physical Exam:
Anicteric sclera, pinkish
conjunctiva, NCLAD, NNVE
Symmetrical chest
expansion, clear breath
sounds, adynamic

Atopic Dermatitis

Management
What should have
What was done?
been done?
Loratadine 10
Hydrocortisone
mg/tab, 1 tab OD x 7 ointment 1% Use 1%
days
ointment 2-3 times
daily.
Prednisone 20
mg/tab, 1 tab BID x 5 Loratadine 10 mg/tab, 1
days
tab OD x 7 days
Health education
done

Health education and

hypoallergenic diet

Advised

Maintain hygiene

Patient

Name:
Dumancas,
Reynaldo Jr.
Address:
Dujmangas,
Iloilo
Birthday:
05-27-77
Clerk in
Charge:
CC Atotubo

Age

38

Sex

Assessment
precordium, normal
cardiac rate and rhythm,
soft nontender abdomen
(+) hyperpigemented
lesions, generalized
(-) redness, pruritus
(+) signs of healing
Chief Complaint:
Skin lesions on the neck,
chest and back, pruritic
HPI:
1 year PTC, onset of
popular lesion, nontender,
erythematous, pruritic
when exposed to
perspiration.
7 months PTC, increase in
the number of lesions in
the neck and back. Other
lesions appear nodular
and abscess formation
was noted.
PMH:
(+) Gouty Arthritis; takes
Colchicine and Prednisone
FHx:
unremarkable
PSHx:
2 pack year smoker,
stopped 3 months ago
Occasional alcoholic
drinker, stopped 2 years
ago
Driver
Physical Exam:
Anicteric sclera, pinkish
conjunctiva, NCLAD, NNVE
Symmetrical chest

Impression

Soft tissue
infection

Management
What should have
What was done?
been done?

Cloxacillin 50
mg/tab, 1 tab QID x
7 days
For referral to
Department of
Surgery
Laboratory and
diagnostic tests:
CBC, FBS, Se. Uric
Acid, Urinalysis,
Fecalysis
Advised

Cloxacillin 50 mg/tab, 1
tab QID x 7 days
Incision and drainage of
abscess
Daily wound dressing
Laboratory and
diagnostic tests: CBC,
FBS, Se. Uric Acid

Patient

Name:
Gayas, Lance
Address:
New Lucena,
Iloilo
Birthday:
01-20-15
Clerk in
Charge:
CC Atotubo

Age

6
mont
hs

Sex

Assessment
expansion, clear breath
sounds, adynamic
precordium, normal
cardiac rate and rhythm,
soft nontender abdomen
(+) papulonodular lesion
in the neck and back
(+) abscess and pustules
in the back
(+) hyperpigmented areas
and scarring in the neck
and back
Chief Complaint:
White patches on the
buccal area x 3 days
Skin rash in the back area
x 1 week
Diaper rash
HPI:
1 week PTC, development
of maculopapular rash at
the back with scaling and
dryness noted. No
management was done.
3 days PTC, development
of whitish plaques in the
buccal mucosa.
1 day PTC, development of
maculopapular rash in the
buttocks
PMH:
No previous admissions
(-) FDA, BA
FHx:
Unremarkable
PSHx:
Exclusively breastfed up to
6 months

Impression

Oral thrush
Atopic dermatitis

Management
What should have
What was done?
been done?

Nystatin Oral
Suspension
1 mL QID x 10 days
Hydrocortisone 1%
cream, apply once a
day

Hydrocortisone
ointment 1% Use 1%
ointment 2-3 times
daily.
Nystatin Oral
Suspension
1 mL QID x 10 days
Advise hypoallergenic
diet
To come back anytime if
with problems

Patient

Name:
Madoginog,
Samantha
Address:
Maasin, Iloilo
Birthday:
1-21-13
Clerk in
Charge:
CC Atotubo

Age

Sex

Assessment
Started solid food 3 days
ago
Immunizations up to date
Development at par with
age
Physical Exam:
Active, good cry, good
suck, Anicteric sclera,
pinkish conjunctiva,
NCLAD, NNVE
Symmetrical chest
expansion, clear breath
sounds, adynamic
precordium, normal
cardiac rate and rhythm,
soft nontender abdomen
(+) white plaques in the
buccal mucosa
(+) maculopapular rash in
the back and buttocks
Chief Complaint:
Skin lesion in the nose,
chin and waist
HPI:
1 week PTC, Patient
experienced cough,
productive with post
tussive vomiting. They
consulted PP and was
prescribed with CoAmoxiclav and Prednisone
for 7 days. Cough resolved
and when medications
were completed, onset of
apthuous lesions in the
tongue appeared.
3 days PTC, lesion in the
nose and chin appeared.

Impression

PCAP B
Impetigo

Management
What should have
What was done?
been done?

Cefaclor 250mg/5mL,
3 mL BID x 7 days

Cefaclor 250mg/5mL, 3
mL BID x 7 days

Cetirizine 5mg/5mL,
3 mL BID x 5 days

Cetirizine 5mg/5mL, 3
mL BID x 5 days

Mupirocin ointment,
apply TID

Mupirocin ointment,
apply TID

Hypoallergenic diet

Hypoallergenic diet

Advised

Advised

Patient

Age

Sex

Assessment
Folks applied calamine on
affected area. Cough
returned, productive with
whitish phlegm.
PMH:
(-) previous
hospitalizations
(+) BA, last attack- 7-1515
FHx:
(+) BA, HTN, DM, CA
(lung)
(+) TB exposure
PSHx:
Acive, good family and
peer relations,
development at par with
age, no exposure to
smoking, complete
immunizations, exclusive
breastfeeding for the first
weeks and mixed feeding
thereafter
Physical Exam:
Anicteric sclera, pinkish
conjunctiva, NCLAD, NNVE
Symmetrical chest
expansion, clear breath
sounds, adynamic
precordium, normal
cardiac rate and rhythm,
soft nontender abdomen
(+) multiple lesions and
scarring in the extremities
(+) apthuous lesions in
the tongue
(+) oneycomb lesion in
the chin and nose,
crusting noted

Impression

Management
What should have
What was done?
been done?

Patient
Name:
Suniega,
Kristine
Address:
Cabatuan, Iloilo
Birthday:
10-04-04
Clerk in
Charge:
CC Atotubo

Age
10

Sex
F

Assessment

Impression

Chief Complaint:
Skin lesions in the upper
extremities
HPI:
2 days PTC, patient
developed vesicular
lesions, pruritic and
spread gradually. Folks
applied antifungal
ointment with relief.
Lesions developed and
became pustular.
DOC, persistence of
lesions with increased
amount of pustules.
PMH:
(+) Skin Asthma
Previous skin infection
treated with Cloxacillin
and Cotrimazole cream,
relieved (Nov 2014)
FHx:
(+) HTN, DM, BA
PSHx:
NANS, no exposure to
smoke
Physical Exam:
Anicteric sclera, pinkish
conjunctiva, NCLAD, NNVE
Symmetrical chest
expansion, clear breath
sounds, adynamic
precordium, normal
cardiac rate and rhythm,
soft nontender abdomen
(+) pustular lesion at the
right arm
(+) abscess formation

Atopic Dermatitis
with secondary
Bacterial
Infection

Management
What should have
What was done?
been done?
Advised admission
Advised admission but
but mother refused;
mother refused; risks
risks and
and consequences
consequences
explained.
explained.
Co-Amoxiclav
Co-Amoxiclav
400mg/5mL, 5mL TID x
400mg/5mL, 5mL TID 7 days
x 7 days
Cetirizine 5 mg/5mL,
Cetirizine 5 mg/5mL, 5mL BID
5mL BID
Mupirocin ointment,
Mupirocin ointment,
apply TID
apply TID
Hypoallergenic diet
Hypoallergenic diet
Follow up on Monday,
Follow up on
July 27, 2015
Monday, July 27,
2015
Advised
Advised

Patient

Age

Sex

Assessment

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Impression

Management
What should have
What was done?
been done?

Patient

Age

Sex

Assessment

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Impression

Management
What should have
What was done?
been done?

Patient

Age

Sex

Assessment

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Impression

Management
What should have
What was done?
been done?

Patient
Clerk in
Charge:

Age

Sex

Assessment
FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:

Impression

Management
What should have
What was done?
been done?

Patient

Age

Sex

Assessment
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:

Impression

Management
What should have
What was done?
been done?

Patient

Age

Sex

Assessment
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Impression

Management
What should have
What was done?
been done?

Patient

Age

Sex

Assessment

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Impression

Management
What should have
What was done?
been done?

Patient

Age

Sex

Assessment

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Impression

Management
What should have
What was done?
been done?

Patient

Age

Sex

Assessment

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Impression

Management
What should have
What was done?
been done?

Patient
Clerk in
Charge:

Age

Sex

Assessment
FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:

Impression

Management
What should have
What was done?
been done?

Patient

Age

Sex

Assessment
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:

Impression

Management
What should have
What was done?
been done?

Patient

Age

Sex

Assessment
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Impression

Management
What should have
What was done?
been done?

Patient

Age

Sex

Assessment

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Impression

Management
What should have
What was done?
been done?

Patient

Age

Sex

Assessment

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Impression

Management
What should have
What was done?
been done?

Patient

Age

Sex

Assessment

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Impression

Management
What should have
What was done?
been done?

Patient
Clerk in
Charge:

Age

Sex

Assessment
FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:

Impression

Management
What should have
What was done?
been done?

Patient

Age

Sex

Assessment
PSHx:
Physical Exam:

Name:

Chief Complaint:

Address:

HPI:

Birthday:

PMH:

Clerk in
Charge:

FHx:
PSHx:
Physical Exam:

Impression

Management
What should have
What was done?
been done?