Name: KNEDRICK KEVIN C.

MACALMA Course/Year: DOCTOR OF MEDICINE III

Subject: INTERNAL MEDICINE
Date and Time of Interview and Assessment: Nov. 10, 2017 at 2:00 PM

GENERAL DATA:
E.E. is a 43-year-old, male, married, Roman Catholic, residing in San Nicolas, Ilocos Norte. Informant is the
patient with 90% reliability.

CHIEF COMPLAINT: Chills

HISTORY OF PRESENT ILLNESS:

One year prior to admission, patient was hospitalized for three weeks due to stroke. At the same hospitalization,
he was diagnosed of Diabetes Mellitus type 2 with RBS as high as 340mg/dL and Hypertension with usual BP of
160/100 and highest BP of 220/130mmHg. Losartan 50 mg tab BID, Rosuvastatin 40 mg tab OD, and Amlodipine 5
mg tab BID were prescribed for hypertension and Insulin BID for Diabetes Mellitus. Follow up checkups were done
every 2 weeks until his blood pressure were stabilized and monthly thereafter. Due to financial constraints and
improvement of symptoms, patient stopped complying with checkups and medications.

4 months prior to admission, he had left flank pain accompanied by dizziness, nausea and weakness. He was
admitted for 2 weeks and was diagnosed of Chronic Kidney disease. Laboratory workups were done showing low
hemoglobion (80g/L) and high creatinine. Highest Blood pressure of 220/110 mmHg and unrecalled high RBS was
also noted. Left Internal Jugular Vein catheter was placed and advised for dialysis every two weeks after his
discharge. Medications were also prescribed such as Losartan 50 mg tab BID, Rosuvastatin 40 mg tab OD, and
Amlodipine 10 mg tab BID were for hypertension and Insulin BID for Diabetes Mellitus. No untoward symptoms were
experienced after the placement of IJ catheter and dialysis and with good medication compliance.

2 weeks prior to admission, placement of AV fistula access on his left brachiocephalic was done. He is compliant
with his dialysis schedule of twice a week and in taking his medications for hypertension and diabetes.

4 hours prior to admission, patient experienced chills accompanied by nausea after his usual dialysis session.
Laboratory and diagnostic workups revealing infection hence admitted.

PAST MEDICAL HISTORY:

Childhood Illnesses
Chickenpox date unrecalled
Medical/Surgical
Typhoid fever in 1989
Psychiatric
None
Immunizations:
Claims to have complete childhood immunizations; with positive BCG mark on right deltoid

FAMILY HISTORY:

Patient is the eldest of the 2 siblings. His father died at the age 54 due to complication of hypertension. His
mother, 61 years old, is diagnosed with hypertension. All other family members are apparently well. His family has no
history of thyroid disease, arthritis, tuberculosis, headache, seizure disorder, mental illness, and other malignancies.
 PERSONAL AND SOCIAL HISTORY
The patient is high school graduate and currently manages their bakery. He lives with his wife and 4 children in a
rented bungalow type of house consisting of 3 rooms. Water source for domestic purposes is from NAWASA and
drinking water comes from a refilling station. He usually sleeps for 3-4 hours a day and he has no form of
exercise.

The patient already quits smoking for a year with a history 19 pack years after he had stroke. He was a
former heavy alcoholic drinker consuming 2 330-ml bottle of Gin every day and is usually fond of eating salty
and fatty foods as pulotan. The patient has no allergies to food or drugs. Currenty he was prescribed with a low
salt low fat diet but is noncompliant. Patient tried using marijuana once due to curiousity. There is no history of
recent travel.

REVIEW OF SYSTEMS
GENERAL: (+) Weight loss, (+) easy fatiguability, (+) Weakness, (-) Trouble sleeping, (-) fever
SKIN: (-) Rashes, (-) Lumps, (-) Itching, (-) Dryness, (-) Wounds, (+) Color change, (-) Hair and nail changes
HEAD: (+) Headache, (-) Head injury, (-) Neck pain
EARS: (-) decreased hearing, (-) Tinnitus, (-) Earache, (-) Drainage
EYES: (-) Vision changes, (-) Pain, (-) Redness, (+) Blurry vision, (-) Specks, (-) Glaucoma, (-) Cataracts, (-) Dryness
NOSE: (-) Stuffiness, (-) Discharge, (-) Nosebleeds, (-) Sinus pain
THROAT/MOUTH: (-) Bleeding, (-) Sore tongue, (-) Dry mouth, (-) Sore throat, (-) Hoarseness
NECK: (-) Lumps, (-) Swollen glands, (-) Stiffness
RESPIRATORY: (-) Cough, (+) Mucoid sputum, (-) Hemoptysis, (-) Wheezing, (-) Painful breathing
CARDIOVASCULAR: (-) Chest pain, (-) Tightness, (-) Palpitations, (-) Easy fatigability, (-) Orthopnea, (-) Fainting
spells, (-) Cyanosis
GASTROINTESTINAL: (-) Swallowing difficulty, (-) Change in appetite, (-) Rectal bleeding, (+) Constipation,
(-) Diarrhea, (-) Food intolerance, (-) Abdominal pain
GENITOURINARY: (-) Frequency, (-) Urgency, (-) Hematuria, (-) Incontinence, (-) Change urinary strength,
(-) Change in color, (-) Enuresis, (-) Discharge
MUSCULOSKELETAL: (-) Muscle pain, (-) Joint pain, (-) Stiffness, (-) Back pain, (-) Redness of joints, (-) Swelling of
joints, (-) Limping, (-) Limitation of motion
NEUROLOGICAL: (-) Depression, (-) Memory loss, (+) Dizziness, (-) Fainting, (-) Seizures, (-) Weakness,
(-) Numbness, (-) Tingling, (-) Tremor, (+) Temper outbursts, (-) Hallucinations
HEMATOLOGIC: (-) Easy bruising, (-) Easy bleeding, (-) Past transfusion reactions
ENDOCRINE: (+) Cold intolerance, (-) Sweating, (-) Frequent urination, (-) Polydipsia, (-) Polyphagia

PHYSICAL EXAM
General Survey
He was seen lying in bed, alert, conversant, responsive and not in cardiopulmonary distress.

Vital Signs
Temp: 36.8oC, Axillary Oxygen saturation: 96%
Respiratory Rate: 26 breaths per minute Height: 163 cm
Heart Rate: 84 beats per minute Weight: 67 kg
Blood Pressure: 160/100 mmHg right upper BMI: 25.18 (overweight)
extremity, sitting

ASSESSMENT FINDINGS

Skin is moist and warm. With 3 inches vertical hyperpigmentation on the middle lower back at the
Integumentary
level of T10-T12. With good skin turgor.
Head and Neck
With dry hair, of equal distribution and fine texture. With frontal hairline regression. Scalp without
Head
lesion and tenderness
Vision of 20/50 - 1 OD, 20/400 + 1 OS, without corrective glasses. Visual fields full by
confrontation. Palpebral conjunctiva pale; anicteric sclera. Pupils 4mm constricted to 3mm, round,
Eyes
regular, equally reactive to light. Extraocular movement intact. Disc margin sharp, with mild
papilledema left eye nasally, no exudates.
 With round lesion in the left antihelix. With minimal earwax occluding the tympanic membrane both
Ears
on the left and right ear. no hearing deficit, good whisper test , (-) Weber, (+) AC > BC in Rinne;
Nose Mucosa pale, septum midline, no nasal flaring, no sinus tenderness.
Throat and Oral mucosa pale. Tongue midline. No ulcerations noted. 2nd and 3rd lower right molars and upper
Mouth molars are missing, other teeth have dental carries. Tonsils grade 1, Pharynx without exudates.
Neck supple. With dry right IJ catheter. No erythema, swelling or discharge noted on the IJ
Neck
catheter site. Trachea midline. Thyroid not palpable. No palpable lymph nodes.
Breast Symmetrical. No masses; nipples without discharge.
Chest moves symmetrically with respiration with no deformity seen. No scar or prominent dilation.
Chest expansion equal anteriorly and posteriorly at all three zones of the lung. Egophony,
Lungs and Thorax increased tactile fremitus and bronchophony present on the right lower lung field. With dullness on
the right lower lung field anteriorly and posteriorly. Resonant anteriorly and posteriorly on other
lung fields. With fine inspiratory crackles at the right lower lung field. No rhonchi, or wheezes.
Chest symmetrical. With adynamic precordium. Carotid upstroke brisk and rapid, without bruits.
Cardiovascular PMI is tapping at the left midclavicular, 5th ICS, without heaves and thrills. Good S1 and S2, no S3
and S4. No murmurs noted.
Round, protuberant, appearing distended with ascites. Blood vessels seen on the epigastric
region. With hypoactive bowel sounds. Tympanitic in the epigastric region and dull in other
Abdominal Exam regions. Liver span of 10.5 cm in the right midclavicular line and 5cm in the midsternal line. No
tenderness or masses. nonpalpable liver edge. Spleen and kidneys not felt. No costovertebral
angle tenderness. With positive fluid wave test.
The urethral orice is patent with pink mucosa located at the tip of the glans. There are no visible
Genitalia hernia, swelling, discharge and active lesions. The testes are descended, smooth, non-tender, and
symmetric with no hydrocele. Positive transillumination test.
Rectal Rectal vault without masses, stool brown, without fecal blood.
Warm. With nonpitting edema in the upper extremities and bipedal pitting edema grade1. Calves
Extremities
supple, nontender.
No varicosities. No stasis pigmentation or ulcers. Pulses 2+ (brisk) in the radial, femoral, popliteal,
dorsalis pedis and posterior tibial. Presence of thrills and bruit in the AV Fistula, left
Peripheral brachiocephalic.
Vascular Radial Femoral Popliteal Dorsalis Pedis Posterior tibial
Right 2+ 2+ 2+ 2+ 2+
Left 2+ 2+ 2+ 2+ 2+
Spine in midline with partial lumbar kyphosis. No joint deformities. Good range of motion in hands,
Musculoskeletal
wrists, elbows, shoulders, spine, hips, knees, ankles. Muscle strength of 5/5.
Neurologic
Mental
Alert and cooperative. Thought coherent. Oriented to person, time and place.
Status
CN1 - can identify the smell; CN2 - diminished vision on OS, PERRLA 3 mm, (-) field defect;
CN3,4,6 - normal ocular muscle movements, (-) nystagmus; CN5 - no motor deficits and wasting,
symmetric, intact pain, light touch and temperature sensation;
Cranial
CN7 - symmetric, no motor deficits, (-) pain; CN8 no hearing deficit, good whisper test , (-)
Nerves
Weber, (+) AC > BC in Rinne; CN9,10 - can differentiate taste, can swallow and opens mouth
wide, (+) gag reflex; CN11 - (+) shoulder shrug, able to fight resistance; CN12 - can protrude
tongue and move side-to-side.
Motor Good muscle bulk and tone. Strength 5/5 all throughout.
Rapid arm movement, point-to-point movement intact. Gait stable, normal. (+) Left-right
Cerebellar
discrimination.
Sensory Pinprick, light touch, position sense, vibration and stereognosis intact. Negative Romberg.
2+ (Brisk and normal) reflexes in Right Biceps, Triceps, Brachioradialis and Patellar; 1+ in Achilles.
Left Biceps not assessed.
Reflexes Biceps Triceps Brachioradialis Patellar Achilles
Right 2+ 2+ 2+ 2+ 1+
Left Not assessed 2+ 2+ 2+ 1+
 PATIENT EVALUATION

DIFFERENTIAL DIAGNOSIS

Pulmonary Embolism
Rule in: History of smoking, presence of dyspnea, crackles and tachypnea.
Rule out: No abrupt onset of pleuritic chest pain, syncope, hypotension, cyanosis or hypoxia.

Pleural effusion
Rule in: Presence of dyspnea, dull percussion noted on the area.
Rule out: Presence of increased tactile fremitus, crackles, no pleuritic chest pain.

Left sided Heart Failure

Rule in: Presence of hypertension, dyspnea, easy fatigability, inspiratory crackles, ascites and bipedal
edema (long term complication).
Rule out: Presence of increased tactile fremitus, dull percussion over the area, acyanotic.

Chronic Bronchitis
Rule in: Presence of easy fatigability, chills, sputum production, inspiratory crackles, dyspnea
and history of smoking.
Rule out: Acyanotic, No cough, Presence of increased tactile fremitus, dull percussion over the area.

Pulmonary Edema secondary to Kidney Failure

Rule in: Presence of easy fatigability, dyspnea, dizziness and weakness and crackles
Rule out: no tachycardia, no orthopnea, and no hypoxia

Hospital Acquired Pneumonia

Rule in: Dullness upon percussion over the area, presence of inspiratory crackles, presence of
increased tactile fremitus, egophony and brochophony; presence of nausea, weakness,
sputum, easy fatigability.
Rule out: no decreased in oxygen saturation, did not occur 48 hours after hospitalization

PRESENT WORKING IMPRESSION

Community Acquired Pneumonia

DM Type 2, insulin requiring
Hypertension
Chronic Kidney Disease

Bases for the Diagnosis of Community Acquired Pneumonia:

Manifestations occurring less than 24 hours Dullness upon percussion over the area, presence of
inspiratory crackles, presence of increased tactile fremitus, egophony and brochophony; presence of
nausea, weakness, sputum, easy fatigability.