Date of Interview : April 12, 2018

Time of Interview : 1:30PM

Place of Interview : Mariano Marcos Memorial Hospital and Medical Center (MMMH-
MC) Internal Medicine Ward
Informant : Patient
Reliability : 90%

I- General Data
Patient R.R.M., 41 year old, male, single, and residing at Batac, Ilocos Norte. He is
an affiliate of Iglesia Filipina Independiente and a herdsman. He was admitted on April 12,
2018 and this is his first time admission.

II- Chief Complaint

“haanak nga makaanges” (difficulty of breathing)

III- History of Present Illness

On August 5, 2016, the patient was apparently well until he experienced a sudden
onset of difficulty of breathing while herding the animals in the morning after he had his
breakfast. It is associated with easy fatigability. He denied of having palpitation, dizziness,
headache, edema, or visual problems. The patient was able to herd the animals but he
observed to have a sudden onset of productive cough with transparent (clear) mucoid
discharge amounting to approximately 1 tablespoon. He took a rest and a glass of water to
relieve difficulty of breathing but it got even worse. He then decided to seek for consult at
MMMH-MC. At the ER, he has an elevated blood pressure with unrecalled reading. He was
advised to for a chest x-ray and ultrasound. X-ray result revealed that his heart was
enlarged (cardiomegaly) and his lungs have a fluid (pulmonary edema). He was given a
home medications and maintenance drug of captopril 12.5mg to be taken twice a day for
his hypertension and spironolactone 25mg once a day until his congestion resolves. The
patient claimed to be compliant to his medications.
1 day prior to admission, the patient performed his daily routine of herding the
animals after taking his breakfast. When he was at 10m distance away from their house,
he felt a sudden onset of difficulty of breathing with easy fatigability. He denied of having
palpitation, dizziness, headache, edema, or visual problems. The patient still continues to
herd the animals but took some rest after 20 steps because he feels tired and difficulty of
breathing ensues. It then followed by productive cough with yellowish discharge
amounting to approximately half tablespoon. Coughing was triggered by shortness of
breathing and feeling of obstructed phlegm in the throat. Difficulty of breathing was not
fully relieved by rest and aggravated by movement. The patient rested and able to herd
home the animals but still with difficulty of breathing and easy fatigability. He was not able
to sleep at night due difficulty of breathing aggravated by productive cough. He had a 4-
pillow orthopnea. His mother gave her carbocisteine for his cough. He somehow felt
relieved but had a sensation of shortness of breathing that interrupts her sleep (paroxysmal
nocturnal dyspnea).
Few hours prior to admission, the patient was able to herd the animals but
difficulty of breathing is getting worse. He noticed that he already had difficulty of
breathing with 10 steps so he immediately went at MMMH-MC for consult.
Physical Examination
A. General Survey
The patient is awake, alert, and well-groomed. He is in cardiopulmonary
distress. Words are clear and speech is fluent. Thought processes are coherent and
memory is intact. He is oriented to person, time, date, and place. He is attentive,
remain focused and maintained eye contact. He has a heplock on her right dorsal
hand, in supplemental oxygen via nasal canula regulated at 1-2LPM, and with an
indwelling Foley catheter connected to a urine bag draining dark yellow urine.

B. Vital Signs
BP = 120/90mmHg
RR = 33bpm
PR = 87bpm
T° = 37.1°C
O2 Sat = 93%
Wt. = 64kg
Ht. = 170.5cm
BMI = 21.99

C. Skin, Hair, and Nails

1. Skin
No lesion and rash. Skin is cold and clammy to touch. With good skin
turgor.
2. Hair
Hair is curly and black in color. Moist, fine, and equally distributed.
Scalp has no lesion, scaling or infestation. No tenderness or mass.
3. Nails
No clubbing or cyanosis.

D. HEENT
1. Head
Skull is symmetrical in contour.

2. Eyes
Symmetrical. Jaundice sclera. Palpebral conjunctiva is pinkish. No ptosis
or nystagmus. No discharge. Bilaterally positive ROR.

3. Ears
Symmetrical without swelling. Both ears have minimal wet yellowish-
brownish earwax partially occluding the tympanic membrane. positive cone of light.
No mass, lesion, or deformity. No tenderness.
4. Nose
Nasal mucosa is moist and pink. No swelling, bleeding, or exudates.
Septum is midline. Whitish discharge noted. No tenderness and negative
transillumination on sinuses.
5. Throat and Mouth
Oral mucosa is moist and pale. Tongue has no lesions. Pharynx has no
swelling, bleeding, or exudates. Tonsil is grade II. 1st and 2nd lower right and left
molars and upper right central incisor are missing. Teeth have dental carries.
Uvula is in the midline.

E. Neck
Trachea is in midline. Thyroid isthmus is palpable and mobile. No mass. With
2cm horizontal scar on left sternocleidomastoid area.
Pakidagdag na lang sa neuro guys:
CN II
Visual fields:
Central and peripheral visions are intact in all fields by confrontation test.
Visual acuity:
OD: 20/20
OS: 20/30 + 1

CN II and III
Pupils are equally round and reactive to light and accommodation (constrict from 3mm
to 2mm).

CN III, IV, VI
Extraocular movement (EOM) intact in six directions
No nystagmus.

CN VIII
Weber Test: lateralizes midline
Rinne Test:
AU: AC > BC