3C ISO 1

▪ G.T.
▪ 59/F
▪ separated, unemployed
▪ Christian
General Data ▪ Born 11/28/58
▪ Residing at Novaliches, QC
▪ Admitted for the 1st time at FEU-NRMF on March 25, 2018
 CHIEF ▪difficulty of
COMPLAINT breathing
HISTORY OF PRESENT
ILLNESS
 ▪ Intermittent, non-productive cough
▪ No associated:
▪ Dyspnea
▪ chest pain
4 months ▪ Colds
▪ Headache
PTA ▪ Nausea/vomiting

▪ (+) consult with oncologist

▪ No medications taken
 ▪ Still with the same signs and symptoms, now with SOB
and DOB
2 months ▪ (+) consult to oncologist
PTA ▪ prescribed with Ambroxol 30mg/tab
 ▪ Still with the same signs and symptoms, now with pain
on the left hip, dull in character, 5/10 pain scale,
3 days radiating to the left leg and foot
▪ (+) consult at Bernardino Hospital
PTA
▪ prescribed with Morphine 10mg/tab
 ▪ Sudden SOB
▪ Associated with
▪ DOB
▪ Productive cough
▪ Constipation
Few hours
▪ Vomiting 3 episodes PIF
PTA ▪ No associated
▪ colds, fever, abdominal pain
▪ Salbutamol neb, afforded temporary relief
▪ Symptoms prompted consult
 ▪ (+) chickenpox
▪ Unrecalled childhood immunizations
▪ Known case of Breast CA St IV with bone mets since
2014
PAST MEDICAL ▪ Her2neu - equivocal

HISTORY ▪ ER/PR positive

▪ S/p Chemo x 6 cycles, RT x 33 days
▪ S/p MRM, Right 2014
▪ Bone Scan - July 2017
 ▪ Zoledronic acid x 2cycles last dose January 2018
▪ Anastrazole x 3 years last dose April 2017
▪ EPO 4000
PAST MEDICAL ▪ Morphine 10mg BID
HISTORY ▪ Iberet + FA OD
▪ Ca + Vit D OD
▪ Mosegor Vita OD
 ▪ Bernardino Hospital - Breast mass excision, Right April
2013
▪ Lung Center of the Philippines - MRM, Right October
2013
PAST MEDICAL ▪ Non-asthmatic, non-hypertensive, non-diabetic
HISTORY ▪ No liver, thyroid, renal diseases, cardiovascular dse, no
blood transfusion, no accidents or trauma
▪ No known allergies to food or drugs
 ▪ Father: deceased at 83 years old due to pneumonia
▪ Mother: deceased at 94 years old due to old age
▪ 8/8 siblings
▪ One sibling with pancreatic CA
▪ One sibling with breast CA
FAMILY ▪ One sibling with lung CA
HISTORY ▪ With heredofamilial tendencies of malignancy, BA,
hypertension and diabetes mellitus
▪ No heredofamilial tendencies such as heart, lung, liver,
thyroid, and kidney diseases
 ▪ M - 11 1/12 years
▪ I - regular

MENSTRUAL & ▪ D - 3-5 days

▪ A - 6 ppd, moderately soaked
OBSTETRIC ▪ S - (-)
HISTORY ▪ Nulligravid
▪ Menopause for 12 years
 Constitutional symptoms: (+) weight loss- 5kg in the past
3 months; (-) loss of appetite; (-) generalized body
weakness
Skin: (-) itchiness; (-) excessive dryness or sweating; (-)
pallor; (-) jaundice; (-) erythema
Head: (-) vertigo; (-) headache; (-) dizziness

ROS Eyes: (+) use of correctional lenses; (-) lacrimation, (-)

pain; (-) double vision;
Ears: (-) decreased hearing; (-) earache; (-) ear
discharge; (-) tinnitus
Nose and Sinuses: (-) changes in smell; (-) nose
bleeding; (-) nasal discharge; (-) pain over paranasal
sinuses
 Mouth and Throat: (-) toothache; (-) gum bleeding; (-)
sore throat; (-) disturbance in taste
Neck: (-) pain; (-) limitation of movement; (-) mass
Breast: (-) pain; (-) lumps; (-) nipple discharge

ROS Cardiovascular: (-) palpitations; (-) chest pain; (-)

syncope
Gastrointestinal: (-) dysphagia; (-) diarrhea; (+)
constipation; (-) melena; (-) hematochezia; (-) nausea; (-)
vomiting
 Genitourinary: (+) polyuria (-) genital pruritus; (-)
incontinence; (-) urethral discharge; (-) hesitancy
Extremities: (+) pain on left hip radiating down to the
legs; (-) swelling of joints; (-) numbness; (+) difficulty in
ambulation
ROS Nervous: (-) confusion, (-) loss of consciousness; (-)
paralysis; (-) paresthesia
Hematologic: (-) bleeding tendency; (-) easy bruising
Endocrine: (-) cold/heat intolerance; (-) polydipsia
 ▪ General Survey: Patient is conscious, coherent, in mild
cardiorespiratory distress, with the following vital signs:
BP: 120/80 mmHg CR: 97 bpm RR: 20 cpm
PHYSICAL T: 37.6 ˚C O2: 98%
▪ HT: 5’1’’
EXAMINATION ▪ WT: 42kg
▪ BMI: 17.5 - underweight
▪ Skin: Skin is pale, with normal degree of moisture,
elasticity, mobility and thickness, normal skin turgor;
nail beds are pale, nail plates are smooth and thick, no
lesions, nail folds are normal looking.
▪ Head: Patient has black hair; scalp is clean. Head is
normocephalic, symmetrical, without swelling, no
deformities, no tenderness and no masses. Temporal
arteries are not visible but palpable with strong equal
pulsations.
▪ Eyes: Eyebrows are black, thick, evenly distributed, no
erythema and no lesions noted; normal palpebral
fissures; Eyes on the midline, eyelashes are thin, with
outward direction of growth, no matting. Pale palpebral
conjunctivae, anicteric sclerae, iris is brown with
regular contours, 2-3mm pupils equally reactive to light,
no exophthalmos, no enophthalmos and no nystagmus,
(+) ROR
▪ Ears: Symmetrical auricles, no lesions, no tenderness,
auditory canals are patent, no discharge, no swelling or
redness of the walls of the canal, tympanic membranes
are pearly white and intact, normal contour with visible
cone of light, and has no perforation
▪ Nose: Symmetrical, bilaterally patent vestibules, pink
mucosa without lesions, nasal septum is in the midline,
without perforations, turbinates are pink, flat, moist, with
abundant hair and not congested, no nasal discharges,
no tenderness over the frontal and maxillary sinuses.
▪ Oral Cavity: Lips are moist, pale and symmetrical, no
deformities. Buccal mucosa is pink. Tongue is moist and
in midline, symmetrical. Uvula is at midline.
▪ Neck: Normal in size, symmetrical, no visible mass,
swelling or deformity, no tenderness, full range of
motion, with no jugular distention. Trachea is in the
midline, with no palpable cervical lymph nodes.
Thyroid gland is not visible or palpable. Strong carotid
pulse, regular rhythm, equal pulses, soft walls.
▪ Thorax and Lungs: Skin is brown, symmetrical in
shape, with normal muscle development, symmetrical
chest expansion, (+) intercostal retractions, (+) crackles,
(+) rhonchi, bilateral
▪ Cardiovascular: Adynamic precordium, no heaves, no
thrills. Normal rate, regular rhythm, no murmur, (+)
jugular vein distention
▪ Abdomen: Abdomen is flabby, soft, brown skin, no
lesions, umbilicus is inverted, no visible pulsations in
the epigastric region, no dilated superficial blood
vessels. Normoactive bowel sounds, non-tender.
▪ Extremities: No gross deformities, full and equal
pulses, CRT < 2 seconds, no edema.
 ▪ GCS: 15 (E4V5M6)
NEUROLOGICAL ▪ Appropriately groomed and cooperative
EXAMINATION ▪ Can talk spontaneously
 ▪ Can perform finger-nose-finger test, alternating
pronation and supination, and heel to shin test
▪ Romberg’s test: negative
Cerebellum ▪ Tandem gait: able to perform
▪ (-) Nystagmus
 ▪ CN I: Both nostrils are patent, able to identify substance presented
which is coffee
▪ CN II: Both pupils 2-3 mm equally & briskly reactive to light; (+)
Red Orange Reflex; 2:3 AV ratio, (-) hemorrhages, (-) papilledema
▪ CN III, IV, VI: Complete opening of left eye. Intact extraocular
muscles, no nystagmus, no noted ptosis;
▪ CN V: can feel pain and light touch on both sides of the face, can
CRANIAL clench teeth
▪ CN VII: can frown, raise eyebrows, close both eyes tightly equally
NERVES on both sides, and smile
▪ CN VIII: responsive to verbal sounds; on Weber’s test – equally
heard on both ears
▪ CN IX & X: no dysphonia nor dysarthria, (+) gag reflex
▪ CN XI: can turn head from side to side against force, can shrug
shoulders
▪ CN XII: tongue has no atrophy nor fasciculation, midline on
protrusion, can move tongue from side
 Motor
Sensory
DTR
 ▪ (-) Babinski
Pathologic ▪ (-) Oppenheim
Reflexes ▪ (-) Chaddock
 ▪ 59/F
▪ CC: DOB
▪ (+) SOB, vomiting PIF 3x, productive cough
▪ Frail-looking, generalized pallor
▪ Bilateral crackles and rhonchi, intercostal retractions
Salient ▪ Known case of Breast CA St IV with bone mets since
2014 (Her2neu - equivocal, ER/PR positive)
Features ▪ S/p Chemo x 6 cycles, RT x 33 days
▪ S/p MRM, Right 2014
▪ With heredofamilial tendencies of malignancy, BA,
hypertension and diabetes mellitus
▪ BMI: 17.5
 ▪ Pneumonia in the Immunocompromised Host
▪ Breast CA Stage 4 with Bone Metastasis
Admitting
▪ Euvolemic Hypoosmolar Hyponatremia
Diagnosis ▪ Anemia of Chronic Disease
 ▪ Diet: Full diet
▪ IVF: PNSS x 60 cc/hr
▪ Diagnostics: CBC, Na, K, BUN, Crea, SGPT, CXR PA-L, Sputum
GS/CS, CBG, IoCa, Mg, ABG, Urinalysis, 12-L ECG
▪ Medications:
▪ Piperacillin-Tazobactam 4.5gm IV Q8 ( ) ANST
▪ Levofloxacin 750mg/tab 1 tab then OD in AM

Plan ▪ Salbutamol + Ipratropium Br neb 1 neb q6

▪ Ambroxol 75mg/cap 1 cap then OD
▪ Plasil 10mg IV q6
▪ Omeprazole 40mg/tab 1 tab then OD in AM
▪ O2 @ 3-4lpm via nasal cannula
▪ Repeat Na tomorrow
▪ Transfuse 1 unit pRBC properly typed and crossmatched