Patient Profile
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Transcript of Patient Profile
Patient Profile
N.F., 55 years old Filipino female, married housewife, Roman Catholic, from Makati City
Admitted last December 3, 2011
Patient Profile Land lady, manages her own general
merchandise (family’s primary source of income)
Lives in a bungalow (mixed concrete and wood), located along the road, with 5 occupants, 3 rooms, 1 CR, with electricity, MAYNILAD as source of water, garbage collected daily
Patient Profile Daly activities:
Doing household chores, accompanies grandson to school
Sleeping habit:10PM-6AM and 12NN-3PM
Patient Profile Food preference: rice, vegetables and
fish Drinks >1L/day; rarely drinks coffee;
non-alcoholic beverage drinker Non-smoker Regular BM (1x daily) Urinates 4-5x daily, total of 2.5L/day
Chief Complaint Body weakness of 8 days duration
History of Present Illness 9 days PTA (+) fever (38°C), relieved by 1 tab of Bioflu
8 days PTA (+) body weakness described as feeling
of fatigue, advised bed rest by her daughter, avoided her usual activities
History of Present Illness 6 days PTA still with body weakness (+) decrease appetite (from the usual 1
cup of rice/meal 3x a day with snacks in between to 2-3 glasses of milk and 2-3 crackers)
History of Present Illness 2 days PTA Persistence of weakness & decrease in
appetite + vague epigastric pain (feeling of hunger, PS of 5-6/10) prompted consult at a private physician
Given Omeprazole, Mefenamic Acid and Iselpin w/c relieved the pain after taking 1 tab each
History of Present Illness 2 days PTA Advised to drink 1 glass of Ensure per
day but did not comply due to unpleasant taste
Series of laboratory examinations done
History of Present Illness Day of admission Follow-up consult with the same
physician for laboratory results showed elevated BUN, Creatinine, FBS, total cholesterol, triglycerides, HDL, LDL, SGPT, uric acid, K, and WBC? (we still don’t have the copy of lab results done outside, sir X will try to contact the said private physician)
History of Present Illness Day of admission (+) bipedal edema, grade 1 noted by the
physician
Advised admission
Temporal Profile
9 8 7 6 5 4 3 2 1 0
Fever
Generalized body weakness
Appetite
Epigastric pain
PTA (Days)
Inte
nsity
of s
ympt
om
Past Medical History (+) UTI – 1997, treated for 1 month;
patient claimed to be recurrent (frequency not established) though no laboratories done to support, self medicated with Bactrim 1-2 doses per episode
Past Medical History (+) Hypertension - 2005
On Losartan 50mg PRN (sorry, couldn’t find the right term, basta pagnagagalit lang dw siya) so di xa noncompliant coz that was the exact advised daw sa kanya ng dr.
Usual BP: 130-140/80-90
(+) Diabetes Mellitus Type 2 - 2005On Gliclazide 80mg BID, with poor
compliance
Past Medical History Use of Herbal supplements (Taheebo)
for 6 months – 2005
(-) hx of nephrolithiasis, (-) chronic use of NSAIDS
(-) exposure to CT scan with contrast
Family History (+) Hypertension (+) Diabetes Mellitus – both sides
Review of Systems General: (?) weight loss Skin: (-) rashes, (-) pruritus Eyes: (-) visual disturbances (do we need
to specify?) Respiratory: (-) cough/colds, (-) DOB Cardiovascular: (-) orthopnea, (-) dyspnea GIT: (-) nausea/vomiting, (-) hematomesis,
(-) diarrhea, (-) constipation, (-) hematochezia, (-) melena
Review of Systems Urinary: (-) dysuria, (-) polyuria, (-)
nocturia, (-) hematuria, (-) tea-colored urine Extremities: (-) cyanosis, (-) muscle cramps Nervous System: (-) headache, (-)
dizziness, (-) altered mental status, (-) loss of consciousness,
Endocrine: (-) intolerance to heat and cold, (-) neck surgery/irradiation, (-) excessive thirst/hunger, (-) thyroid problems
Admitting Physical Examination Vital Signs
BP = 140/80 mmHgHR = 93 bpmRR = 17 cpmTemperature = 36.4C
Admitting Physical Examination Head and Neck
Dirty scleraePink palpebral conjunctivaeNo cervical lymphadenopathiesNo tonsillo-pharyngeal congestion
Chest and LungsSymmetric chest expansionNo retractionsClear breath sounds
Admitting Physical Examination Heart
Adynamic precordiumDistinct S1 and S2Normal rateRegular rhythmNo murmur appreciated
Admitting Physical Examination
AbdomenFlabby abdomenSoftNon-tender upon palpation
ExtremitiesFull and equal pulsesBipedal edemaNo cyanosis
Opthalmologic ExamVisual Acuity OD OS
Far vision w/ correction 20/125 20/125
w/o correction 20/125 20/100
Pinhole test 20/63 20/80
Near vision w/ correction J7 J10
w/o correction J5 J7
•Opthalmologic Impression: • Nonproliferative DM retinopathy, OD-mild,
OS-normal• Immature cataract OU