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MARIA KRISTINA G. DE JESUS 2H MEDICINE

  August 6, 2010 Referred from: N.K.T.IHistory taken by: Rizza De Leon Informant: Patient

Jaelyn Anciro % Reliability: 70%

IDENTIFYING DATA Amado Palitic, 63 years old, male, married, Filipino, Roman Catholic, was born on September 13,

1947 at San Carlos, Pangasinan, is currently residing at LaonLaan, admitted for the first time at FEU ±NRMF Medical Center last August 4, 2010.

CHIEF COMPLAINTPainful right foot

HISTORY OF PRESENT ILLNESSNine months prior to admission, the patient noticed that he would easily feel fatigue. Usually, due

to his work, he owned a food stall which caters viand. He would usually start at early morning, going tothe wet market to buy ingredients which he would be cooking, served it to his customers and close upuntil dinner time. Not until prior to his consult, he eventually did noticed that the usual stamina during theday has decreased. He described the decreasing stamina as in by the duration of which he is standingduring the day. Before the easy fatigability, he can stand up from morning until noon. But as the dayspass by, he would be easily tired and feel weak. Hence the consult to the center, the physician requestedfor FBS, the result was high which was unrecalled as told by the patient. The physician diagnosed thepatient to have Diabetes mellitus and prescribed him Metformin and Betaloc.

Six months prior to admission, the patient had noticed that his right foot began to swell. Theswelling was not pitting. It would just be temporary. There were days that there was no swelling and dayswhen there is swelling. Hence, the swelling was not accompanied by any pain. So the patient just did notgive any attention to it. He did not take any medications nor seek any consultation.

Five days prior to admission, the patient noticed that his right foot was swollen again. There wasalso a boil on his right foot. Yet there was no pain or tenderness felt. This time, the swell pitting. He seektreatment to an ³albularyo hoping it was just because of supernatural elements like dwarves which wereonly thought to be playing with him so it resulted to the boil and swelling. The ³albularyo chewed some

betel nuts or the ³ikmo´ or ³nganga´ . He turned it into a paste-like structure then applied it to the patient¶sright foot. After which, the ³albularyo wrapped the foot with cloth. The patient was then sent home after the so called treatment.

Four days prior to admission, the right foot, still swollen, the patient decided to check on it, sawthat it was watery, with clear thin fluid oozing out. There was also pain. The pain was precipitated whenthe patient stands up, walk or at least when foot gets in contact with hard surfaces. The pain waslocalized only to the right foot up the right knee; there was no radiation to other parts of the body. Thepain was tolerable because the patient can still walk but just for a short time. No other symptoms werenoted like fever. The patient did not seek consult nor take any medications.

Three days prior to admission, the patient still experienced the above symptoms. He then askedhis wife to accompany him to seek consult. But it was not to the nearby center or to the ³albularyo . Theyimmediately left their province and went to Laon Laan Quezon city. They stayed to their sister-in-lawshouse. They did not go to the hospital upon arriving to Quezon City. The two just rest and decided to go

to the hospital the next day. No other symptoms were noted like fever. The patient did not seek consultnor take any medications.

One day prior to admission, the patient and his wife decided to seek consult at National Kidneyand Transplant Institute in East Avenue Quezon City. Due to their dismay, there was no Diabetologistavailable there. They were referred to FEU ± NRMF Medical Center, went to our institution, hence theadmission.

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PAST MEDICAL HISTORYNovember 2009 ± diagnosed to have DM type 2, maintained with MetforminMay 2010 ± had an allergic reaction after intake of shrimps and chicken, applied

³Katchalis´ The patient cannot recall if he was given vaccines during his childhood, did not have the usual

childhood diseases like Chickenpox, measles, has not undergone any surgical procedures, previous

hospitalizations, vehicular accidents and blood transfusion.

FAMILY HISTORYFather ± died at the age of 78, due to complications of HypertensionMother ± died at the age of 79, due toOther siblings: 1 sister, 3 brothers ± (+) DM

2 brothers ± (+) HPN

PERSONAL AND SOCIAL HISTORYThe patient is a former food stall owner, worked together with his wife to maintain their business,

has a 21 year old daughter whom is apparently well. He is fond of native cakes, salty foods, and softdrinks, has no regular exercise especially when he stopped working on their business. He is a non-alcoholic and non-smoker. He lives on an up and down type of house wherein they are only three in living

in it. Their house is well ventilated, well-lit, water supply is Jetmatic, and garbage is collected every twotimes a week. Denies use of prohibited drugs. He also still believes on supernatural creatures likedwarves and the like.

REVIEW OF SYSTEMSConstitutional: (-) loss of appetite (+) weakness (-) weight loss Skin: (+) itchiness (-) sweating (-) cyanosis (+) dryness (-) color change Head: (-) headache, (-) dizziness, (-) vertigo Eyes: (+) blurred visions, (-) double vision (+) use of eyeglasses Ears: (-) tinnitus (-) discharge Nose and Sinuses: (-) change in smell, (-) pain (-) nasal obstruction Mouth and throat: (-) sore throat, (-) disturbance in taste, (-) hoarseness, (-) lips Neck: (-) pain, (-) stiff neck, (-) no mass 

Breast: (-) lumps, (-) pain (-) mass Respiratory: (-) crackles, (-) wheezing, (-) dyspnea CVS: (-) substernal pain, (-) syncope (-) palpitation (-) orthopnea GIT: (-) diarrhea, (-) constipation, (-) dysphagia, (-) epigastric pain GUT: (-) dysuria (-) urgency (-) hematuria NMS: (-) arthralgia, (-) myalgia, (-) stiffness Extremities: (-) stiffness, (-) edema (+) weakness, body Nervous system: (-) numbness, (-) loss of memory, (-) confusion, (-) vomiting Endocrine: (-) heat/cold intolerance

PHYSICAL EXAMINATION

GENERAL SURVEY

The patient is conscious, well kempt, looks appropriate for his age, cooperative, oriented to time,place and person, coherent, well-nourished, no gross deformities and ambulatory and with no sign of distress with the following vital signs:

Blood Pressure: 130/80 mmHg Cardiac rate: 79 beats per minuteRespiratory Rate: 18 cycles per minute

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SKINSkin is brown, dry, less elasticity, thickness, mobility: with no visible superficial vessels, body hair 

is scanty, with fine strands, black in color evenly distributed; nails are pink, rough, slightly deformed, andwith normal folds.

HEAD Head is normocephalic and symmetrical. Hair is brown, curly, coarse, moist and evenly

distributed, clean scalp, no mass, no lesion or tenderness. Temporal artery is not visible but palpable withstrong equal pulsation and walls are not thickened.

FACEFace is round in shape, symmetrical, brown skin. There are no pigmentations, with two

hyperpigmented nevi on the left cheek, with normal facie and no involuntary facial movements.

EYES

Thin black eyebrows, evenly distributed, normal palpebral fissure, no lid edema, no ptosis,negative lidlag test; normally set of eye balls, thin black eyelashes, outward direction of growth, nomatting; pale conjunctivae, white sclera, transparent cornea, black iris with regular contour, pupils normalin size and shape, equally reactive to light and accommodation, transparent lens, (+) ROR, 2:3 A:V ratio,optic disc with distinct borders, (-) hemorrhage, (-) papilledema.

EARS Auricles are symmetrical, no lesion or tenderness, no tenderness of the mastoid, both auditory

canals are patent, no discharge, swelling, redness or lesion of the walls, tympanic membranes are pearlywhite, intact normal contour, visible cone of light, malleus not visualized. The cone of light is visualized,no bulging, no retraction, no perforation. NOSE AND PARANASAL SINUSES

Nose is symmetrical, no lesion, no deformity, no tenderness, no flaring of ala nasi, nasal septumat the midline, patent vestibules, mucosa is pink, intact, turbinates not congested, no discharge, notenderness over the frontal and maxillary sinuses, positive transillumination test. 

ORAL CAVITYLips are brown, dry, symmetrical, no lesion or deformities. Tongue is at the midline regular in

size, pink, rough papillae, moist, symmetrical, no lesion, no tremors .Hard and soft palate are pink, nolesion. Uvula at the midline: tonsils are pink not enlarged, no signs of inflammation, and no exudates:posterior pharyngeal wall is pink, no lesion, and no exudates. 

NECKNeck is supple, symmetrical, normal tone, no tenderness, no lesion, no mass. Trachea is in the

midline, no palpable lymph node: thyroid gland not palpable. 

THORAX

Skin is brown, with erythematous pruritic undurated plaques just above the head of themanubrium, and no dilated superficial blood vessel with normal muscle development. Bony thorax iselliptical in shape; symmetrical, and no tenderness. Respiratory rate is 18 cycles per minute, with normalrhythm and deeper depth of respiration, inspiration longer than expiration with effort breathing.

Symmetrical lung expansion. Normal and equal tactile fremitus, percussion note is resonant over the lungfields. Breath sounds are vesicular. Negative for Bronchophony, Egophony and whispered pectoriloquy.Crackles were heard.

HEART

Carotid artery pulses are regular, strong and equal. Jugular veins are not engorged. No precordialbulging, adynamic precordium, apex beat at left 5

thICSMCL, no palpable A2, P2, S3, thrust, lift, heave or 

thrills. Heart rate is 79 bpm with regular rhythm.

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ABDOMEN

 Abdomen is brown, globular, and symmetrical, with erythematous pruritic plaques on the right andleft flank and on the left scapular area, no mass, no localized bulging flanks and no superficial dilatedveins. There are no visible peristalsis and with slightly visible pulsations and umbilicus is inverted.

On auscultation, the bowel sounds are normoactive, no bruits on the epigastric area and on theright and left renal artery areas.

On percussion, there is equal distribution of tympanism and dullness on all the abdominalquadrants, spleen is not appreciated, negative shifting dullness, fluid wave and costovertebral angletenderness.

On palpation, there are no palpable masses and no tenderness

NEUROLOGICAL EXAM

GENERAL CEREBRAL FUNCTION

The patient is conscious, well kempt, looks appropriate for his age, cooperative, oriented to time,place and person, coherent, well-nourished, no gross deformities and ambulatory and with no sign of distress. GCS = 15

CRANIAL NERVES

CN I ± can identify smell of coffeeCN II ± ophthalmic findings - pale conjunctivae, white sclera, transparent cornea, black iris with regular contour, pupils normal in size and shape, equally reactive to light and accommodation, transparent lens,(+) ROR, 2:3 A:V ratio, optic disc with distinct borders, (-) hemorrhage, (-) papilledema

- Plotting of visual fields ± no visual field defectCN III, IV & VI ± Both pupils constrict briskly reactive to light both direct and indirect

- Adduction of both eyes and constriction of both pupils on accommodation test- Equal and complete opening of both eyes- EOM ± can move eyes in 6 cardinal directions of gaze

CN V ± Facial sensation ± can feel pain and light touch equally on both sides- Corneal reflex ± prompt and equal blinking of both eyes- Motor function ± can clench teeth on both sides- (-) jaw jerk

CN VII ± Can identify taste of salt

- Can frown, raise eyebrows, close eyes tightly, nasolabial folds symmetrical on both sidesCN VIII ± Weber ± no latelaralization

- Rinne ± AC > BC- No nystagmus- (-) Romberg¶s test ± no swaying with eyes closed and open

CN IX & X ± No dysphonia, uvula is in the midline, equal elevation of palate on phonation, (+) gag reflexCN XI ± can turn head from side to side against resistance

- Can elevate shoulder equallyCN XII ± No atrophy nor fasciculations, tongue is in the midline on protrusion, moves tongue from side toside