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Central Philippine University

COLLEGE OF MEDICINE
School Year:
First Semester

ADULT PATIENT HISTORY & PHYSICAL ASSESSEMENT
by:
Name: Lizlin Noemi C. Bajada
DATE AND TIME OF ASSESSMENT
Date of Interview: June 18, 2014
Time of Interview: 1:30 P.M
I.General Data

Name : Maria Josephine Tiba
Sex : Female
Age : 49 years old
Birthdate : May 20, 1965
Civil Status : Married
Educational Attainment : High School graduate
Nationality : Filipino
Occupation : Housewife
Religion : Roman Catholic
Place of Residence : Sto. Angel, San Miguel, Iloilo
Source of Data : Patient
Reliability : 95% respectively
Date of Admission : June 18, 2014
Room Number : F15

II. Chief Complaint: Nagaubo ako
III. History of Present Illness
2 years prior to admission, patients experienced persitent productive cough with whitish
phlegm and was admitted at Aleosan District Hospital. Three days after, the cough persisted and
later transferred to Don Benito under Dr. Jalbuena.

2 months prior to admission, patient again experienced cough, but phlegm was not
present. She drank plenty of water to alleviate the pain, but her daily activities still continued.
The cough didnt stop for two months so she decided to seek medical consult at Iloilo Mission
Hospitals.

1 month prior to admission, patient developed intermittent backpain, associated with
night sweats and occasional cough. Awakening at night due to difficulty of breathing was noted.
Significant weight loss was also noted. Patient sought consult and was prescribe with
maintenance. But was not a good compliant due to financial problem.

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2 weeks prior to admission, patient had productive cough with whitist plegm. This time
patient sought consult at Doctor Hospital and was prescribed with carbocisteine and unrecalled
antibiotic with poor compliance.

On the day of admission, patient had persistent back pain and cough, patient decided
further for further work up. Thus opted for admission.

IV. PAST MEDICAL HISTORY
Childhood Illnesses: Chickenpox, Mumps, No Scarlet Fever.
Adult Illness:
Medical: Edema of lower extremities which lasted for a month when she was 15 y.o
Diagnosed of pneumonia and cardiomegaly 44 y.o

Surgery: Tubal Ligation at 27 y.o
Obstetric/Gynecological: Menach- 12 y.o
Menopause 45 y.o
G4P4 TPAL(4-0-0-4)
Normal delivery
Psychiatric: None
Allergies: none
Immunizations: Unrecalled
Screening Tests: Pap smear, X-ray, Protime
V. FAMILY HISTORY
Father died at the age of 74, due to TB. Mother, live with asthma and reported anemic
and has uterine cyst. Patient is the fourth child among seven siblings. Her second sibling is
positive for asthma and died of a heart problem. Patient has 4 children, all well but has a history
of asthma attack.
On the other hand, there were no familial histories of malignancy, lung disease, live
disease, kidney disease, seizure disorder, hematologic disorders, and mental disorder on both
sides of the family.
VI. PERSONAL AND SOCIAL HISTORY

Patient is a resident of San Miguel Iloilo, a high school graduate, housewife, married and
has four children. Husband is an elementary graduate, a part-time construction worker and a
farmer.
They live in a rural area located approximately 100 meters from the main road. Their
house is made of wood and other light materials with a one room. Their toilet is located about 2
meters from their house and utilizes a pour-flush type latrine that drains to a septic tank
approximately 5 meters away from their water source. Water source for drinking, cooking,
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bathing, washing, and cleaning is taken from a well. They rarely heat their water for drinking.
Garbage is disposed by burning.Patient lives alone with her husband.

Patient eats five full meals a day consisting of 3-4 cups of rice, vegetables, chicken, fish
and drinks about 8 glasses of water daily. She rarely drinks soda and coffee.

Patient sleeps at around 8-10 pm and wakes up as early as 4 am. She plants vegetables
around their house and grows chickens and hogs. Walking is her form of exercise. Her free time
is spent watching TV and mending old clothes. She has a harmonious relationship with their
neighbors who live a couple of meters away from their house.

Tobacco: none

Alcohol: none


VII. REVIEW OF SYSTEMS

General:
(+) weight loss
(+) weakness
(-) fatigue
(-) loss of appetite

Skin:
(-) rashes
(-) lumps
(-) itching
(-) dryness
(-) change in skin color
(-) change in nail color
(-) change in hair color
(-) change in size or shape of mole

HEENT

Head:
(-) headache
(-) dizziness
(-) lightheadedness
(-) head injury

Eyes:
(-) pain
(-) redness
(-) excessive tearing
(-) blurred vision

Ears:
(-) hearing loss
(-) vertigo
(-) ear ache
(-) discharges (white)

Nose:
(-) nasal stuffiness
(-) frequent colds
(-) discharges
(-) itching
(-) nasal flaring noted
(-) nosebleed

Throat:
(-) gum bleeding
(-) dentures
(-) sore tongue
(-) dry mouth
(-) hoarseness
(-) frequent sore throat

Neck:
(-) pain
(-) swollen glands
(-) neck stiffness
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Breast:
(-) lumps
(-) pain
(-) nipple discharge

Respiratory:
(-) cough
(-) sputum
(+) dyspnea

Cardiovascular:
(-) heart murmur
(-) chest pain
(-) palpitation
(-) edema

Gastrointestinal:
(-) swallowing difficulty
(-) heartburn
(-) loss of appetite
(-) vomiting
(-) pain during defecation
(-) bleeding
(-) abdominal pain
(-) food intolerance
(-) jaundice

Peripheral vascular:
(-) leg cramps
(-) swelling of leg or foot
(-) redness
(-) tenderness

Urinary:
(-) polyuria
(-) bedwetting
(-) burning sensation during urination
(-) hematuria
(-) suprapubic pain

Genitalia:
(-) lesions
(-) itching
(-) pain
(-) disharges
(-) menarche

Musculoskeletal:
(-) muscle pain
(-) joint pain
(-) stiffness

Neurologic:
(+) dizziness
(-) loss of consciousness
(-) seizure
(-) sensory loss

Hematologic:
(-) anemia
(-) easy bruising/bleeding















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PHYSICAL EXAMINATION

GENERAL SURVEY:

The patient is lying in bed awake, alert, well groomed (wears a hospital gown) and respond
cooperatively. In acute distress, slender, appears according to stated age.Makes eye contact and
responsive to questions asked. IVF of PNSS 1 L at 20 cc/hour infusing well at Left Metacarpal
Vein. Conscious, coherent, and not in cardiopulmonary distress


VITAL SIGNS:

Temperature: 36.4 C
Pulse Rate: 64 beats/min
Respiratory Rate: 19 breaths/min
Blood Pressure: 110/70 mmHg

SKIN:
The patient has a brown complexion. No hypo or hyperpegmented areas. Without swelling,
redness, bruise, cyanosis or pallor. No lesions noted. Normal skin turgor. Warm to touch. Hair is
smooth and evenly distributed. Nails pinkish in color and slightly curved. Edges are smooth and
rounded. Capillary refill < 2 seconds. No clubbing of nails.

HEENT:

A. HEAD: Normocephalic and bilaterally symmetrical. Hair is black with patches of gray hair.
Hair is evenly distributed. Scalp is moist and without lesions. No nodules, masses, depressions,
or tenderness noted upon palpation of the scalp and face. No edema or lesions.

B. EYE: Symmetrical and brown in color. Eyebrows are symmetrical and evenly distributed. No
redness, edema, inflammation or lesions on the eyelids. Irises are flat and symmetrical. Corneas
are clear, convex, without lesions and with good sensitivity. Conjunctivae are clear and shiny.
No redness or exudates. Pale, dirty yellowish sclera noted. Pupils are equally round and
responsive to light and accommodation. There is presence of direct and consensual reactions.
Well coordinated movements of the six cardinal directions of gaze.

C. EAR: External structures are bilaterally symmetrical. Auricles are of equal size, normal in
shape and at level with each other. No lesions, drainage, nodules or redness. External auditory
canals with minimal cerumen. Without redness, swelling or lesions. Mastoid area without
tenderness, redness or warmth. No perforations on both sides of the ears. With good ear recoil.

D. NOSE: Same color as the face. No masses, swelling, bleeding, lesions or foreign bodies.
Without flaring and discharge. Nasal septum midline without lesions or bleeding noted. Nasal
mucosa pale in color, dry, and without swelling. No pain elicited upon palpation of the frontal
and maxillary sinuses.

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E. MOUTH and THROAT: Lips are pinkish and moist. No lumps, lesions, ulcers or surface
abnormalities. Tongue is located in the midline, moves freely, dry, and without lesions but with
scanty white patches. Buccal mucosa ispink, moist, smooth, and is free from lesions. Gums are
pale red in color without swelling, inflammation, lesions or bleeding noted. Uvula is midline,
pink in color without swelling or exudates. Tonsils pink and without hypertrophy. With good gag
reflex.


NECK:
Symmetrical and with intact skin. No scars, visible pulsations, masses, swelling, or venous
distention. Able to perform active range of motion without pain. Lymph nodes non-palpable and
non-tender. Trachea is midline. There are no spasms or rigidity noted. Thyroid gland not
palpable but moves up with swallowing. Lobes not enlarged, without nodules, tenderness or
gritty sensation. No bruits upon auscultation.

THORAX/LUNGS:
Chest wall is symmetrical with good chest expand. Respiratory rate and pattern is even,
coordinated, and regular with occasional sighs. Chest wall feels smooth, warm and dry upon
palpation. No tenderness, bulging or retraction of the chest and intercostal spaces. Front and back
of thorax with warm skin, normal turgor and moisture. No tenderness or subcutaneous crepitus.
Muscles feel firm and smooth.Tactile fremitus with normal vibrations and voice sounds with
normal transmission. No adventitious sounds heard upon auscultation.

CARDIOVASCULAR:
Adynamic precordium. Jugular Venous Pressure is approsimately 5cm above the sternal Agle
with of bed elevated to 30 degree. No bounding ulses. No distended neck veins. Point of
Maximal Impulse at 5
th
intercostal space Mid-Clavicular Line. Carotid Pulse, Brachial Pulse,
And radial Pulse palpable. No heaves or thrills. No bruits. S2 louder than S1 Grade II murmur
was noted

ABDOMEN:
- Inspection: patients abdomen is flat, symmetric, and without masses and exaggerated
pulsations. Umbilicus is depressed with ni signs of inflammation. No lesions and discolorations.
- Auscultation: Normal bowel sounds. No bruits in all four quadrants.
-Percussion: tympany at the upper left quadrant. Dullness noted over the right upper quadrant.
- Palpation: Superficial - no tenderness and masses. Liver, Spleen, and Kidney not palpable.
-No rebound tenderness.

GENITOURINARY:
Not assessed but patient reported that there were no lesions, discharges and warts. Voided straw-
colored urine.

PERIPHERAL VASCULAR:
Arms and legs are symmetrical. Lesions, scars, ulcers, clubbing and edema not noted. All pulses
regular in rhythm and equal in strength. Capillary refill of 2 seconds.

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MUSCULOSKELETAL:
Mandible is midline. Temporo-mandible joint is with good range of motion; without pain,
tenderness and swelling. Spine is with normal curvature and range of motion. Shoulders, arms
and elbows are symmetrical with normal contour; without nodules, swelling deformities, and
webbing between fingers. With normal range of motion. No joint deformities. Good range of
motion in the hips and spine. Legs, ankles and feet are without swelling, redness, nodules and
deformities. No unusual pigmentation. With good range of motion. Patient had some limited
movement due to flank pain.

NEUROLOGIC:
Mental Status: coherent and cooperative. He is oriented to time, place, person and other people.
With good memory, remote memory and general knowledge. Level of consciousness: Alert with
appropriate behaviour and good hygiene. Has clear and spontaneous speech.

Cranial Nerves: I - XII = Intact
Motor System: good muscle bulk and tone
Muscle Strength: 4/5 upper extremities
5/5 lower extremities
Cerebellar : finger-nose intact
Gait with normal base
Romberg test not elicited
No pronator drift
Sensory : Pinprick, light touch, able to distinguish light touch from pain.
Babinski reflex absent
Reflexes. : 2+ and symmetric with plantar reflexes down-going
BICEPS TRICEPS BRANCH. KNEE
RT 2+ 2+ 2+ 2+
LT 2+ 2+ 2+ 2+
Cranial Nerves
CN 1 - Olfactory. - Sense of smell on each side intact.
CN 2 - Optic - Visual Activity - able to read newsprint at 12 inches with eyeglasses.
CN 3 - Ocolomotor - Eyes move in conjugate fashion and converge when they
CN 4 - Trochlear - Look at near object; Able to look up and down
CN 6 - Abducens - Able to look laterally; EOM - intact
CN 5 - Trigemiral - Sensation - with good blinking reflex
Mastication - No difficulty in mastication
CN 7 - Facial Expression - patient is able to smile and frown symmetrically
CN 8 - Vestibulocochlear - Hearing - Able to hear whispered words.
CN 9 - Glossopharyngeal - Swallowing - Able to swallow
CN 10 - Vagus - Gag Reflex - Intact Gag Reflex
CN 11 - Spinal - Neck Motion - Able to rotate the neck, reflexion and Extension, Able to shrug
shoulders.
CN 12 - Hypoglossal - Tongue Protrusion - Able to stick tongue out.


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DIFFERENTIAL DIAGNOSIS:

1. Left- Sided Heart Failure
2. Right Sided Heart Failure
3. Tuberculosis
4. Pneumonia


Rule in Rule out
Left Sided Heart Failure -Productive Cough with
phlegm
-Back Pain
-Weight Loss
-Difficulty of Breathing
-Difficulty of sleeping

Right sided Heart Failure -Weight Loss
-Difficulty of sleeping
-Difficulty of breathing
-Night Sweats
- Pedal Edema
-Distention of Neck Veins
-Dyspnea at rest
-Exertional Dyspnea
Pneumonia -Productive Cough with
phlegm
-Back Pain
-Weight Loss
-Difficulty
-Hemoptysis
-Chills and High Fever
-Body Malaise
Tuberculosis -Productive Cough with
phlegm
-Back Pain
-Weight Loss
-Difficulty of Breathing
-Difficulty of sleeping
- Hemoptysis
-Chills and High Fever
-Body Malaise


WORKING DIAGNOSIS: Left Sided Heart Failure

Laboratory Diagnosis:

Complete blood count (CBC), which may indicate anemia or infection as potential causes of
heart failure
Urinalysis (UA), which may reveal proteinuria, which is associated with cardiovascular disease
Serum electrolyte levels, which may be abnormal owing to causes such as fluid retention or
renal dysfunction
Blood urea nitrogen (BUN) and creatinine levels, which may indicate decreased renal blood
flow
Fasting blood glucose levels, because elevated levels indicate a significantly increased risk for
heart failure (diabetic and nondiabetic patients)
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Liver function tests (LFTs), which may show elevated liver enzyme levels and indicate liver
dysfunction due to heart failure
B-type natriuretic peptide (BNP) and N-terminal pro-B-type (NT-proBNP) natriuretic peptide
levels, which are increased in heart failure; these measurements are closely correlated with the
NYHA heart failure classification
Electrocardiogram (ECG) (12-lead), which may reveal arrhythmias, ischemia/infarction, and
coronary artery disease as possible causes of heart failure

Imaging Studies and procedures

Chest radiography (posterior-anterior, lateral), which may show pulmonary congestion, an
enlarged cardiac silhouette, or other potential causes of the patient's symptoms
2-D echocardiographic and Doppler flow ultrasonographic studies, which may reveal
ventricular dysfunction and/or valvular abnormalities
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Coronary arteriography in patients with a history of exertional angina or suspected ischemic
LV dysfunction, which may reveal coronary artery disease
Maximal exercise testing with/without respiratory gas exchange and/or blood oxygen
saturation, which assesses cardiac and pulmonary function with activity, the inability to walk
more than short distances, and a decreased peak oxygen consumption reflect more severe
disease

Treatment includes the following:
Nonpharmacologic therapy:

Oxygen and noninvasive positive pressure ventilation
Dietary sodium and fluid restriction
Physical activity as appropriate
Attention to weight gain

Pharmacotherapy:

Diuretics,
Vasodilator
Inotropic agents
Anticoagulants
Beta blockers
Digoxin

Surgical options
Electrophysiologic intervention
Revascularization procedures
Valve replacement/repair
Ventricular restoration

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