I.

GENERAL DATA:

This is the case of C.R., 55-years old male, Filipino, Roman Catholic, businessman, born
in October 1962 in San Fernando City, La Union, presently residing in Baguio City. Informant is
the patient with a percentage reliability of 80%. The interview was done on September 6, 2018.

II. Chief complaints: Fever and chills

III. History of Present Illness:

Two days prior to admission, patient had his regular hemodialysis session at SLU-SHS at
12 noon. After his session at 4 o’ clock in the afternoon he experienced tingling of legs with
concomitant nausea but with no vomiting. He also noted at home to have had feverish feeling,
body malaise and easy fatiguability, in which he tried to rest and sleep but to no avail.

One day prior to admission, he had fever and chills in the afternoon to which, he started
his first dose of Paracetamol 500 mg at 3 pm and then every 4 hours thereafter until 7 am the
next morning. No associated signs and symptoms were experienced. No consultation was done.

Few hours PTA, he woke up with similar symptoms, and with cough, difficulty of breathing
and a feeling of urgency. The unimproved condition prompted him for consultation at ER
department of SLU-SHS, and hence admission was suggested and done on September 5, 2018.

One day after admission, patient still had febrile episodes but with no chills and claimed
to have body weakness.

IV. Past Medical History:

Last 2003, patient was diagnosed with Diabetes Mellitus and has been on maintenance of
subcutaneous insulin injection once a day. Follow up check-up was done on a regular bases
monthly.

In 2006, patient had undergone below-the-knee amputation on his left leg due to
gangrenous wound.

In 2007, patient was operated by a private doctor for his enlarged prostate at Pines City
Doctor’s Hospital.

In January 2013, he was diagnosed with Chronic Kidney Disease Stage V. Patient had
been inserted with Intrajugular Catheter, and simultaneously, was operated for Arterio-Venous
Fistula Creation. He underwent his first hemodialysis in the same month and still currently on
three times a week session with ultrafiltration goal of 3 liters for 4 hours, access at Left
atrioventricular fistula, and non-bleeder.

In 2016, he had undergone Cataract Surgery on both eyes.

 V. Family History:

Patient’s parents are both deceased. His mother died when she was 70 from aneurysm;
and his father had history of Chronic Kidney Disease, and had undergone 9 years of Hemodialysis
prior to demise at age 70.

Patient was the youngest child among the three. The first sibling is a female, 66 years
old, and in good health condition. The second sibling is a male, 60 years old, with a history of
stroke and a heart problem currently on maintenance.

Her wife is a 55 years-old and currently in good health. They have an only son aged 16
and also in a good health condition.

No history of other heredo-familial diseases such as cancer, thyroid problems or blood

dyscrasias. No history of twinning.

VI. Social and Environmental History:

The patient started to smoke and drink alcohol when he was 12 years old. He consumes
about one-pack of cigarettes a day for 16 years, he totally stopped from smoking in 1990. He
was an alcoholic beverage drinker of beer and brandy and admits sometimes he exceeded more
than 1 to 2 bottles a week, he only stopped drinking when he was diagnosed with CKD in 2013.

VII. Review of Systems:

General: (-) weight loss, (+) fever, (+) chills, (-) anorexia, (+) weakness
Skin: (-) cyanosis, (+) pallor, no rashes
HEENT:
Head: (-) headache, (-) colds
Eyes: (-) visual difficulties, (-) pain
Ears: (-) ear discharge
Nose: (-) sneezing
Throat: (+) sore throat, (+) dysphagia on spicy foods, no dryness, no
hoarseness of voice,
Respiratory: (+) cough, (+) dyspnea
Cardiac: (-) chest pain, (-) palpitations, (-) orthopnea, (-) paroxysmal nocturnal
dyspnea
GIT: (+) hypogastric pain, (-) vomiting, (-) diarrhea, (-) constipation
GUT: (-) dysuria, (-) hematuria, (-) dribbling, (+) urgency
Musculoskeletal: (-) Joint pains, (-) muscle pains
Endocrine: (+) polyphagia, (+) polydypsia, (+) oliguria, (-) diaphoresis, (-)
dizziness
Neurologic: (-) change in orientation, (+) numbness or loss of sensation, (+)
tingling
VIII. Physical Examination:

General Survey: conscious, coherent, oriented to time, place and person, on oxygen inhalation
at 2-3 lpm via nasal cannula, with right hep-lock.
Temperature: 37.1 C RR: 17 cpm
CR: 67 bpm BP: 90/70 mmHg

Skin: pale skin color, acyanotic, cool to touch with good skin turgor; few nevi on the forearm, no
petechiae or maculopapular rashes

HEENT
Head Hair is gray-black, fine, evenly distributed in scalp. No tenderness, no mass, no
infestations, no scars.

Eyes: Pale palpebral conjunctiva, anicteric sclerae, with exophthalmos, eyebrows are
aligned with evenly distributed hair

Ears: Symmetrically aligned, no scars, no lesion, no tenderness, no discharges, intact

tympanic membrane

Nose: Patent Nares, moist and pinkish nasal mucosa, no nasal discharges, no sinus
tenderness, nasal turbinates not congested

Throat: pink and moist lips, tonsils are not enlarged, JVP 1 cm above sternal angle; no
carotid bruit, no goiter, weak carotid pulses.

Chest and Lungs: symmetrical chest wall expansion, no retractions, use of accessory muscles
in breathing, abdominal breather, resonant, equal tactile fremiti, vesicular breath sounds, with
(+) bibasal crackles

Heart: PMI at the 5th LICS, MCL, no heaves or thrills, with regular rhythm, S1 louder at the apex,
S2 louder at the base, no S3 or S4, no murmurs. Soft ang heart sounds.

Abdomen: Globular, everted umbilicus, normoactive bowel sounds, tympanitic, non-tender, no

organomegaly (+) hypogastric tenderness

Extremities:

Upper: No gross deformities, With good capillary refill, no extra digits, good muscle bulk
and good muscle tone. With AV fistula located on the left posterior arm distal 1/
3, (+) thrill and bruit on Left arm Arteriovenous Fistula

Lower: Skin is same color with the body, (+) left below-the-knee residual leg with intact
sensation and good muscle tone. no joint swelling, no bipedal edema, (+) loss
 of sensation on right lower limbs starting just below the patella with 2-3 seconds
capillary refill

DRE: Not done

Neurologic Exam
Cerebellar: Normal general appearance and behavior. The patient is conscious, coherent
and oriented to person and place

Cranial CN I: not assessed

Nerves: CN II: not assessed
CN III, IV, VI: both pupils reactive to light and able to converge
CN V: (motor) able to close mouth
CN VII: symmetrical facial expression, movement and strength
CN VIII: Not assessed
CN IX, X: Uvula midline, no deviations
CN XI: no limitation of movement during head turning
CN XII: not assessed

Finger to nose test: Cerebellar function is intact

Patellar Reflex: Positive

Babinski Reflex: Negative

Motor: Good muscle tone. No atrophies. No limitations in range of motion in upper extremities.

Body Position: Patient can sit upright without support.

Involuntary movements: with involuntary tremors on both hands, no twitching movements

Muscle bulk: No muscle atrophy noted, body built is endomorph

Sensory: Able to feel light touch on both upper and left lower extremities. Decreased light
touch on right lower extremities.
 R L

100% 100%

75% 100%

Deep Tendon Reflex: +2 Patellar reflex