Case 1

JN, a 65-year-old male from Malabon came in due to bipedal edema. A year ago, patient noted
intermittent bipedal edema relieved by elevating the legs during sleep. He also noted his feet became
heavy after prolonged walking. He is taking Amlodipine 5mg once a day for hypertension and was
advised by his neighbor to take additional enalapril 2.5mg tablet once a day in the afternoon.

A few months prior to consult, he noted persistence of the edema unrelieved by leg elevation.
Accompanied by orthopnea, exertional dyspnea on walking up the stairs and abdominal fullness. He also
started having frequent coughs that awaken his from his sleep.

Patient was hypertensive for 10 years prescribed with Amlodipine 5mg/tab OD with usual BP of
160/100, no diabetes mellitus, no bronchial asthma, no goiter or previous history of stroke or MI.
Patients mother died of diabetes. Patient is a retired carpenter with a 15-pack year smoking history.

Review of systems noted weight loss of 5kgs in 2 months, blurring of vision, no headache, no chest pain,
no palpitations, no epigastric pain, no melena/hematochezia, no bowel movement changes, no dysuria,
no tea-colored urine, urinary urgency, urinary straining and intermittency, bilateral knee pain worse on
prolonged standing and walking long distance.

At the ER patient was awake and not in distress but frequent cough was evident, BP 150/90, HR 86, RR
22, T 36.8°C, Weight 86kg, Height 165cm, Waist circumference 43 inches.

Pink palpebral conjunctivae, anicteric sclerae, (-) ulcers, (-) lymphadenopathies, distended neck veins,
equal chest expansions, (+) bibasal rales, (-) spider angiomata, (-) gynecomastia. Adynamic precordium,
Good S1 and S2, (+) S3 at the apex, normal rate, regular rhythm, no murmurs, apex beat at the 6 th ICS
left anterior axillary line. Flabby abdomen, normoactive bowel sounds, liver slightly tender on palpation,
intact Traube’s space, (+) shifting dullness. Warm extremities and equal pulses, no cyanosis, (+) coarse
crepitus bilateral knee, (-) warmth, tenderness, (-) bulge sign, (+) grade 2 bipedal edema with
hyperpigmentation and scaling predominantly on the medial aspect of the ankle. DRE: good sphincteric
tone, no masses, no tenderness, (+) hard, nodular and enlarged prostate, (+) brown stool per examining
finger, no blood.
Case 2

JL, 22 year old female was rushed to the emergency room due to shortness of breath. The team divided
their work to become more efficient in managing the patient. Half of the team tended to JL while the
others interviewed the relatives. JL was immediately given oxygen support.

On history, JL was a victim during the Taal volcano eruption. Her family wasn’t able to evacuate
immediately despite the early warning from authorities. During the ashfall, JL was getting all of their
clothes that were hanged outside and was protecting herself with own clothing to cover her nose and
mouth. But with the heavy ashfall, she was able to inhale some amounts of ash during that time. She
coughed a bit, but it was no big deal to her.

She and her family were able to evacuate the premises and travelled to a safe zone where her relatives
were waiting, far from the incident. A few days have passed, and JL was doing fine but noted occasional
coughing. No difficulty of breathing was noted at the time. 4 days prior to the consultation, her mother
noted that her cough was becoming more troublesome. She noted that she would wake up at night
because of her coughing. They gave her Robitussin assuming that it would make JL feel better. However,
despite the medication given, it wasn’t enough to relieve her of the symptom. A few hours prior to
consult, JL was coughing incessantly, no fever and was noted to be running out of breath, hence consult.

Review of systems no noted weight loss, blurring of vision, no headache, no chest pain, no palpitations,
no epigastric pain, no melena/hematochezia, no bowel movement changes, no dysuria, no tea-colored
urine, urinary urgency, urinary straining, and intermittency, bilateral knee pain worse on prolonged
standing and walking log distances.

Past medical history showed a history of childhood asthma, and that the last attack was when she was 7
years old. She was hospitalized for 2 days and was discharged well. No maintenance medications were
given at the time. No previous surgeries noted. Family medical history revealed a history of food allergy
from the maternal side. No history of hypertension, diabetes mellitus, or cancer was noted.

At the ER patient was in cardiopulmonary distress, BP 90/50mmHg, HR 111, RR 28, Temp 39.2°C O2
saturation of 87% at room air, Weight 47kg, Height 155cm.

Pale palpebral conjunctivae, anicteric sclerae, (-) ulcers, (-) lymphadenopathies, Symmetric chest
expansion, (+) expiratory wheezes bilateral lung fields. Adynamic precordium, good S1 and S2, no
murmurs, apex beat at the 5th ICS Left anterior axillary line. Flabby abdomen, normoactive bowel
sounds, cold clammy extremities, weak pulses, (+) cyanosis.

The patient was immediately intubated, and was given Dexamethasone 250mg/IV, Paracetamol
300mg/IV, and added Formoterol nebulization connected to the endotracheal tube set. JL’s vitals
stabilized and was immediately transferred to the ICU for further observation and management.