GENERAL DATA HISTORY AND P.E.

ASSESSMENT MANAGEMENT DISPOSITION

R.M.G CC: fever Upper respiratory DIET: Diet as tolerated DISCHARGED

19/M tract infection -
Iguig, Cagayan HPI: Patient was seen during the community bacterial THERAPEUTICS
clinic visit with a 1-day history of fever, Paracetamol 50mg/tab,
intermittent, documented Tmax 38C, 1 tab Q4 prn for fever
associated with 2 episodes of vomiting of Amoxicillin 500mg/cap,
previously ingested food, amounting to 1 cup 1 cap TID x 7days
per bout, and productive cough with yellowish
sputum. Patient took paracetamol for NON
temporary relief of fever. PHARMACOLOGIC
Increase oral fluid
VS intake
BP:110/80 Take adequate rest
PR: 106 Practice proper cough
RR: 24 etiquette
Temp: 36.6 Emphasized
importance of
PE completing antibiotic
Conscious, coherent therapy
(-)pallor, (-)jaundice
Anicteric sclerae, pink palpebral conjunctiva
Symmetrical chest expansion, clear breath
sounds
Adynamic precordium, tachycardic
Flabby, soft, nontender
Grossly male
No edema, full and equal pulses
No neurologic deficits
GCS 15
GENERAL DATA HISTORY AND P.E. ASSESSMENT MANAGEMENT DISPOSITION

R.D.T. CC: hemoptysis Upper respiratory DIET: Diet as tolerated DISCHARGED

25/M tract infection –
Gattaran, Cagayan HPI: 1 wk PTC, patient developed fever, bacterial DIAGNOSTICS
undocumented, intermittent, accompanied by Presumptive PTB Sputum AFB x 2 dets
productive cough and colds, with yellowish to Chest xray PA view
greenish sputum, and body malaise. Patient
self-medicated with Paracetamol for temporary THERAPEUTICS
relief of symptoms. No consultations were Co-amoxiclav
done. 625mg/tab, 1 tab TID x
Interval history revealed resolution of fever, 7days
however there was still persistence of cough.
2 days PTC, there was persistence of the NON
above sx, patient noted 3 episodes of blood- PHARMACOLOGIC
streaked sputum and 1 episode of blood- Increase oral fluid
tinged nasal discharge. Patient consulted at a intake
nearby clinic however there was no available Take adequate rest
physician. Practice proper cough
Few hrs PTC, there was no other episodes of etiquette
blood-streaked sputum however there was still Frequent handwashing
persistence of cough, hence the consultation. Emphasized
importance of
VS completing antibiotic
BP:110/70 PR: 64 RR: 22 Temp: 36.6 therapy
TCB once with results
PE or anytime if with
Conscious, coherent untoward s/sx
(-)pallor, (-)jaundice
Anicteric sclerae, pink palpebral conjunctiva
Symmetrical chest expansion, clear breath
sounds
Adynamic precordium
Flabby, soft, nontender
Grossly male
No edema, full and equal pulses
No neurologic deficits
GCS 15
 GENERAL DATA HISTORY AND P.E. ASSESSMENT MANAGEMENT DISPOSITION

A.T.B CC: cough Community DIET: Diet as tolerated DISCHARGED

59/F acquired
Sta. Teresita, HPI: 2 days PTC, patient developed productive pneumonia- low DIAGNOSTICS
Cagayan coughwith thick whitish sputum. No other risk Serum Crea, K, FBS,
associated symptoms such as fever, chest Lipid Profile, Urinalysis
pain or difficulty of breathing. No medications and 12L ECG
taken, no consultations done.
Few hours PTC, there was still persistence of THERAPEUTICS
pt’s cough, hence the consultation. Co-amoxiclav
(+) sore throat (+) loss of appetite 625mg/tab, 1 tab TID x
(+) weight loss 7days

VS NON
BP:110/70 PHARMACOLOGIC
PR: 94 Increase oral fluid
RR: 22 intake
Temp: 36.6 Introduced pinggang
pinoy
PE Take adequate rest
Conscious, coherent Practice proper cough
(-)pallor, (-)jaundice etiquette
Anicteric sclerae, pink palpebral conjunctiva Frequent handwashing
Symmetrical chest expansion, (+) crackles mid Emphasized
to basal bilateral lungs importance of
Adynamic precordium completing antibiotic
Flabby, soft, nontender therapy
Grossly female TCB once with results
No edema, full and equal pulses or anytime if with
No neurologic deficits untoward s/sx
GCS 15
GENERAL DATA HISTORY AND P.E. ASSESSMENT MANAGEMENT DISPOSITION

N.N.F CC: throat itchiness Allergic cough DIET: Diet as tolerated DISCHARGED
24/F
Calayan, Cagayan HPI: 7 weeks PTC, patient noted throat THERAPEUTICS
itchiness accompanied by tinnitus occurring Ebastine +
usually at night and early morning and Betamethasone
worsens with cold weather. No medications 100mg/500mcg/tab,
taken, no consultations were done. 1 tab ODHS
Interval history revealed persistence of
symptoms but still no consultations were done.
Few hrs PTC, there was still persistence of the NON
above symptoms, hence the consult. PHARMACOLOGIC
(+) cough - colorless to whitish sputum Increase oral fluid
(+) nasal congestion intake
(+) headache/dizziness- occasional Avoid exposure to
(+) ear pain - occasional allergens such as dust,
strong scents, and
VS biofuel gas that might
BP:110/70 trigger or worsen
PR: 77 allergies
RR: 19 TCB anytime if with
Temp: 36.6 untoward s/sx

PE
Conscious, coherent
(-)pallor, (-)jaundice
Anicteric sclerae, pink palpebral conjunctiva
Symmetrical chest expansion, clear breath
sounds
Adynamic precordium, normal rate and regular
rhythm
Flabby, soft, nontender
Grossly female
No edema, full and equal pulses
No neurologic deficits
GCS 15
GENERAL DATA HISTORY AND P.E. ASSESSMENT MANAGEMENT DISPOSITION

G.S.I. CC: whitish spots on tonsil Acute DIET: Diet as tolerated DISCHARGED
24/M tonsillopharingitis,
Tuguegarao, HPI: 2 weeks PTC, patient developed fever, exudative THERAPEUTICS
Cagayan undocumented, associated with Clindamycin
tonsillopharyngeal congestion, odynophagia, 300mg/tab, 1tab QID
and body malaise. Patient took paracetamol after meals x 7days
for temporary relief. No consultations were
done. NON
11 days PTC, still with the persistence of the PHARMACOLOGIC
above symptoms, patient consulted at a Increase oral fluid
private hospital, was diagnosed as a case of intake
tonsillitis bacterial. Pt was then sent home with Practice oral hygiene
Paracetamol and unrecalled antibiotics as take Introduced pinggang
home meds. pinoy
Few hrs PTC, patient’s symptoms have Advised weight
already resolved however pt noticed presence reduction and to do
of whitish spots on his tonsils, hence the mild to moderate
consult. intensity aerobic
exercises for 30-
VS 45mins/day, 3-4x/week
BP:120/80 PR: 88 RR: 20 Temp: 36.6 Emphasized
importance of
PE completing antibiotic
Conscious, coherent therapy
(-)pallor, (-)jaundice Follow up after 1 week
Anicteric sclerae, pink palpebral conjunctiva, or anytime if with
(+) tonsillopharyngeal congestion with (+) untoward s/sx
white spots
Symmetrical chest expansion, clear breath
sounds
Adynamic precordium, tachycardic
Flabby, soft, nontender
Grossly male
No edema, full and equal pulses
No neurologic deficits
GCS 15