University of Santo Tomas

Faculty of Medicine and Surgery

Department of Internal Medicine
Clinical Division
Room/Bed 212B One day PTC, patient had loss of appetite and felt weakness and
Hospital Number 20-160000262644 dizziness. He had 5 episodes of yellowish watery diarrhea, amounting
Admission Number 20B00338 to around one glass per episode. He was brought to USTH ERCD.
Patient PASCUAL, SIMOUN GUINOCOR Incidentally, his HbA1C was elevated at 9.66 and his non-healing
Age/Sex 46/M wounds were assessed. Patient was toxic-looking and weak. He was
Date of Birth 09/24/1973 subsequently admitted.
Civil Status Married
Nationality/Citizenship Filipino Review of Systems
General Survey: (-) fever, (-) difficulty of sleeping,
Home Address B22 L16 Dist. 15 Dela Costa Homes IV,
Cutaneous: (-) pallor, (-) jaundice, (-) cyanosis, (+) rashes, (-) pruritus, (-)
CSJDM, Bulacan
hyper/hypo/depigmentation (-) change in hair growth, (-) excessive
Occupation Factory worker
sweating
Religion Roman Catholic
Eye: (-) eye pain, (-) blurring of vision, (-) doubling of vision, (-) eye
Date of Admission 02/26/2020
discharge, (-) redness, (-) itchiness, (-) photophobia
Time of Admission 07:59 PM Ear: (-) hearing loss/deafness, (-) discharge, (-) ear pain, (-) tinnitus
Informant Patient Nose: (-) epistaxis, (-) discharge, (-) obstruction, (-) sinus pain, (-)
Reliability (%) Good abnormal sense of smell, (-) postnasal drip
Attending Physician Dr. Jean Uy-Ho Mouth: (-) bleeding gums, (-) soreness of tongue, (-) fissures, (-) oral
Resident/s-in-Charge Dr. Lay/Dr. Badion ulcers, (-) disturbance/change of taste, (-) dental pain
Throat: (-) sore throat, (-) voice change/hoarseness, (-) itchiness
Chief Complaint Non-healing wounds on both feet Neck: (-) neck stiffness, (-) dysphagia, (-) odynophagia, (-) limitation of
motion, (-) mass
History of Present Illness: Respiratory: (-) dyspnea, (-) coughs, (-) colds
Jan. 2015, patient noted numbness of feet, bilateral, with no other Cardiology: (-) chest pain, (-) palpitations, (-) orthopnea, (-) PND, (-)
accompanying symptoms. No consult was sought, nor medications bipedal edema
taken. Vascular: (-) phlebitis, (-) variceal pain, (-) variceal swelling, (-)
claudication, (-) leg discoloration, (-) extremity temperature change
Sept. 2019, the wife noticed the patient began to have polydipsia, Gastrointestinal: (-) hematemesis, (-) melena, (-) hematochezia, (-)
polyphagia, and polyuria. She also noted weight loss, characterized as ingestion, (-) heartburn, (-) flatulence, (-) abdominal pain, (-) abdominal
arms and legs becoming thinner. Still, no consult sought. distension, (-) abdominal mass, (-) hemorrhoids, (-) change in stool
color/contents
Nov. 2019, patient was lacerated during machine operations and Genitourinary: (-) dysuria, (+) anuria for 12 hours, (-) nocturia (-) CVA
sustained a 2cm wound. He self-medicated with povidone-iodine, but tenderness
the wound did not heal. Instead, the digit blackened over time and Musculoskeletal: (-) muscle pain/weakness/wasting, (-) cramps, (-) joint
became painful and eventually, devoid of feeling. pains/swelling/stiffness, (-) limitations of movement, (-) arthralgia
Endocrine: (-) polyuria, (-) polydipsia, (-) polyphagia, (-) heat/cold
Dec. 2019, patient’s right leg was sunburnt, which brought about intolerance, (-) paresthesia
multiple erythematous painful blisters on the dorsum of the foot and Hematologic: (-) easy bruisability, (-) petechiae, (-) epistaxis
the anterior lower leg, right. These would spontaneously rupture and Neurologic: (-) headache, (-) seizure, (-) paralysis, (-) dizziness, (-) loss of
reveal pink shiny skin. Patient would apply povidone-iodine to the consciousness, (-) abnormality of sensation, (-) motor dysfunction or
lesions twice a day, yet the lesions persisted. No consult done. weakness or paralysis, (-) abnormality of coordination, (-) speech
disturbance, (-) mental change, (-) head trauma, (-) tremors, (-) loss of
Feb. 1, 2020, patient’s left foot was injured while pushing his memory or ability to concentrate
motorcycle, which opened up a heavy bleeding fissure on the lateral Psychiatric: (-) anxiety, (-) depression, (-) hallucination, (-) delusion, (-)
side of the fifth toe, left. His left foot became swollen, erythematous, paranoia, (-) violent behavior, (-) mood change, (-) difficulty
and tender. He was brought to Bermudez Polymedic Hospital. X-ray concentration, (-) agitation, (-) tension, (-) suicidal thoughts, (-)
showed no osseous changes in both feet but revealed osteolytic irritability
changes in the distal phalanx of the 1st left digit, suggestive of
Osteomyelitis. He was assessed with T2DM and HTN. He was then Past Medical History
prescribed with unrecalled doses of Cefuroxime (for 7 days), Adult illness and hospitalization:
Clindamycin (for 7 days), Prednisone, Linagliptin, Gliclazide, Losartan, (+) HTN (2020) - UBP: 130/80, HBP: 160/90
Atorvastatin, and B complex. Amputation of his 5th toe, left, and Previous surgery: None
wound debridement of his right foot were done. He was subsequently Blood transfusion: None
discharged. Allergies: None known

Feb. 18, 2020, patient was again admitted at Bermudez Polymedic Current Heath Status/ Risk Factors
Hospital due to pain on his thumb and feet, characterized as Non-smoker, denies illicit drug use
“kumikirot”. He was given Paracetamol/Tramadol 325/37.5 mg/tab (+) Alcoholic beverage drinker- 500-1000 mL/day of beer
PRN, which afforded relief. He was discharged after a few days.
Current Medications:
Gliclazide 30 mg/tab BID
 University of Santo Tomas
Faculty of Medicine and Surgery
Department of Internal Medicine
Clinical Division
Linagliptin 5 mg/tab ODHS CN IX, X – uvula in midline
Atorvastatin 20 mg/tab ODHS CN XI – can shrug both shoulders with resistance, can turn head
Losartan 100 mg/tab OD side to side against resistance
Clopidogrel 75 mg/tab BID CN XII – tongue protrusion in midline, able to do tongue
Paracetamol/Tramadol 325/37.5 mg/tab PRN movements
B-complex tablet BID Cerebellum: (-) tremors, (-) dysdiadochokinesia, (-) dysmetria
Sensory: 100% on upper extremities, 90% on right foot, no sensation
on dorsum of left foot, 60% on left sole
Herbal medications: Motor: MMT 5/5 on all extremities, except plantar and dorsiflexion
None Reflexes: ++ DTR on all, except Achilles tendon reflex
Meningeal: (-) Brudzinski, (-) Kernig’s, (-) Nuchal rigidity
Family History
(+) HTN – father Initial Assessment:
(+) DM – mother, maternal grandmother T2DM, poorly controlled; Sepsis sec. to non-healing wound, left thumb,
(+) Breast CA – sister right foot, left foot; ASHD; PAOD; AKI sec. to 1. Dehydration, 2. Sepsis
(+) stroke – father
(+) CKD – mother Plans
Please admit to room under the service of Dr. J. Uy-Ho
Physical Examination on Admission Secure consent for admission and care
General Survey: conscious, coherent, not in cardiorespiratory distress, Diet: 1500 kcal/day, 50% CHO, 30% fat, 20% protein, <200 mg
ambulatory cholesterol, <7% saturated fats divided into 3 meals and 2 snacks. No
Vital signs: BP: 130/80 mmHg, PR: 98 bpm, regular, RR: 20 cpm, Temp: sources of simple sugars.
37.1°C, SpO2: 99% Monitor vital signs q1 and record
Skin/Cutaneous: cold, dry skin, (-) pallor, (-) jaundice, (+) multiple Monitor I&O qshift and record
erythematous ill-defined patches with scaling on the face and scalp IVF D5LRS 1L at 100 cc/hr
Head: normocephalic, (-) gross deformities, (-) palpable masses, evenly Diagnostics:
distributed hair - CBC-Pt
Eye: pink palpebral conjunctivae, anicteric sclera, isocoric 2-3mm ERTL - Na, K, BUN, Creatinine
Ears: (-) tragal tenderness, (-) aural discharge, intact tympanic - 12L ECG
membrane AU - CXR
Nose: nasal septum midline, non-hyperemic nasal mucosa, turbinates - UA
non-congested, no nasal discharge - Fecalysis
Mouth: pink lips, dry lips and buccal mucosa, (-) oral ulcers, (-) gingival - PT, aPTT
hypertrophy, tonsils not enlarged and non-hyperemic, (-) exudates, - X-ray of left hand and both feet
non-hyperemic posterior pharyngeal wall - Blood C&S, 2 sites
Neck: trachea in midline, no palpable cervical lymphadenopathies, Therapeutics:
thyroid not enlarged, neck veins not distended - Antimicrobials c/o ID service
Respiratory: symmetrical chest expansion, equal vocal and tactile - No insulin, no OHAs for now
fremiti, resonant on all lung fields, clear breath sounds CBG monitoring q1
Cardiovascular: Adynamic precordium, apex beat at 5th LICS MCL, loud Refer to ID, Cardiology, and Nephrology for Co-management
S1 followed by a soft S2 at apex, loud S2 followed by soft S1 at the Refer to Orthopedic Surgery and Dermatology for further evaluation
base, no heaves, no lifts, no thrills, no murmurs and management
Gastrointestinal: Flat, non-rigid, non-tender abdomen, no visible
pulsations, normoactive bowel sounds, tympanitic on all quadrants PEREZ DE
Genitourinary: (-) CVA tenderness, (-) suprapubic tenderness TAGLE/PONCE/QUENERI/RABARA/RAGPA
Extremities: (+) gangrenous first digit of the left hand, (+) gangrenous Clinical Clerks-in-Charge
fourth and fifth digits of the left hand, (+) non-healing ulcer on the
lower leg, right, (-) pulse on left dorsalis pedis, all other pulses full and DR. LAY/DR. BADION
equal Residents-in-Charge

Neurological Exam
Conscious, coherent, oriented to time place and person, GCS 15
(E4V5M6)
Cranial Nerves:
CN I – no anosmia
CN II – intact direct and consensual pupillary light reflex; isocoric
pupils 2-3 mm ERTL
CN III, IV, VI – EOMs full intact
CN V – can clench teeth; no jaw deviation, no facial sensory deficit
CN VII – no facial asymmetry, can smile, frown, raise eyebrows, puff
cheeks, close eyes and open against resistance
CN VIII – gross hearing intact