Medicine Ward Presentation

Dr. Emmanuel Ruiz

Professor

Group 6 MD-2
Section C

SARMIENTO, Adrian
MASIGAN, Joyce-Ann
MAGYANO, Keren Kezia
GONZALES, Liral

HEALTH HISTORY

PATIENT’S PROFILE
Name: D,E
Age: 52 years old
Address: Gattaran, Cagayan
Gender: female
Birthday: September 11, 1966
Marital Status: Married
Occupation: Housewife
Race: Filipino
Religion: Roman Catholic
Date of Admission: April 18 , 2019

Source of History:
Reliability: 97-99% reliable, self-referred.
CHIEF COMPLAINTS
Difficulty of breathing, easy fatigability, and swelling of the lower extremities.

HISTORY OF PRESENT ILLNESS

2017, the patient went home from the farm and noticed that she wounded her left foot.
Weeks later, she noticed that her wound havent even healed so she decided to go to a nearby
hospital to check on her wound. She was eventually diagnosed with Diabetes Mellitus.
One month prior to admission, the patient was admitted at CVMC due to swelling of her
lower extremities and difficulty of breathing. she was given unrecalled medicines and was able
to recover and was discharged after 10 days.
Few weeks after she was discharged in the hospital, the patient reported the she again
experienced of having edema on her both lower extremities bigger than her past expeciences
with edema on her legs. She had a hard time on walking due to the heaviness, swelling and
tingling sensation she felt while walking.The patient also reported that she was experiencing
difficulty of breathing and easy fatigability even upon doing simple activities. She also reported
that there were nights that she will suddenly wake up because she had a hard time breathing. As
these symptoms being experienced by the patient, her husband immediately rushed her to CVMC
for admission.

PAST MEDICAL HISTORY

Childhood Illnesses: No measles, chickenpox, rheumatic fever, nor polio. No allergies.
Adult Illnesses:
o Medical:
 2017: Diagnosed with Diabetes Mellitus Type II and Hypertension
 November 2018: Admitted at CVMC and diagnosed with Heart Failure
 March 2019: Admitted at CVMC and diagnosed with Cardiac Failure

o Surgical: Undergone a left eye sugery due to catarct.

HEALTH MAINTENANCE:
Immunizations: Cannot recall if had undergone immunization nor vaccination.

 Taking Metformin for the management of diabetes

 Taking unrecalled drugs for hypertension
FAMILY HISTORY
Mother died due to senility.
The patient is the youngest out of the 6 siblings. Reports that her other 5 siblings are well and
healthy.
Reports that her husband and their 5 children are well and healthy.

PERSONAL AND SOCIAL HISTORY

Born and raised in Gattaran, Cagayan. She wasn’t able to finish her high school and
married at a young age. She is currently living with her family. She often mingles with her
relatives and neighbors.
Exercise and diet: admitts that she doesnt exercise. She loves to junk foods and meat with less
intake of vegetables. She often drinks coffee and reported that she had been eating 2 cups of rice
per meal on her daily routine.
Life Style Risk: Her husband is a chronic smoker. Engages herself in unhealthy diet.

REVIEW OF SYSTEMS AND PHYSICAL EXAM

GENERAL (+) significant weight loss from 50kgs to 44kgs

BP: 110/90 mmHg

HR: 72 bpm
T: 35.5 °C
RR: 20 cpm
SKIN (+) paleness of palms and nails
CRT: 3-4 seconds
No itching, rashes, sores, dryness, discolorations.
HEENT:
HEAD No headache nor dizziness.

EYES Complete loss of vision on the left eye due to cataract. No

blurring of vision on the right eye, pain, nor redness. With
pupil reactive to light and accommodation at 2 – 3mm
EARS:
No foul-smelling discharge. No noted decrease in audition
 No sinus pain, nose bleeding nor nasal stuffiness. No watery
nasal discharge. With good sense of smell. No dentures. No
NOSE:
bleeding of gums nor sore throat. No ulcerations.
No soreness, tonsillopharingeal wall congestions, nor
THROAT: hoarseness.

NECK No lumps, goiter, nor pain.

No swollen lymph nodes palpated.
BREAST No lumps nor discharges.
RESPIRATORY (+) difficulty of breathing, shortness of breath, dyspnea on
exertion, orthopnea, and paroxysmal nocturnal dyspnea

CARDIOVASCULAR PMI: Slightly deviated in the anterior axillary line.

Elevated left anterior chest wall or Left Precordial Bulge.
Normal heart rate. Regular Rhythm. No chest pain.
GASTROINTERTINAL With good appetite.
Occasional mild abdominal pain
No diarrhea nor constipation. No masses.
URINARY Normal urine output.
(-)dysuria
(-)hematuria
GENITAL No pelvic infections.
MUSCULOSKELETAL (+) pitting edema in the lower extremities
(+) scolosis
NEUROLOGIC No fainting, seizures, paralysis nor involuntary movements.
With good memory. Well oriented to time, date, and place.
HEMATOLOGIC No anemia, bleeding nor easy bruising.
ENDOCRINE (+) Type II Diabetes Mellitus
PSCYCHIATRIC No history of depression nor treatment for psychiatric
disorders.

IMPRESSION:
Caronary Artery Disease
Congestive Heart Failure secondary to Type II DM