Identifying Data:

This is a case of P. B, a 71 year old female, Widow, born on February 26, 1949, Housewife, Roman
Catholic from. The informant is the patient herself and her daughter with a reliability of 90%.

Chief Complaint:
3 month persistence of cough

History of Present Illness:

3 months prior to consult, patient noted an intermittent productive cough with whitish occasionally blood
tinged sputum. This was not associated with fever, chest tightness, dyspnea, weight loss, loss of appetite,
fatigue, nausea, headache, or vomiting. Patient sought consult in a private clinic and was given,
Ceterizine and Amoxicillin/ Clavulanic Acid with unrecalled dosage and frequency. The patient claims to
finish the course of treatment which provided temporary relief.
2 months prior to consult, patient noted persistence of prior symptoms that prompted the patient to self-
medicate with Guaifenesin 100mg/5ml 1 tablespoon QID that provided temporary relief. This was now
associated with undocumented weight loss, fatigue and fever with a highest documented temperature of
37.2oC that prompted the patient to self-medicate with Paracetamol 500mg OD that provided full relief.

1 day prior to consult, persistence of symptoms prompted the patient to seek consult in a private clinic.
Xray was done and noted to have a result of Pulmonary Tuberculosis thus was advised for TBDOTS
consult for further management.

Past Medical History:

The patient has no known comorbidities.
The patient has no known food and drug allergies.
The patient is not on maintenance medications.
The patient has unrecalled childhood vaccinations.
The patient has no prior hospitalizations however was diagnosed with Pulmonary Tuberculosis (1977)
and claims to have completed her treatment course.

Family History:

The patient has a family history of Hypertension (Paternal side) and Goiter, Diabetes Mellitus (Maternal
side). The patient has five children. The patient’s mother and father died of natural causes as claimed.

Personal and Social History:

The patient is a nonsmoker and an occasional alcoholic drinker. The patient lives with her children and
grandchildren. The patient’s diet is composed mostly of fish, vegetables and rice. The patient’s activity
daily includes household chores and resting afterwards. The patient lives next to an eatery that grills
barbecue, isaw and the like.

OB History:
The patient is a G5P5(5-0-0-5) with all deliveries via home birth with no complications as claimed. The patient's
menarche is at 15 years old, with regular intervals of 28 to 35 days per menstrual cycle, 7 days duration. She does
not recall the flow and number of pads used per day. Patient claims no associated symptoms such as dysmennorhea.
The patient's menopause is at 49 years of age. She denies contraceptive use. The patient noted no history of sexually
transmitted diseases. She claims to have only one sexual partner. The patient cannot recall to have undergone Pap’s
smear or Mammogram tests.

Review of Systems:

General
(-) Change in weight (-) Fever, Chills and Sweats (-) Change in appetite
Skin
(-) Itching (-) Moles (-) Color (-) Rash (-) Pigmentation (-) Vasomotor changes (-) Photosensitivity (-) Paleness

Endocrine
(-) Thyroid gland (-) Salt cravings
(-) Unusually hot/cold (-) Excessive thirst
(-) Loss of sexual drive

Hematopoietic
(-) Abnormal bleeding (-) Pica (-) Bruising (-) Frequent infection
(-) Anemia (-) Swelling/Lumps/Bumps (-)Adenopathy

Musculoskeletal
(-) Joint stiffness (-) Kyphosis (-) Low back pain (-) Wasting (-) Trauma
(-) Swelling (-) Scoliosis (-)Lordosis ‘ (-) Frequent fractures

Head and Neck

(-) Headache (-) Neck stiffness
(-) Head injury

Eyes
(-) Bright flashes/Light (-) Spots in visual fields
(-) Changes in vision (-) Double vision
(-) Blind spot bordered (-) Pain by shimmering light

Ears, Nose, Sinuses, Mouth, Throat

(-) Sore throat (-) Difficult speech (-) Ringing in the ears
(-) Painful tooth (-) Hoarseness (-) Tinnitus
(-) Decrease or change (-) Nasal drainage or nosebleeds
in sense of taste (-) Change or loss of hearing

Respiratory
(-) SOB
(-) Wheezing or
(-)Tightness in your chest

Neurologic
(- ) Loss of feeling/sensation (-) Memory disorder
(-) Seizures (-) Headaches
(-) Weakness on one or both (-) Dizziness
sides of the body (-) Loss of balance/Lack of coordination
(-) Tremors (-) Sleep disorder

Psychiatric
(-) Nervousness/Anxiety (-) Intrusive thoughts (-) Auditory hallucinations
(-) Depression (-) Loss of good judgment or insight
(-) Mania (-) Visual hallucinations

Physical Examination:
The patient is awake, conscious, coherent, not in respiratory distress.
Vital signs:
BP: 150/80 HR: 109bpm RR: 24 cycles per minute Temp: 36.2oC
O2 sat: 96% Wt: 49.5 kgs HT: 5 feet
Skin: No active lesions. Good turgor. Warm to touch.
HEENT: Anicteric sclera, Pale conjunctiva, No sinus tenderness, No TPC
Neck: No NVE, No LAD, No tracheal deviation,
Chest and Lungs: ECE, CBS, No retractions, No wheezing, No rales
Abdomen: Flat, soft, NABS, Nontender, No palpable mass
CVS: Adynamic precordium, PMI at 5th LICS MCL, Distinct heart sounds, No murmurs
GUT: (-) KPS bilaterally
Extremities: Strong peripheral pulses, CRT 2seconds
Neurologic:
CNI- Olfactory intact
CNII- PERRLA, no visual field defects
CNIII, CNIV, CNVI- EOM intact, no ptosis, no diplopia, no nystagmus
CNV- (+) Corneal reflex
CNVII- No facial asymmetry
CNVIII- Hearing intact
CNIX, CNX - Uvula at midline, intact gag reflex
CNXI- Bilateral shoulder strength intact
CNXII- Tongue at midline

Motor: Sensory: DTR:

Cerebellar: (-) Ataxia (-) Incoordination

Meningeal signs: (-) Nuchal rigidity (-) Kernig’s sign (-) Brudzinski’s sign