A.

BIOGRAPHICAL DATA

Name: Grace Marcelino

Age: 60 years old
Birthdate:
Address: Matang Tubig San Rafael Bulacan
Gender: Female
Provider of History: The Patient itself
Place of Birth:
Race or Ethnic Background:
Primary and Secondary Language:
Marital Status: Widowed
Religious or Spiritual Practices:
Educational Level: College Graduate
Occupation: Retired Teacher
Diagnosis: Moderate COPD/EMPHYSEMA
Date of Admission: October 15, 2020

B. PHYSICAL ASSESSMENT

General Appearance:
Mrs.Marcelino was afebrile and no respiratory distress.Her blood pressure reads 120 / 90
mmhg.

Skin,Hair and Nails:

Mrs. Marcelino has no cyanosis in color

Head, Neck and Cervical Lymph nodes:

There’s jugular venous distention nor were there palpable masses or lymphadenopathy in
the neck.

Thorax and Lungs:

The patient’s lung sounds were vesicular but were somewhat diminished bilaterally.

Heart and Circulation:

The patient's heart sounds and findings from an abdominal examination and examination
of his extremities were unremarkable

C. PAST AND PRESENT HISTORY

October 15, 2020

REASON FOR SEEKING HEALTH CARE

The patient was admitted to Castro Maternity and General Hospital last October 15, 2020
with a chief complaint of Breathlessness after moderate exertion.
HISTORY OF PRESENT HEALTH CONCERN
The patient scored 3 on the modified Medical Research Council (mMRC) scale (Fletcher
et al, 1959), indicating she is unable to walk more than 100 yards without stopping due to
breathlessness. Ms Marcelino also has a cough that produces yellow sputum (particularly
in the mornings) and an intermittent wheeze. Her symptoms have worsened over the last
six months. She feels anxious leaving the house alone because of her breathlessness and
reduced exercise tolerance, and scored 26 on the COPD Assessment Test (CAT,
catestonline.org), indicating a high level of impact.

Upon admission Dr. Herrera requested for chest x-ray and spirometry testing ..He also
ordered to start venoclysis of PLRS il at KVO rate . O2 inhalation at 2-3/ Lpm via nasal
cannula . an initial dose of Hydrocortisone 200 mg TIV is to be given , then 100 mg q 8 X
3 doses then switch to prednisone 30 mg p.o O.D ,budesonide 1 repulse q 8hrs . Since the
symptoms have been quite sometime an initial loading of amoxicillin clavulanate 500mg
TIV q 8 is also given and azithromycin 500 mg tab O.D for 5 days ..advised to continue
her inhaler as needed. She is on DAT with SAP and was ordered CPT after each
nebulization. She is also on ABG monitoring

PAST HEALTH HISTORY

Ms. Marcelino smokes 10 cigarettes a day and has a pack-year score of 29.
She has had three exacerbations of COPD in the previous 12 months, each managed in
the community with antibiotics, steroids and salbutamol.

FAMILY HEALTH HISTORY

His father died of ischemic heart disease and emphysema at the age of 67 years.