LOWER BACK PAIN

S>

Came in for check up

Chief complaint: Lower back pain, right x 1 year

HPI: 1 year prior to consult, (+) constant pain on right lower back, localized at the lumbosacral
area, characterized as numbing, precipitated lying supine and sitting down. PRS of 6/10,
temporarily relieved by pain reliever. No fever, no dysuria, no history of trauma or injuries.

3 months prior to consult, patient had lumbosacral xray at a private hospital with normal
findings. With take home meds of pain reliever.

Interim, still with constant back pain, temporarily by pain reliever

Days prior to consult, (+) still with pain on lower back, with PRS of 7/10 and unrelieved by pain
reliever. Hence, consult.

Past Medical history unremarkable

Non diabetic, non-hypertensive

No known allergies to food and drinks

With family history of hypertension

Personal/Social:

Patient works as a CAD operator

Non smoker, non alcoholic beverage drinker

O>

Patient was examined sitting, alert, conscious, coherent, and conversant, not in cardiorespiratory
distress, oriented to time, place and person.

Vital signs:

BP: 110/80

HR: 94 bpm
RR: 18 cpm

O2sat: 96%

The patient has stable vital signs and essentially normal physical examination.

INTEGUMENT:

Skin: warm, dry with good skin turgor fair in color. No rashes, no active lesions, no cyanosis, no
edema

Nails: with good capillary refill of <2 seconds. No clubbing, no breaks, no ridges

HEENT:

Head: Normocephalic. Atraumatic, symmetric with no lesions, tenderness, and breaks. Hair is
black in color, fine with equal distribution, no alopecia, no lice infestation, with dandruff, no
breaks, no tenderness, no active lesions

Eyes: Non-sunken eyes, pale palpebral conjunctivae, anicteric sclerae, pupils are equally reactive
to light and accommodation

Ears: symmetric, aligned with lateral canthus of eyes, no tenderness, no impacted cerumen, no
abnormal discharges, no hearing impairment

Mouth and Throat: no dentures, buccal mucosa is moist and pinkish. Lips are pinkish and oral
mucosa is moist.

Uvula and tonsils: midline, no tonsilopharyngeal congestion

NECK: Trachea is at midline; thyroid gland is non-palpable. Thyroid cartilage moves upward
upon deglutition, with no palpable and tender cervical lymph nodes, no visible pulsation, ROM
unimpaired

BREASTS: No discoloration, nipples are everted, no discharges, no palpable lymph nodes, no

lumps, no tenderness

CHEST and LUNGS:

Inspection: No retractions, no apparent respiratory distress

Palpation: symmetric expansion, no tenderness

Percussion: resonant on all lung field

Auscultation: clear breath sounds

CARDIOVASCULAR:

Inspection: adynamic heart, no precordial bulging

Palpation: PMI is not measured, adynamic apex precordium, carotid pulse is brisk and sharp, and
synchronous with apex pulsations. No thrills, no heaves

Auscultation: Radial pulse is synchronous with heart sounds, with regular rate and rhythm, no
murmurs

ABDOMEN:

Inspection: Umbilicus everted, no visible veins nor lesions.

Auscultation: Normoactive bowel sounds

Palpation: No organomegaly, no palpable masses

GUT: No discharges, no voiding problems.

EXTREMITIES: Symmetric, equal in length and size on both sides, no edema, no cyanosis, no
deformities.

BACK and SPINE: no abnormal deviations,(+) Lumbosacral Pain, PRS 7/10, no visible bulging,
no redness (-) Inflammation. No CVA tenderness;

NEUROLOGIC: no neurologic deficit

 
A> T/C Spondylolisthesis

P> Laboratory:

1. Lumbosacral xray APL view

Medications:

1. Orphenadine Citrate + Paracetamol 50/650mg tab. 1 tab 3x a day for pain

To come back with laboratory result

Advise

PGI Garcia/Dr. Mojica

LEFT SIDED BODY WEAKNESS

S>

Came in for check up

Chief complaint: Left sided body weakness x 2 years

HPI:

2 years prior to consultation, (+) onset of left sided body weakness and dizziness, consulted at a
private clinic with take home medications of  Cinnarazine 75mg/cap, 1 cap once a day for 2
weeks, Betahistine 16mg/tab 1/2 tablect 2x a day. For referral to a neurologist, but unable to seek
consult.

Interim, patient claimed to have good compliance to medications, however, failed to seek consult
at the neurologist

Week prior to consultation, still with left sided body weakness, now unable to do ADLs without
support of her wife. Consulted at a private MD with take home meds of Atorvastatin 20mg/tab
once a day, Amlodipine 5mg/tab, once a day, Febuxostat 80mg/tab 1x a day. Persistence of
symptoms prompted consultation

Past Medical history unremarkable

Non diabetic, hypertensive

No known allergies to food and drinks

With family history of hypertension, Diabetes Mellitus and BPH

Personal/Social:

Patient works as a fisherman

Non smoker, non alcoholic beverage drinker

O>

Patient was examined sitting, alert, conscious, coherent, and conversant, not in cardiorespiratory
distress, oriented to time, place and person.

Vital signs:
BP: 130/80

HR: 87 bpm

RR: 18 cpm

O2sat: 97%

The patient has stable vital signs and essentially normal physical examination.

INTEGUMENT:

Skin: warm, dry with good skin turgor fair in color. No rashes, no active lesions, no cyanosis, no
edema

Nails: with good capillary refill of <2 seconds. No clubbing, no breaks, no ridges

HEENT:

Head: Normocephalic. Atraumatic, symmetric with no lesions, tenderness, and breaks. Hair is
black in color, fine with equal distribution, no alopecia, no lice infestation, with dandruff, no
breaks, no tenderness, no active lesions

Eyes: Non-sunken eyes, pale palpebral conjunctivae, anicteric sclerae, pupils are equally reactive
to light and accommodation

Ears: symmetric, aligned with lateral canthus of eyes, no tenderness, no impacted cerumen, no
abnormal discharges, no hearing impairment

Mouth and Throat: no dentures, buccal mucosa is moist and pinkish. Lips are pinkish and oral
mucosa is moist.

Uvula and tonsils: midline, no tonsilopharyngeal congestion

NECK: Trachea is at midline; thyroid gland is non-palpable. Thyroid cartilage moves upward
upon deglutition, with no palpable and tender cervical lymph nodes, no visible pulsation, ROM
unimpaired

BREASTS: No discoloration, nipples are everted, no discharges, no palpable lymph nodes, no

lumps, no tenderness

CHEST and LUNGS:

Inspection: No retractions, no apparent respiratory distress

Palpation: symmetric expansion, no tenderness

Percussion: resonant on all lung field

Auscultation: clear breath sounds

CARDIOVASCULAR:

Inspection: adynamic heart, no precordial bulging

Palpation: PMI is not measured, adynamic apex precordium, carotid pulse is brisk and sharp, and
synchronous with apex pulsations. No thrills, no heaves

Auscultation: Radial pulse is synchronous with heart sounds, with regular rate and rhythm, no
murmurs

ABDOMEN:

Inspection: Umbilicus everted, no visible veins nor lesions.

Auscultation: Normoactive bowel sounds

Palpation: No organomegaly, no palpable masses

GUT: No discharges, no voiding problems.

EXTREMITIES: Symmetric, equal in length and size on both sides, no edema, no cyanosis, no
deformities.

BACK and SPINE: no abnormal deviations, no visible bulging, no redness (-) Inflammation. No
CVA tenderness;

 
NEUROLOGIC: 

Cranial nerves:

CN I: Intact 

CN II: Intact visual fields by conformation. Pupils are equally rounds and reactive to direct and
consensual lght

CN III, IV, VI: Extraocular movement are intact, with no nystagmus

CN V: Sensory: No sensory loss, Motor: intact, midline location of the jaw and equal contraction
during mastication

CN VII: No facial asymmetry. Facial muscle is normal and equal bilaterally

CN VIII: Hearing is intact bilaterally

CN IX, X: The palate and uvula elevate symmetrically, with normal voice. Intact gag reflex

CN XI: Shoulder shrug and head turning is strong and equal bilaterally. No fasciculation.

CN XII: (+) Tongue deviation to the right and move symetrically. No atrophy

Motor: Good muscle bulk and tone. Strength 5/5 throughout. 

Cerebellar: Rapid alternating movements, point to point movement intact. Gait stable

Sensory: Pinprick, light touch, position sense intact

Diagnostics:

Blood Chemistry (05/03/2022)

Creatinine: 117umol/L (HIGH)

Total cholesterol: 6.04mmol/L (HIGH)

BUA: 512 umol/L (HIGH)

 
GFR: 56.4ml/min

A> 1.CVD

2. Hypertension-controlled

2. Hyperuricemia

P> Laboratory:

1. CT scan with contrast 

Continue maintenance medications:

1.Atorvastatin 20mg/tab once a day

2. Amlodipine 5mg/tab, once a day

3.Febuxostat 80mg/tab 1x a day

To come back with laboratory result

Advise

PGI Garcia/Dr. Mojica

 
 
S>

Came in for check up

Chief complaint: Headache from head injury x 5 months, with occasional dizziness.
Characterized as pulsating, PRS 7/10. No fever, no vomiting. No medications taken.

HPI: 5 months prior to consult, patient had head trauma

NOI: Alleged head trauma from falling debri

POI: San roque, Samar

TOI: 10:00am

DOI: 1st week of December 2022

Past Medical history unremarkable

Non diabetic, non-hypertensive

No known allergies to food and drinks

Family history unremarkable

Personal/Social:

Patient works as a construction foreman

Non smoker, Alcoholic beverage drinker

O>

Patient was examined sitting, alert, conscious, coherent, and conversant, not in cardiorespiratory
distress, oriented to time, place and person.

Vital signs:

BP: 140/100
HR: 102 bpm

RR: 18 cpm

O2sat: 98%

The patient has stable vital signs and essentially normal physical examination.

INTEGUMENT:

Skin: warm, dry with good skin turgor fair in color. No rashes, no active lesions, no cyanosis, no
edema

Nails: with good capillary refill of <2 seconds. No clubbing, no breaks, no ridges

HEENT:

Head: Normocephalic. (+) Tenderness upon palpation. symmetric with no lesions. Hair is black
in color, fine with equal distribution, no alopecia, no lice infestation, with dandruff, no breaks,
no tenderness, no active lesions

Eyes: Non-sunken eyes, pale palpebral conjunctivae, anicteric sclerae, pupils are equally reactive
to light and accommodation

Ears: symmetric, aligned with lateral canthus of eyes, no tenderness, no impacted cerumen, no
abnormal discharges, no hearing impairment

Mouth and Throat: no dentures, buccal mucosa is moist and pinkish. Lips are pinkish and oral
mucosa is moist.

Uvula and tonsils: midline, no tonsilopharyngeal congestion

NECK: Trachea is at midline; thyroid gland is non-palpable. Thyroid cartilage moves upward
upon deglutition, with no palpable and tender cervical lymph nodes, no visible pulsation, ROM
unimpaired

BREASTS: No discoloration, nipples are everted, no discharges, no palpable lymph nodes, no

lumps, no tenderness

CHEST and LUNGS:

Inspection: No retractions, no apparent respiratory distress

Palpation: symmetric expansion, no tenderness

Percussion: resonant on all lung field

Auscultation: clear breath sounds

CARDIOVASCULAR:

Inspection: adynamic heart, no precordial bulging

Palpation: PMI is not measured, adynamic apex precordium, carotid pulse is brisk and sharp, and
synchronous with apex pulsations. No thrills, no heaves

Auscultation: Radial pulse is synchronous with heart sounds, with regular rate and rhythm, no
murmurs

ABDOMEN:

Inspection: Umbilicus everted, no visible veins nor lesions.

Auscultation: Normoactive bowel sounds

Palpation: No organomegaly, no palpable masses

GUT: No discharges, no voiding problems.

EXTREMITIES: Symmetric, equal in length and size on both sides, no edema, no cyanosis, no
deformities.

BACK and SPINE: no abnormal deviations,(+) Lumbosacral Pain, PRS 7/10, no visible bulging,
no redness (-) Inflammation. No CVA tenderness;

NEUROLOGIC: no neurologic deficit

 

A> Head injury

P> Laboratory:

1. Ct scan of the head with contrast

2. Creatinine

Medications:

1. Celecoxib 200mg/tab 2x a day for pain

To come back with laboratory result

Advise

PGI Garcia/Dr. Mojica

 
Subjective:

Came in for check up

Chief complaint: Right knee pain x 4 months, skin lesions x 2 years

History of Present Illness: 

PROBLEM #1: Right knee pain

4 months prior to consult, (+) right knee pain, aggravated by walking, PRS of 3/10, temporarily
relived by pain reliever.

Interim, still with right knee pain temporarily relived by pain reliever.

Due to persistence of symptoms, sought consult to our center.

Problem #2: Skin lesion

2 years prior to consult (+) itchy skin lesion on both thenar eminence, self medicated with topical
ointment which afforded temporary relief. No medications taken. No consult done.

Interim, persistence of symptom.

Past Medical history unremarkable

Hypertensive with maintenance medications of Amlodipine 10mg/tab once a day and Losartan
50mg/tab 1 tab once a day

No known allergies to food and medications

With family history of hypertension, DM

Personal/Social:

Patient works as a housewife

Non smoker, alcoholic beverage drinker

 
Objective:

Patient was examined sitting, alert, conscious, coherent, and conversant, not in cardiorespiratory
distress, oriented to time, place and person.

Vital signs:

BP: 150/110mmHg

HR: 98 bpm

RR: 20 cpm

O2sat: 99%

Temp: 36.7

Weight: 90.2kg

Height: 5'2

BMI: 36.4 (Obesity)

The patient has stable vital signs and essentially normal physical examination.

INTEGUMENT:

Skin: (+) lichenification on both thenar eminence, warm, dry with good skin turgor fair in color.
No rashes, no cyanosis, no edema

Nails: with good capillary refill of <2 seconds. No clubbing, no breaks, no ridges

HEENT:

Head: Normocephalic. Atraumatic, symmetric with no lesions, tenderness, and breaks. Hair is
black in color, fine with equal distribution, no alopecia, no lice infestation, with dandruff, no
breaks, no tenderness, no active lesions

Eyes: Non-sunken eyes, pale palpebral conjunctivae, anicteric sclerae, pupils are equally reactive
to light and accommodation
Ears: symmetric, aligned with lateral canthus of eyes, no tenderness, no impacted cerumen, no
abnormal discharges, no hearing impairment

Mouth and Throat: no dentures, buccal mucosa is moist and pinkish. Lips are pinkish and oral
mucosa is moist.

Uvula and tonsils: midline, no tonsilopharyngeal congestion

NECK: Trachea is at midline; thyroid gland is non-palpable. Thyroid cartilage moves upward
upon deglutition, with no palpable and tender cervical lymph nodes, no visible pulsation, ROM
unimpaired

BREASTS: No discoloration, nipples are everted, no discharges, no palpable lymph nodes, no

lumps, no tenderness

CHEST and LUNGS:

Inspection: No retractions, no apparent respiratory distress

Palpation: symmetric expansion, no tenderness

Percussion: resonant on all lung field

Auscultation: clear breath sounds

CARDIOVASCULAR:

Inspection: adynamic heart, no precordial bulging

Palpation: PMI is not measured, adynamic apex precordium, carotid pulse is brisk and sharp, and
synchronous with apex pulsations. No thrills, no heaves

Auscultation: Radial pulse is synchronous with heart sounds, with regular rate and rhythm, no
murmurs

ABDOMEN:

Inspection: Umbilicus everted, no visible veins nor lesions.

Auscultation: Normoactive bowel sounds

Palpation: No organomegaly, no palpable masses

GUT: No discharges, no voiding problems.

EXTREMITIES: Symmetric, equal in length and size on both sides, no edema, no cyanosis, no
deformities.

BACK and SPINE: no abnormal deviations, no visible bulging, no redness (-) Inflammation. No
CVA tenderness;

NEUROLOGIC: no neurologic deficit

A> T/C Arthritis

Eczema

P> Laboratory examination:

1. Lipid profile
2. FBS
3. BUA
4. Creatinine

Medications:

1. Betamethasone+Gentamicin+Clotrimazole ointment apply 2x a day for 7 days

To come back once with laboratory result

Advise

 
 

 
S> (+) 3 days yellowish watery stool, 3-4x per day
(+) Generalized abdominal pain, cramping 
1 day (+) low grade fever relieved by Paracetamol
Past medical history and family history unremarkable
Fully vaccinated
O> BP : 120/70mmHg, HR: 87bpm, RR: 15cpm
CBS, SCE
AP, NRRR
Full and equal pulses
 
A> Acute gastroenteritis
 
P> Lab exam: CBC, UA and stool exam
Medications:
1. Erceflora neb 1 neb TID
2. HNBB 10mg/tab 1 tablet TID
3. Oresol sachet dissolve 200ml per bout of stool or as needed
> To come back once with lab result

DIARRHEA, VOMITING, FEVER

S> Came in for checkup

Chief complaint: Abdominal pain x 7 days, diarrhea x 3 days, vomiting x 3 days, fever x 3 days

History of Present Illness:

7 days prior to consult (+) Generalized abdominal pain, characterized as cramping, PRS 7/10,
self medicated with Loperamide which gave temporary relief. Associated with loose watery stool
diarrhea, vomiting and fever. No other medications taken, no consult done.

Persistence of symptoms prompted patient for consult

Past Medical history unremarkable

Non diabetic, non-hypertensive

No known allergies to food and drinks

With family history of hypertension

Personal/Social:

Patient works as a laundry woman

Non smoker, alcoholic beverage drinker

 

O>

Patient was examined sitting, alert, conscious, coherent, and conversant, not in cardiorespiratory
distress, oriented to time, place and person.

Vital signs:

BP: 120/80

HR: 97 bpm

RR: 24 cpm

O2sat: 97%

The patient has stable vital signs and essentially normal physical examination.

INTEGUMENT:

Skin: warm, dry with poor skin turgor fair in color. No rashes, no active lesions, no cyanosis, no
edema

Nails: with prolonged capillary refill of >2 seconds. No clubbing, no breaks, no ridges

HEENT:

Head: Normocephalic. Atraumatic, symmetric with no lesions, tenderness, and breaks. Hair is
black in color, fine with equal distribution, no alopecia, no lice infestation, with dandruff, no
breaks, no tenderness, no active lesions

Eyes: Sunken eyes, pale palpebral conjunctivae, anicteric sclerae, pupils are equally reactive to
light and accommodation

Ears: symmetric, aligned with lateral canthus of eyes, no tenderness, no impacted cerumen, no
abnormal discharges, no hearing impairment

Mouth and Throat: no dentures, buccal mucosa is moist and pinkish. Lips are pinkish and oral
mucosa is moist.

Uvula and tonsils: midline, no tonsilopharyngeal congestion

NECK: Trachea is at midline; thyroid gland is non-palpable. Thyroid cartilage moves upward
upon deglutition, with no palpable and tender cervical lymph nodes, no visible pulsation, ROM
unimpaired

BREASTS: No discoloration, nipples are everted, no discharges, no palpable lymph nodes, no

lumps, no tenderness

CHEST and LUNGS:

Inspection: No retractions, no apparent respiratory distress

Palpation: symmetric expansion, no tenderness

Percussion: resonant on all lung field

Auscultation: clear breath sounds

CARDIOVASCULAR:

Inspection: adynamic heart, no precordial bulging

Palpation: PMI is not measured, adynamic apex precordium, carotid pulse is brisk and sharp, and
synchronous with apex pulsations. No thrills, no heaves

Auscultation: Radial pulse is synchronous with heart sounds, with regular rate and rhythm, no
murmurs

ABDOMEN:

Inspection: Umbilicus everted, no visible veins nor lesions.

Auscultation: Normoactive bowel sounds

Palpation: No organomegaly, no palpable masses

GUT: No discharges, no voiding problems.

 
EXTREMITIES: Symmetric, equal in length and size on both sides, no edema, no cyanosis, no
deformities.

BACK and SPINE: no abnormal deviations, no visible bulging, no redness (-) Inflammation. No
CVA tenderness;

NEUROLOGIC: no neurologic deficit

A> Acute gadtroenteritis

P> Laboratory examination:

1. CBC
2. Fecalysis

Medications:

1. Erceflora neb 1 neb TID

2. Racecadotril 100mg/cap TID
3. Oresol sachet dissolve 200ml per bout of stool or as needed

To come back with laboratory result

Advise

 
 HEMORRHOIDS
S> Came in for checkup
Chief complaint: Protruding anal mass x 3 months
History of present illness:
3 months prior to consult, (+) protruding anal mass, painless upon palpation and straining, reducible.
Occasional blood on stool
Past Medical history unremarkable
Non diabetic, non-hypertensive
No known allergies to food and drinks
With family history of hypertension
Personal/Social:
Patient works as a market vendor
Non smoker, non alcoholic beverage drinker
 
O>
Patient was examined sitting, alert, conscious, coherent, and conversant, not in cardiorespiratory distress,
oriented to time, place and person.
Vital signs:
BP: 100/70
HR: 81 bpm
RR: 23 cpm
O2sat: 98%
The patient has stable vital signs and essentially normal physical examination.
INTEGUMENT:
Skin: warm, dry with good skin turgor fair in color. No rashes, no active lesions, no cyanosis, no edema
Nails: with good capillary refill of <2 seconds. No clubbing, no breaks, no ridges
 
HEENT:
Head: Normocephalic. Atraumatic, symmetric with no lesions, tenderness, and breaks. Hair is black in color,
fine with equal distribution, no alopecia, no lice infestation, with dandruff, no breaks, no tenderness, no active
lesions
Eyes: Non-sunken eyes, pale palpebral conjunctivae, anicteric sclerae, pupils are equally reactive to light and
accommodation
Ears: symmetric, aligned with lateral canthus of eyes, no tenderness, no impacted cerumen, no abnormal
discharges, no hearing impairment
Mouth and Throat: no dentures, buccal mucosa is moist and pinkish. Lips are pinkish and oral mucosa is moist.
Uvula and tonsils: midline, no tonsilopharyngeal congestion
NECK: Trachea is at midline; thyroid gland is non-palpable. Thyroid cartilage moves upward upon deglutition,
with no palpable and tender cervical lymph nodes, no visible pulsation, ROM unimpaired
BREASTS: No discoloration, nipples are everted, no discharges, no palpable lymph nodes, no lumps, no
tenderness
 
CHEST and LUNGS:
Inspection: No retractions, no apparent respiratory distress
Palpation: symmetric expansion, no tenderness
Percussion: resonant on all lung field
Auscultation: clear breath sounds
 
CARDIOVASCULAR:
Inspection: adynamic heart, no precordial bulging
Palpation: PMI is not measured, adynamic apex precordium, carotid pulse is brisk and sharp, and synchronous
with apex pulsations. No thrills, no heaves
Auscultation: Radial pulse is synchronous with heart sounds, with regular rate and rhythm, no murmurs
 
ABDOMEN:
Inspection: Umbilicus everted, no visible veins nor lesions.
Auscultation: Normoactive bowel sounds
Palpation: No organomegaly, no palpable masses 
GUT: No discharges, no voiding problems.
 
Digital Rectal Exam: Good sphincteric tone, (+) painless protruding mass, reducible, brownish fecl matter on
examining finger, smooth mucosal walls
 
EXTREMITIES: Symmetric, equal in length and size on both sides, no edema, no cyanosis, no deformities.
 
BACK and SPINE: no abnormal deviations, no visible bulging, no redness (-) Inflammation. No CVA
tenderness;
 
NEUROLOGIC: no neurologic deficit
 
A> Internal hemorrhoids, grade 2
 
P> Medications:
1. Bismuth subgallate 2g, menthol 1g, Menthol 1g, Zinc Oxide 8g, Calcium carbonate 5g,
ROWATANAL CREAM, apply on affected area 3x a day after defecation
Advise to do hot sitz bath
Advise
 VERTIGO
S> Came in for checkup 

Chief complaint: Dizziness x 1 year

1 year prior to consult: (+) onset of dizziness, lasts for a few seconds to minutes, triggered by
sudden head movements changes, alleviated by rest, self medicated with pain reliever. 

(+) throbbing headache PRS 6/10, radiates in a band like fashion bilaterally from forehead to
occiput 

(+) nausea and vomiting

(+) tinnitus

Past Medical history unremarkable

Non diabetic, non-hypertensive

No known allergies to food and drinks

With family history of hypertension

Personal/Social:

Patient works as a supervisor at a fuel refilling station

Non smoker, alcoholic beverage drinker

O>

Patient was examined sitting, alert, conscious, coherent, and conversant, not in cardiorespiratory
distress, oriented to time, place and person.

Vital signs:

BP: 110/70

HR: 74 bpm

RR: 23 cpm
O2sat: 99%

The patient has stable vital signs and essentially normal physical examination.

INTEGUMENT:

Skin: warm, dry with good skin turgor fair in color. No rashes, no active lesions, no cyanosis, no
edema

Nails: with good capillary refill of <2 seconds. No clubbing, no breaks, no ridges

HEENT:

Head: Normocephalic. Atraumatic, symmetric with no lesions, tenderness, and breaks. Hair is
black in color, fine with equal distribution, no alopecia, no lice infestation, with dandruff, no
breaks, no tenderness, no active lesions

Eyes: Non-sunken eyes, pale palpebral conjunctivae, anicteric sclerae, pupils are equally reactive
to light and accommodation

Ears: symmetric, aligned with lateral canthus of eyes, no tenderness, no impacted cerumen, no
abnormal discharges, no hearing impairment

Mouth and Throat: no dentures, buccal mucosa is moist and pinkish. Lips are pinkish and oral
mucosa is moist.

Uvula and tonsils: midline, no tonsilopharyngeal congestion

NECK: Trachea is at midline; thyroid gland is non-palpable. Thyroid cartilage moves upward
upon deglutition, with no palpable and tender cervical lymph nodes, no visible pulsation, ROM
unimpaired

BREASTS: No discoloration, nipples are everted, no discharges, no palpable lymph nodes, no

lumps, no tenderness

CHEST and LUNGS:

Inspection: No retractions, no apparent respiratory distress

Palpation: symmetric expansion, no tenderness

Percussion: resonant on all lung field

Auscultation: clear breath sounds

CARDIOVASCULAR:

Inspection: adynamic heart, no precordial bulging

Palpation: PMI is not measured, adynamic apex precordium, carotid pulse is brisk and sharp, and
synchronous with apex pulsations. No thrills, no heaves

Auscultation: Radial pulse is synchronous with heart sounds, with regular rate and rhythm, no
murmurs

ABDOMEN:

Inspection: Umbilicus everted, no visible veins nor lesions.

Auscultation: Normoactive bowel sounds

Palpation: No organomegaly, no palpable masses

GUT: No discharges, no voiding problems.

EXTREMITIES: Symmetric, equal in length and size on both sides, no edema, no cyanosis, no
deformities.

BACK and SPINE: no abnormal deviations, no visible bulging, no redness (-) Inflammation. No
CVA tenderness;

NEUROLOGIC: no neurologic deficit

A> Vertigo
P> Medications:

1. Betahistine 16mg/tab 3x a day for 5 days

Advise

 
SUBJECTIVE:

Chief Complaint: Numbness of lower extremities x 1 month

HISTORY OF PRESENT ILLNESS:

1 month prior to consultation, (+) numbness of lower extremeties, with associated occasional
joint pains. Relieved by massage. No associated symptoms such as fever, vomiting or diarrhea.
No history of trauma. No medications, no consult done.

Persistence of symptoms prompted consult

OBJECTIVE:

Patient was examined sitting, alert, conscious, coherent, and conversant, not in cardiorespiratory
distress, oriented to time, place and person.

Vital signs:

BP: 140/80

HR: 99 bpm

RR: 20 cpm

O2sat: 99%

Temp: 36.9

The patient has stable vital signs and essentially normal physical examination.

INTEGUMENT:

Skin: warm, dry with good skin turgor fair in color. No rashes, no active lesions, no cyanosis, no
edema

Nails: with good capillary refill of <2 seconds. No clubbing, no breaks, no ridges

 
HEENT:

Head: Normocephalic. Atraumatic, symmetric with no lesions, tenderness, and breaks. Hair is
black in color, fine with equal distribution, no alopecia, no lice infestation, with dandruff, no
breaks, no tenderness, no active lesions

Eyes: Non-sunken eyes, pale palpebral conjunctivae, anicteric sclerae, pupils are equally reactive
to light and accommodation

Ears: symmetric, aligned with lateral canthus of eyes, no tenderness, no impacted cerumen, no
abnormal discharges, no hearing impairment

Mouth and Throat: no dentures, buccal mucosa is moist and pinkish. Lips are pinkish and oral
mucosa is moist.

Uvula and tonsils: midline, no tonsilopharyngeal congestion

NECK: Trachea is at midline; thyroid gland is non-palpable. Thyroid cartilage moves upward
upon deglutition, with no palpable and tender cervical lymph nodes, no visible pulsation, ROM
unimpaired

BREASTS: No discoloration, nipples are everted, no discharges, no palpable lymph nodes, no

lumps, no tenderness

CHEST and LUNGS:

Inspection: No retractions, no apparent respiratory distress

Palpation: symmetric expansion, no tenderness

Percussion: resonant on all lung field

Auscultation: clear breath sounds

CARDIOVASCULAR:

Inspection: adynamic heart, no precordial bulging

Palpation: PMI is not measured, adynamic apex precordium, carotid pulse is brisk and sharp, and
synchronous with apex pulsations. No thrills, no heaves
Auscultation: Radial pulse is synchronous with heart sounds, with regular rate and rhythm, no
murmurs

ABDOMEN:

Inspection: Umbilicus everted, no visible veins nor lesions.

Auscultation: Normoactive bowel sounds

Palpation: No organomegaly, no palpable masses

GUT: No discharges, no voiding problems.

EXTREMITIES: Symmetric, equal in length and size on both sides, no edema, no cyanosis, no
deformities.

BACK and SPINE: no abnormal deviations,no visible bulging, no redness (-) Inflammation. No
CVA tenderness;

NEUROLOGIC: no neurologic deficit

ASSESSMENT:

Polyneuropathy T/C Diabetes Mellitus

Hypertension-Controlled

PLAN:

Laboratory examination:

1. Lipid profile
 2. BUA
3. Creatinine
4. FBS
5. SGPT
6. CBC
7. Urinalysis

Medications:

1. Vitamin B complex tab 1 tablet once a day

To come back once with lab result

Advise

 
 POLYNEUROPATHY
SUBJECTIVE:

Chief Complaint: Numbness of extremities x 4 months

HISTORY OF PRESENT ILLNESS:

4 months prior to consultation, (+) numbness of extremeties, (+) occasional cough with
yellowish phlegm (+) weight loss approx 8 kilos in 2 months.(+) joint pains. No associated
symptoms such as fever, vomiting or diarrhea.No medications taken, no consult done.

1 day prior to consultation, still with persistence of symptoms. Patient had CBG of 257mg/dl
hence consultation

OBJECTIVE:

Patient was examined sitting, alert, conscious, coherent, and conversant, not in cardiorespiratory
distress, oriented to time, place and person.

Vital signs:

BP: 100/70

HR: 97 bpm

RR: 20 cpm

O2sat: 99%

Temp: 36.7

Weight: 50.4 kg

Height: 5'2

BMI: 20.3 (Normal)

 
The patient has stable vital signs and essentially normal physical examination.

INTEGUMENT:

Skin: warm, dry with good skin turgor fair in color. No rashes, no active lesions, no cyanosis, no
edema

Nails: with good capillary refill of <2 seconds. No clubbing, no breaks, no ridges

HEENT:

Head: Normocephalic. Atraumatic, symmetric with no lesions, tenderness, and breaks. Hair is
black in color, fine with equal distribution, no alopecia, no lice infestation, with dandruff, no
breaks, no tenderness, no active lesions

Eyes: Non-sunken eyes, pale palpebral conjunctivae, anicteric sclerae, pupils are equally reactive
to light and accommodation

Ears: symmetric, aligned with lateral canthus of eyes, no tenderness, no impacted cerumen, no
abnormal discharges, no hearing impairment

Mouth and Throat: no dentures, buccal mucosa is moist and pinkish. Lips are pinkish and oral
mucosa is moist.

Uvula and tonsils: midline, no tonsilopharyngeal congestion

NECK: Trachea is at midline; thyroid gland is non-palpable. Thyroid cartilage moves upward
upon deglutition, with no palpable and tender cervical lymph nodes, no visible pulsation, ROM
unimpaired

BREASTS: No discoloration, nipples are everted, no discharges, no palpable lymph nodes, no

lumps, no tenderness

CHEST and LUNGS:

Inspection: No retractions, no apparent respiratory distress

Palpation: symmetric expansion, no tenderness

Percussion: resonant on all lung field

Auscultation: clear breath sounds

CARDIOVASCULAR:

Inspection: adynamic heart, no precordial bulging

Palpation: PMI is not measured, adynamic apex precordium, carotid pulse is brisk and sharp, and
synchronous with apex pulsations. No thrills, no heaves

Auscultation: Radial pulse is synchronous with heart sounds, with regular rate and rhythm, no
murmurs

ABDOMEN:

Inspection: Umbilicus everted, no visible veins nor lesions.

Auscultation: Normoactive bowel sounds

Palpation: No organomegaly, no palpable masses

GUT: No discharges, no voiding problems.

EXTREMITIES: Symmetric, equal in length and size on both sides, no edema, no cyanosis, no
deformities.

BACK and SPINE: no abnormal deviations,no visible bulging, no redness (-) Inflammation. No
CVA tenderness;

NEUROLOGIC: no neurologic deficit

ASSESSMENT:
Polyneuropathy T/C Diabetes Mellitus

Hypertension-Controlled

PLAN:

Laboratory examination:

1. Lipid profile
2. BUA
3. Creatinine
4. FBS
5. SGPT
6. CBC
7. Urinalysis
8. NaKCl

Medications:

1. Vitamin B complex tab 1 tablet once a day

Continue maintenance medication of Amlodipine 10mg/tab once a day

To come back once with lab result

Advise

Past Medical history unremarkable

(+) Hypertensive with maintenance medication of Amlodipine 10mg/tab once a day, with good
compliance to medications

No known allergies to food and drinks

With family history of hypertension and Diabetes Mellitus

Personal/Social:

Patient works as a supervisor at City Engineers Office

(+) Smoker, 18.5 pack years

(+) Alcoholic beverage drinker, consumes 2 L/day

BODY MALAISE
SUBJECTIVE:

Chief Complaint: Body malaise x 1 month

HISTORY OF PRESENT ILLNESS:

1 month prior to consult, (+) body malaise, (+) occasional headache no other associated
symptoms, no medications taken. 

Persistence of symptom prompt consult

OBJECTIVE:

Patient was examined sitting, alert, conscious, coherent, and conversant, not in cardiorespiratory
distress, oriented to time, place and person.

Vital signs:

BP: 160/90

HR: 105 bpm

RR: 20 cpm

O2sat: 99%

Temp: 36.7

Weight: 67.7 kg

Height: 5'2

BMI: 27.3 (Normal)

The patient has stable vital signs and essentially normal physical examination.
 

INTEGUMENT:

Skin: warm, dry with good skin turgor fair in color. No rashes, no active lesions, no cyanosis, no
edema

Nails: with good capillary refill of <2 seconds. No clubbing, no breaks, no ridges

HEENT:

Head: Normocephalic. Atraumatic, symmetric with no lesions, tenderness, and breaks. Hair is
black in color, fine with equal distribution, no alopecia, no lice infestation, with dandruff, no
breaks, no tenderness, no active lesions

Eyes: Non-sunken eyes, pale palpebral conjunctivae, anicteric sclerae, pupils are equally reactive
to light and accommodation

Ears: symmetric, aligned with lateral canthus of eyes, no tenderness, no impacted cerumen, no
abnormal discharges, no hearing impairment

Mouth and Throat: no dentures, buccal mucosa is moist and pinkish. Lips are pinkish and oral
mucosa is moist.

Uvula and tonsils: midline, no tonsilopharyngeal congestion

NECK: Trachea is at midline; thyroid gland is non-palpable. Thyroid cartilage moves upward
upon deglutition, with no palpable and tender cervical lymph nodes, no visible pulsation, ROM
unimpaired

BREASTS: No discoloration, nipples are everted, no discharges, no palpable lymph nodes, no

lumps, no tenderness

CHEST and LUNGS:

Inspection: No retractions, no apparent respiratory distress

Palpation: symmetric expansion, no tenderness

Percussion: resonant on all lung field

Auscultation: clear breath sounds

 

CARDIOVASCULAR:

Inspection: adynamic heart, no precordial bulging

Palpation: PMI is not measured, adynamic apex precordium, carotid pulse is brisk and sharp, and
synchronous with apex pulsations. No thrills, no heaves

Auscultation: Radial pulse is synchronous with heart sounds, with regular rate and rhythm, no
murmurs

ABDOMEN:

Inspection: Umbilicus everted, no visible veins nor lesions.

Auscultation: Normoactive bowel sounds

Palpation: No organomegaly, no palpable masses

GUT: No discharges, no voiding problems.

EXTREMITIES: Symmetric, equal in length and size on both sides, no edema, no cyanosis, no
deformities.

BACK and SPINE: no abnormal deviations,no visible bulging, no redness (-) Inflammation. No
CVA tenderness;

NEUROLOGIC: no neurologic deficit

ASSESSMENT:

 
T/C Anemia

Hypertension Stage 2

PLAN:

Give Losartan+Amlodipine 50/5mg 1 tab now, recheck BP after 15 mins

Laboratory examination:

1. CBC
2. Lipid profile
3. FBS
4. BUA
5. Creatinine
6. SGPT
7. Urinalysis
8. Na, K, Cl

Medications:

1. Ferrous Sulfate + Iron tablet, 1 tablet once a day

2. Losartan+Amlodpine 50/5mg/tab 1 tab once a day at bedtime
3. Atorvastatin 20mg/tab, 1 tab once a day for bedtime

To come back once with lab result

Advise
 MASSIVE ASCITES
 

SUBJECTIVE:

Chief Complaint: Abdominal enlargement x 1 month, abdominal pain x 3 days

HISTORY OF PRESENT ILLNESS:

1 month prior to consult, (+) sudden onset abdominal enlargement. No other associated
symptoms. No medications taken. No consult done

3 days prior to consult, (+) generalized abdominal pain, nonradiating, characterized as cramping,
PRS 7/10. No medications taken, no consult done.

Persistence of symptom prompt consult

OBJECTIVE:

Patient was examined sitting, alert, conscious, coherent, and conversant, not in cardiorespiratory
distress, oriented to time, place and person.

Vital signs:

BP: 120/90

HR: 134 bpm

RR: 23 cpm

O2sat: 98%

Temp: 36.8

Weight:58.4 kg

Height: 5'0
BMI: 24.6 (Normal)

The patient has stable vital signs and essentially normal physical examination.

INTEGUMENT:

Skin: warm, dry with good skin turgor fair in color. No rashes, no active lesions, no cyanosis, no
edema

Nails: with good capillary refill of <2 seconds. No clubbing, no breaks, no ridges

HEENT:

Head: Normocephalic. Atraumatic, symmetric with no lesions, tenderness, and breaks. Hair is
black in color, fine with equal distribution, no alopecia, no lice infestation, with dandruff, no
breaks, no tenderness, no active lesions

Eyes: Non-sunken eyes, pale palpebral conjunctivae, anicteric sclerae, pupils are equally reactive
to light and accommodation

Ears: symmetric, aligned with lateral canthus of eyes, no tenderness, no impacted cerumen, no
abnormal discharges, no hearing impairment

Mouth and Throat: no dentures, buccal mucosa is moist and pinkish. Lips are pinkish and oral
mucosa is moist.

Uvula and tonsils: midline, no tonsilopharyngeal congestion

NECK: Trachea is at midline; thyroid gland is non-palpable. Thyroid cartilage moves upward
upon deglutition, with no palpable and tender cervical lymph nodes, no visible pulsation, ROM
unimpaired

BREASTS: No discoloration, nipples are everted, no discharges, no palpable lymph nodes, no

lumps, no tenderness

CHEST and LUNGS:

Inspection: No retractions, no apparent respiratory distress

Palpation: symmetric expansion, no tenderness

Percussion: resonant on all lung field

Auscultation: clear breath sounds

CARDIOVASCULAR:

Inspection: adynamic heart, no precordial bulging

Palpation: PMI is not measured, adynamic apex precordium, carotid pulse is brisk and sharp, and
synchronous with apex pulsations. No thrills, no heaves

Auscultation: Radial pulse is synchronous with heart sounds, with regular rate and rhythm, no
murmurs

ABDOMEN:

Inspection: (+) Globular abdomen, 31inches,  Umbilicus everted, no visible veins nor lesions.

Auscultation: Normoactive bowel sounds

Palpation: Firm, tender upon palpation

GUT: No discharges, no voiding problems.

EXTREMITIES: Symmetric, equal in length and size on both sides, no edema, no cyanosis, no
deformities.

BACK and SPINE: no abnormal deviations,no visible bulging, no redness (-) Inflammation. No
CVA tenderness;

NEUROLOGIC: no neurologic deficit

ASSESSMENT:
Massive Ascites, etiology to be determined

PLAN:

Laboratory examination:

1. Whole abdomimanl UTZ

Medications:

1. Paracetamol+Tramadol 37.5/325mg/tab 1 tab 3x a day for pain

To come back once with lab result

Advise
 GERIATRICS
Alimangohan, Anacorita, 70/Female

CC: Abdominal Pain; (+) Knee joint pains

Subjective:

HPI: 2 months prior to consult, patient noted Episgastric pain, Radiating to RUQ, sharp, burning in
character, with PRS of 7/10. Triggered by hunger and relieved by food intake.

2 days prior to consult, patient still noted epigastric pain, now associated with loose bowel movement.
Occassional right knee joint pains was also noted. Patient was already worked-up, hence follow- up
check up.

ROS: (+) Epigastric pains, (+) right knee joint pain, no fever

Objective : Seen awake, conscious, ambulatory, not in cardiorespiratory distress

BP: 130/80 HR:83 RR: 20 T: 36.7 C SPO2: 97 %

Skin smooth, warm with good skin turgor, no rashes, no hematoma

HEENT:Head: Head normocephalic, symmetrical facial features

Eyes: anicteric sclerae, pink palpebral conjunctiva

Ears: No tenderness or discharges

Nose: Septum at midline, no tenderness or discharges

Mouth: Moist oral cavity, Pink gums, no bleeding or ulcers

Neck and throat: no cervical lymphadenopathies

CHEST AND LUNGS: Symmetric lung expansion, Clear breath sounds

HEART AND CVS: Adynamic precordium, NRRR, no heaves or thrills, no murmurs

ABDOMEN: Soft, flabby, (+) Epigastric tenderness, no masses

BACK & SPINE: Symmetrical with no masses, no tenderness

EXTREMITIES: Full equal pulses, no clubbing or cyanosis, no edema, CRT <2 s

Diagnostics:

BUA: 533.20

FBS: 6:13

ECG: Sinus rhthym, Normal axis, no ischemic changes, no chamber enlargment

2D Echo: Concentric LV remodeling; Normal systolic function; mild diastolic dysfucntion; Mitral and
Aortic vavle stenosis; Physiologic mitral and Tricuspid and Pulmonic regurgitation; Atherematous Aorta;
Normal pulmonary pressure.

A: Hypertensive Cardiovascular Disease (HCVD)(I11) Hypertensive heart disease ; T2DM - controlled;

Hyperuricemia

P: Fecalysis; repeat BUA;

Continue present medications:

Losartan 100 mg tab OD

Metformin 500 mg tab TID

Febuxostat 40 mg OD

Dr. Monge/ PGI Tamayo

PMHx: (+) DM maintained on Metformin 500 mg OD,

(+)HPN maintained on Losartan 100 mg OD

2014: Heart problem (Diagnosis unknown): Maintained on Aspirin

Family Hx: HPN & DM (maternal), Heart Disease (Siblings)

Psychosocial: Non-alcoholic beverage drinker, Non-smoker, With a smoker family member, Usual diet:
Fish, Rice and Vegetables
 CHOELITHIASIS
SUBJECTIVE:

With laboratory result

Came in for followup checkup

Chief Complaint:

Occasional epigastric pain x 3 months

HISTORY OF PRESENT ILLNESS:

3 months prior to consult, (+) epigastric pain, consulted at a polyclinic at Ormoc City, laboratory
exam done and was diagnosed with Cholelithiasis, with take home medications of
Ursodeoxycholic Acid 250mg/cap 1 capsule 3x a day, Liverprime capsule 1 capsule 2x/a day,
and Melatonin 3mg/cap 1 capsule one a day at bedtime. With poor compliance to medication but
opted to self medicate with various herbal supplements.

Interim, (+) Occasional epigastric pain and occasional joint pains prompted consult

ROS: (+) Epigastric pains, (+) joint pains, no weight loss, no fever

OBJECTIVE:

Seen awake, conscious, ambulatory, not in cardiorespiratory distress

BP: 120/70 HR:83  RR: 20 T: 36.7 C SPO2: 97 %

Weight: 62kg
Skin smooth, warm with good skin turgor, no rashes, no hematoma

HEENT:Head: Head normocephalic, symmetrical facial features

Eyes: anicteric sclerae, pink palpebral conjunctiva

Ears: No tenderness or discharges

Nose: Septum at midline, no tenderness or discharges

Mouth: Moist oral cavity, Pink gums, no bleeding or ulcers

Neck and throat: no cervical lymphadenopathies

CHEST AND LUNGS: Symmetric lung expansion, Clear breath sounds

HEART AND CVS: Adynamic precordium, NRRR, no heaves or thrills, no murmurs

ABDOMEN: Soft, flabby, no masses

BACK & SPINE: Symmetrical with no masses, no tenderness

EXTREMITIES:  Full equal pulses, no clubbing or cyanosis, no edema, CRT <2 s

NEUROLOGIC: No neurologic deficit

Short Geriatric Screen Score: Low Risk

Diagnostics:

Blood Chemistry (2/14/2022)

ALT- 31.39 (High)

BUA- 375.58 umol/L (High)

Whole Abdomen Ultrasound (02/10/2022)

Cholelithiasis

ASSESSMENT:

Cholelithiasis;

Hyperuricemia

PLAN:

Medications:

1. Urodeoxycholic acid 300mg/cap, 1 capsule 3x a day

2. Febuxostat 40mg/tab, 1 tablet once a day for 14 days

Refer to Surgery Department for further evaluation and management of Cholelithiasis

Advise limiting intake of herbal supplements

Advise

Dr. Mojica/ PGI Garcia

PMHx: 

Non-hypertensive

Non-diabetic
(+) Cholelithiasis diagnosed last Feb 2022, poor compliance to prescribed medications

Family Hx: Unremarkable

Psychosocial: Non-alcoholic beverage drinker, Non-smoker 

Usual diet: Fish, Rice and Vegetables, fatty foods

 FRACTURE
 

SUBJECTIVE:

With laboratory result

Came in for checkup

Chief Complaint:

Shoulder pain x 2 weeks

HISTORY OF PRESENT ILLNESS:

2 weeks prior to consult, alleged trauma from falling debri

NOI: Alleged trauma from falling debri

POI: Linao, Ormoc city

DOI: May 26, 2022

TOI: 3pm

Consulted at nearest hospital, laboratory exam taken with take home medications of Diclofenac
Sodium and Vitamin B complex

Interim, (+) shoulder pain, left (+) epigastric pain hence consult

ROS: (+) Epigastric pain, (+) shoulder pain, no weight loss, no fever
 

OBJECTIVE:

Seen awake, conscious, ambulatory, not in cardiorespiratory distress

BP: 190/60 HR:70  RR: 22 T: 36.7 C SPO2: 98 %

Weight: 38kg

Skin smooth, warm with good skin turgor, no rashes, no hematoma

HEENT:Head: Head normocephalic, symmetrical facial features

Eyes: anicteric sclerae, pink palpebral conjunctiva

Ears: No tenderness or discharges

Nose: Septum at midline, no tenderness or discharges

Mouth: Moist oral cavity, Pink gums, no bleeding or ulcers

Neck and throat: no cervical lymphadenopathies

CHEST AND LUNGS: Symmetric lung expansion, Clear breath sounds

HEART AND CVS: Adynamic precordium, NRRR, no heaves or thrills, no murmurs

ABDOMEN: Soft, flabby, no masses

BACK & SPINE: Symmetrical with no masses, no tenderness

EXTREMITIES:  (+) Limited ROM on left arm, Full equal pulses, no clubbing or cyanosis, no
edema, CRT <2 s

NEUROLOGIC: No neurologic deficit

 
Short Geriatric Screen Score: Low Risk

ASSESSMENT:

Complete fracture of left clavicle

PLAN:

Refer to Orthopedic Department for further evaluation and management of fracture

Advise

Dr. Mojica/ PGI Garcia

PMHx: 

Non-hypertensive

Non-diabetic

(+) BPH 2000 (Resolved)

Family Hx: Unremarkable

Psychosocial: 

(+) Alcoholic beverage drinker

Tobacco smoker, 51 pack years

Usual diet: Fish, Rice and Vegetables

 PNEUMONIA
 

SUBJECTIVE:

Chief Complaint: Productive cough x 2 weeks

HISTORY OF PRESENT ILLNESS:

2 weeks prior to consult, (+) productive cough with whitish phlegm, (+) occasional chest pain
when coughing, no fever, no weight loss. Admitted at City Hospital for 6 days and was
diagnosed with Pneumonia. Xpert MTB not detected, chest xray revealed unsettled and hazy
densities. With take home medications of Co-Amoxiclav for 7 days and Azinomycin for 2 more
days. With good compliance to medication. 

Persistence of symptoms prompted consult

OBJECTIVE:

Patient was examined sitting, alert, conscious, coherent, and conversant, not in cardiorespiratory
distress, oriented to time, place and person.

Vital signs:

BP: 120/90

HR: 66 bpm

RR: 20 cpm
O2sat: 98%

Temp: 36.7

Weight:59.3 kg

Height: 5'2

BMI: 23.9 (Normal)

The patient has stable vital signs and essentially normal physical examination.

INTEGUMENT:

Skin: warm, dry with good skin turgor fair in color. No rashes, no active lesions, no cyanosis, no
edema

Nails: with good capillary refill of <2 seconds. No clubbing, no breaks, no ridges

HEENT:

Head: Normocephalic. Atraumatic, symmetric with no lesions, tenderness, and breaks. Hair is
black in color, fine with equal distribution, no alopecia, no lice infestation, with dandruff, no
breaks, no tenderness, no active lesions

Eyes: Non-sunken eyes, pale palpebral conjunctivae, anicteric sclerae, pupils are equally reactive
to light and accommodation

Ears: symmetric, aligned with lateral canthus of eyes, no tenderness, no impacted cerumen, no
abnormal discharges, no hearing impairment

Mouth and Throat: no dentures, buccal mucosa is moist and pinkish. Lips are pinkish and oral
mucosa is moist.

Uvula and tonsils: midline, no tonsilopharyngeal congestion

NECK: Trachea is at midline; thyroid gland is non-palpable. Thyroid cartilage moves upward
upon deglutition, with no palpable and tender cervical lymph nodes, no visible pulsation, ROM
unimpaired

BREASTS: No discoloration, nipples are everted, no discharges, no palpable lymph nodes, no

lumps, no tenderness

 
CHEST and LUNGS:

Inspection: No retractions, no apparent respiratory distress

Palpation: symmetric expansion, no tenderness

Percussion: resonant on all lung field

Auscultation: (+) crackles heard on both lower lungs fields

CARDIOVASCULAR:

Inspection: adynamic heart, no precordial bulging

Palpation: PMI is not measured, adynamic apex precordium, carotid pulse is brisk and sharp, and
synchronous with apex pulsations. No thrills, no heaves

Auscultation: Radial pulse is synchronous with heart sounds, with regular rate and rhythm, no
murmurs

ABDOMEN:

Inspection: Umbilicus everted, no visible veins nor lesions.

Auscultation: Normoactive bowel sounds

Palpation: Firm, tender upon palpation

GUT: No discharges, no voiding problems.

EXTREMITIES: Symmetric, equal in length and size on both sides, no edema, no cyanosis, no
deformities.

BACK and SPINE: no abnormal deviations,no visible bulging, no redness (-) Inflammation. No
CVA tenderness;
 

NEUROLOGIC: no neurologic deficit

ASSESSMENT:

Pneumonia

PLAN:

Medications:

1. Cefixime 200mg, 1 tablet 2x a day for 7 days 

2. Butamirate citrate 50mg/tab 1 tab 3x a day for 5 days

To come back with still with symptoms

Advise

PMHx:

Pneumonia (2019) 

Hypertensive

Diabetic (05/22) with maintenance if Metformin 500mg/tab, 1tab 2x a day

Family Hx: Hypertension and Diabetes Mellitus

Psychosocial: 

(+) Alcoholic beverage drinker

Tobacco smoker, 42 pack years

Usual diet: Fish, Rice and Vegetables

 EPIGASTRIC PAIN AND POLYNEUROPATHY
 SUBJECTIVE:

Chief Complaint: Numbness on both upper and lower extremeties x 1 month

Epigastric pain x 1 week

HISTORY OF PRESENT ILLNESS:

1 month prior to consultation, (+) Numbness on both upper and lower extremeties, no
medications taken

1 week prior to consult, (+) epigastric pain, aggravated by hunger and after eating, non radiating,
no medications taken

Persistence of symptoms prompted consult

OBJECTIVE:

Patient was examined sitting, alert, conscious, coherent, and conversant, not in cardiorespiratory
distress, oriented to time, place and person.

Vital signs:

BP: 140/80

HR: 109 bpm

RR: 20 cpm

O2sat: 98%

Temp: 36.7

Weight:63 kg

Height: 5'5

BMI: 23.1 (Normal)

The patient has stable vital signs and essentially normal physical examination.

INTEGUMENT:
Skin: warm, dry with good skin turgor fair in color. No rashes, no active lesions, no cyanosis, no
edema

Nails: with good capillary refill of <2 seconds. No clubbing, no breaks, no ridges

HEENT:

Head: Normocephalic. Atraumatic, symmetric with no lesions, tenderness, and breaks. Hair is
black in color, fine with equal distribution, no alopecia, no lice infestation, with dandruff, no
breaks, no tenderness, no active lesions

Eyes: Non-sunken eyes, pale palpebral conjunctivae, anicteric sclerae, pupils are equally reactive
to light and accommodation

Ears: symmetric, aligned with lateral canthus of eyes, no tenderness, no impacted cerumen, no
abnormal discharges, no hearing impairment

Mouth and Throat: no dentures, buccal mucosa is moist and pinkish. Lips are pinkish and oral
mucosa is moist.

Uvula and tonsils: midline, no tonsilopharyngeal congestion

NECK: Trachea is at midline; thyroid gland is non-palpable. Thyroid cartilage moves upward
upon deglutition, with no palpable and tender cervical lymph nodes, no visible pulsation, ROM
unimpaired

BREASTS: No discoloration, nipples are everted, no discharges, no palpable lymph nodes, no

lumps, no tenderness

CHEST and LUNGS:

Inspection: No retractions, no apparent respiratory distress

Palpation: symmetric expansion, no tenderness

Percussion: resonant on all lung field

Auscultation: Clear breath sounds

CARDIOVASCULAR:
Inspection: adynamic heart, no precordial bulging

Palpation: PMI is not measured, adynamic apex precordium, carotid pulse is brisk and sharp, and
synchronous with apex pulsations. No thrills, no heaves

Auscultation: Radial pulse is synchronous with heart sounds, with regular rate and rhythm, no
murmurs

ABDOMEN:

Inspection: Umbilicus everted, no visible veins nor lesions.

Auscultation: Normoactive bowel sounds

Palpation: Firm, tender upon palpation

GUT: No discharges, no voiding problems.

EXTREMITIES: Symmetric, equal in length and size on both sides, no edema, no cyanosis, no
deformities.

BACK and SPINE: no abnormal deviations,no visible bulging, no redness (-) Inflammation. No
CVA tenderness;

NEUROLOGIC: no neurologic deficit

ASSESSMENT:

Polyneuropathy T/C Diabetes Mellitus

Dyspepsia

 
PLAN:

Laboratory Examinations:

1. FBS
2. Lipid profile
3. CBC
4. Urinalysis
5. BUA
6. Lipid Profile
7. NaKCl
8. Creatinine
9. SGPT

Medications:

1. Vitamin B complex tab, 1 tab once a day

2. Sodium Alginate+Sodium Bicarbonate+Calcium Carbonate tab, 1 tab 3x a day for 5 days

To come back once with laboratory result

Advise

Jun 13, 2022 09:27

PMHx:

Non hypertensive

Non diabetic

Family Hx: Unremarkable

(+) Alcoholic beverage drinker

Non smoker

Usual diet: Fish, Rice and Vegetables

NASAL POLYPS
SUBJECTIVE:
Chief Complaint: Inflamed nostrils left x 3 days
HISTORY OF PRESENT ILLNESS:
1 week prior to consult, (+) toothache and headache, (+) fever. Consulted at private MD, labs ordered and
unrecalled medications given. 
3 days prior to consult, (+) inflamed nostril, left, no fever, No medications taken
Persistence of symptoms hence consult
OBJECTIVE:
Patient was examined sitting, alert, conscious, coherent, and conversant, not in cardiorespiratory distress,
oriented to time, place and person.
Vital signs:
BP: 120/80
HR: 89 bpm
RR: 20 cpm
O2sat: 98%
Temp: 36.7
Weight:63 kg
Height: 5'5
BMI: 23.1 (Normal)
The patient has stable vital signs and essentially normal physical examination.
INTEGUMENT:
Skin: warm, dry with good skin turgor fair in color. No rashes, no active lesions, no cyanosis, no edema
Nails: with good capillary refill of <2 seconds. No clubbing, no breaks, no ridges
 
HEENT:
Head: Normocephalic. Atraumatic, symmetric with no lesions, tenderness, and breaks. Hair is black in color,
fine with equal distribution, no alopecia, no lice infestation, with dandruff, no breaks, no tenderness, no active
lesions
Eyes: Non-sunken eyes, pale palpebral conjunctivae, anicteric sclerae, pupils are equally reactive to light and
accommodation
Ears: symmetric, aligned with lateral canthus of eyes, no tenderness, no impacted cerumen, no abnormal
discharges, no hearing impairment
Nose: Visible mass in the nostril
Mouth and Throat: no dentures, buccal mucosa is moist and pinkish. Lips are pinkish and oral mucosa is moist.
Uvula and tonsils: midline, no tonsilopharyngeal congestion
NECK: Trachea is at midline; thyroid gland is non-palpable. Thyroid cartilage moves upward upon deglutition,
with no palpable and tender cervical lymph nodes, no visible pulsation, ROM unimpaired
BREASTS: No discoloration, nipples are everted, no discharges, no palpable lymph nodes, no lumps, no
tenderness
 
CHEST and LUNGS:
Inspection: No retractions, no apparent respiratory distress
Palpation: symmetric expansion, no tenderness
Percussion: resonant on all lung field
Auscultation: Clear breath sounds
 
CARDIOVASCULAR:
Inspection: adynamic heart, no precordial bulging
Palpation: PMI is not measured, adynamic apex precordium, carotid pulse is brisk and sharp, and synchronous
with apex pulsations. No thrills, no heaves
Auscultation: Radial pulse is synchronous with heart sounds, with regular rate and rhythm, no murmurs
 
ABDOMEN:
Inspection: Umbilicus everted, no visible veins nor lesions.
Auscultation: Normoactive bowel sounds
Palpation: Firm, tender upon palpation
 
GUT: No discharges, no voiding problems.
 
EXTREMITIES: Symmetric, equal in length and size on both sides, no edema, no cyanosis, no deformities.
 
BACK and SPINE: no abnormal deviations,no visible bulging, no redness (-) Inflammation. No CVA
tenderness;
 
NEUROLOGIC: no neurologic deficit
 
ASSESSMENT:
t/c Nasal polyp
 
PLAN:
Medications:
1. Mometasone furoate monohydrate nasal spray,2 sprays each nostril 2x a day for 7 days
Refer to ENT Department for further management and evaluation of nasal polyp
To come back once with laboratory result
Advise

EPIGASTRIC PAIN
 SUBJECTIVE:

Chief Complaint: Epigastric pain x 1 month

HISTORY OF PRESENT ILLNESS:

1 month prior to consult, (+) epigastric pain, gnawing pain 10/10,non-radiating associated with
vomiting, (+) feeling of bloatedness, consulted with medicatons of omeprazole and ranitidine,
with temporary relief.

Persistence of symptoms prompted consult

OBJECTIVE:

Patient was examined sitting, alert, conscious, coherent, and conversant, not in cardiorespiratory
distress, oriented to time, place and person.

Vital signs:

BP: 90/60

HR: 88 bpm

RR: 20 cpm

O2sat: 98%

Temp: 36.5

Weight: 59.5

Height: 4'11

BMI: 26.7 (Overweight)

The patient has stable vital signs and essentially normal physical examination.

INTEGUMENT:

Skin: warm, dry with good skin turgor fair in color. No rashes, no active lesions, no cyanosis, no
edema

Nails: with good capillary refill of <2 seconds. No clubbing, no breaks, no ridges

HEENT:

Head: Normocephalic. Atraumatic, symmetric with no lesions, tenderness, and breaks. Hair is
black in color, fine with equal distribution, no alopecia, no lice infestation, with dandruff, no
breaks, no tenderness, no active lesions

Eyes: Non-sunken eyes, pale palpebral conjunctivae, anicteric sclerae, pupils are equally reactive
to light and accommodation

Ears: symmetric, aligned with lateral canthus of eyes, no tenderness, no impacted cerumen, no
abnormal discharges, no hearing impairment
Mouth and Throat: no dentures, buccal mucosa is moist and pinkish. Lips are pinkish and oral
mucosa is moist.

Uvula and tonsils: midline, no tonsilopharyngeal congestion

NECK: Trachea is at midline; thyroid gland is non-palpable. Thyroid cartilage moves upward
upon deglutition, with no palpable and tender cervical lymph nodes, no visible pulsation, ROM
unimpaired

BREASTS: No discoloration, nipples are everted, no discharges, no palpable lymph nodes, no

lumps, no tenderness

CHEST and LUNGS:

Inspection: No retractions, no apparent respiratory distress

Palpation: symmetric expansion, no tenderness

Percussion: resonant on all lung field

Auscultation: Clear breath sounds

CARDIOVASCULAR:

Inspection: adynamic heart, no precordial bulging

Palpation: PMI is not measured, adynamic apex precordium, carotid pulse is brisk and sharp, and
synchronous with apex pulsations. No thrills, no heaves

Auscultation: Radial pulse is synchronous with heart sounds, with regular rate and rhythm, no
murmurs

ABDOMEN:

Inspection: Umbilicus everted, no visible veins nor lesions.

Auscultation: Normoactive bowel sounds

Palpation: Firm, tender upon palpation

 

GUT: No discharges, no voiding problems.

EXTREMITIES: Symmetric, equal in length and size on both sides, no edema, no cyanosis, no
deformities.

BACK and SPINE: no abnormal deviations,no visible bulging, no redness (-) Inflammation. No
CVA tenderness;

NEUROLOGIC: no neurologic deficit

ASSESSMENT:

Dyspepsia t/c PUD

PLAN:

Laboratory Examinations:

1. H.pylori testing
2. Hepatobiliarytree UTZ

Medications:

1. Omeprazole 40mg/tab, one tab once a day for 2 weeks

2. Sodium Alginate sachet 3x a day for 5 days after meals

To come back once with laboratory result

Advise
 RECURRENT UTI
SUBJECTIVE:

Chief Complaint: Hypogastric pain x 4 months

HISTORY OF PRESENT ILLNESS:

4 months prior to consult, (+) Hypogastric pain, gnawing, nonradiating, PRS of 5/10, (+) dysuria.
(-) Fever. Consulted at a lying in clinic, diagnosed with UTI with home medications of Cefalexin
for 7 days. Urinalysis was done, still with infection, and was prescribed Cefuroxime for 7 days.
Urinalysis after was done with unresolved UTI, Fosmomycin was then prescribed and still with
unresolved UTI.

3 days prior to consult, (+) Hypogastric pain, gnawing, radiating to lumbosacral area, with PRS
of 5/10, (+) Fever. Consulted at a lying in clinic with laboratory request for KUB UTZ and urine
culture.

Persistence of symptoms prompted consult

OBJECTIVE:

Patient was examined sitting, alert, conscious, coherent, and conversant, not in cardiorespiratory
distress, oriented to time, place and person.

Vital signs:

BP: 100/80

HR: 58 bpm

RR: 20 cpm

O2sat: 98%

Temp: 36.5

Weight: 61.9

Height: 5'0

BMI: 26.7 (Overweight)

The patient has stable vital signs and essentially normal physical examination.

INTEGUMENT:

Skin: warm, dry with good skin turgor fair in color. No rashes, no active lesions, no cyanosis, no
edema

Nails: with good capillary refill of <2 seconds. No clubbing, no breaks, no ridges

HEENT:
Head: Normocephalic. Atraumatic, symmetric with no lesions, tenderness, and breaks. Hair is
black in color, fine with equal distribution, no alopecia, no lice infestation, with dandruff, no
breaks, no tenderness, no active lesions

Eyes: Non-sunken eyes, pale palpebral conjunctivae, anicteric sclerae, pupils are equally reactive
to light and accommodation

Ears: symmetric, aligned with lateral canthus of eyes, no tenderness, no impacted cerumen, no
abnormal discharges, no hearing impairment

Mouth and Throat: no dentures, buccal mucosa is moist and pinkish. Lips are pinkish and oral
mucosa is moist.

Uvula and tonsils: midline, no tonsilopharyngeal congestion

NECK: Trachea is at midline; thyroid gland is non-palpable. Thyroid cartilage moves upward
upon deglutition, with no palpable and tender cervical lymph nodes, no visible pulsation, ROM
unimpaired

BREASTS: No discoloration, nipples are everted, no discharges, no palpable lymph nodes, no

lumps, no tenderness

CHEST and LUNGS:

Inspection: No retractions, no apparent respiratory distress

Palpation: symmetric expansion, no tenderness

Percussion: resonant on all lung field

Auscultation: Clear breath sounds

CARDIOVASCULAR:

Inspection: adynamic heart, no precordial bulging

Palpation: PMI is not measured, adynamic apex precordium, carotid pulse is brisk and sharp, and
synchronous with apex pulsations. No thrills, no heaves

Auscultation: Radial pulse is synchronous with heart sounds, with regular rate and rhythm, no
murmurs
 

ABDOMEN:

Inspection: Umbilicus everted, no visible veins nor lesions.

Auscultation: Normoactive bowel sounds

Palpation: Firm, (+) hypogastric pain

GUT: (+) dysuria No discharges

EXTREMITIES: Symmetric, equal in length and size on both sides, no edema, no cyanosis, no
deformities.

BACK and SPINE: no abnormal deviations,no visible bulging, no redness (-) Inflammation. No
CVA tenderness;

NEUROLOGIC: no neurologic deficit

ASSESSMENT:

G2P0 (0010) PU 25 4/7 weeks AOG, Recurrent UTI

r/o Nephrolithiasis

PLAN:

Laboratory Examinations:

1. KUB UTZ
2. Urine culture

Medication:
 1. Duphaston 10mg/tab, 1 tab 3x a day for 7 days

Encourage increase oral fluid intake

Advise

PAST MEDICAL HISTORY:

(+) Recurrent UTI

(+) Asthmatic

Non hypertensive

Non diabetic

FAMILY HISTORY: Unremarkable

OBSTETRIC HISTORY:

G2P0 (0010) PU 25 4/7 weeks AOG

LMP: December 24, 2021

EDC: September 30, 2022

MENSTRUAL HISTORY:

M-11 years old

I- 28-30 days

D-3 days

A-4 pads/day
S-None

PERSONAL AND SOCIAL HISTORY:

Occasional alcoholic beverage drinker

Non smoker

Usual diet: Fish, Rice and Vegetables

Patient works as a saleslady

DIABETES MELLITUS
SUBJECTIVE:
Came in for follow up check up
With laboratory result
(+) Numbness on extremeties
OBJECTIVE:
Vital signs:
BP: 90/60
HR: 88 bpm
RR: 20 cpm
O2sat: 98%
Temp: 36.5
 
ASSESSMENT:
(E11.4+G63.2*) Non-insulin-dependent diabetes mellitus Diabetic polyneuropathy 
(A02.2+M01.3*) arthritis 
 
PLAN:
 Medications:
1. Sitagliptin+Metformin 50/1gram tab OD after lunch
2. Atorvastatin 20mg/tab, OD HS 
3. Febuxostat 40mg/tab OD for 1 month
4. Continue Amlodipine 5mg/tab 1 tab OD
For repeat FBS, HBA1C, BUA after 1 month
For followup after 1 month at DM clinic 5 July 14, 2022
Advise DM diet and low purine diet
Advise
 
Dr. Somera/PGI Garcia
 

DIABETES MELLITUS
SUBJECTIVE:

Came in for follow up check up

With laboratory result

(+) Numbness on extremeties

OBJECTIVE:

Vital signs:

BP: 120/80

HR: 88 bpm

RR: 20 cpm

O2sat: 98%

Temp: 36.5

Weight:63 kg

Height: 5'5
BMI: 23.1 (Normal)

Diagnostics(06/14/2022)

FBS: 19.26(High)

SGPT/ALT: 44.53 (High)

BUA: 260.20 (Low)

Triglycerides: 2.90 (High)

ASSESSMENT:

(E10.4+G63.2*) Insulin-dependent diabetes mellitus Diabetic polyneuropathy 

PLAN:

Medications:

1. Human premixed insulin 70/30. Inject 22 'u' before breakfast, inject 11 'u' before dinner

For followup after 1 month at DM clinic 5 July 14, 2022

Advise DM diet 

Advise

HYPERTENSION
SUBJECTIVE:

Chief Complaint: Elevated blood pressure x 1 year

HISTORY OF PRESENT ILLNESS:

1 year prior to consult, (+) elevated blood pressure ranging from 160-140/90-100, (+) occasional
dizziness and joint pains. No fever, no weight loss, no cough. No medications taken. No consult
done.
Persistence of symptoms prompted consult

OBJECTIVE:

Patient was examined sitting, alert, conscious, coherent, and conversant, not in cardiorespiratory
distress, oriented to time, place and person.

Vital signs:

BP: 140/100

HR: 98 bpm

RR: 22 cpm

O2sat: 98%

Temp: 36.7

Weight: 54.4 kg

Height: 5'3

BMI: 21.1 (Normal)

The patient has stable vital signs and essentially normal physical examination.

INTEGUMENT:

Skin: warm, dry with good skin turgor fair in color. No rashes, no active lesions, no cyanosis, no
edema

Nails: with good capillary refill of <2 seconds. No clubbing, no breaks, no ridges

HEENT:

Head: Normocephalic. Atraumatic, symmetric with no lesions, tenderness, and breaks. Hair is
black in color, fine with equal distribution, no alopecia, no lice infestation, with dandruff, no
breaks, no tenderness, no active lesions
Eyes: Non-sunken eyes, pale palpebral conjunctivae, anicteric sclerae, pupils are equally reactive
to light and accommodation

Ears: symmetric, aligned with lateral canthus of eyes, no tenderness, no impacted cerumen, no
abnormal discharges, no hearing impairment

Mouth and Throat: no dentures, buccal mucosa is moist and pinkish. Lips are pinkish and oral
mucosa is moist.

Uvula and tonsils: midline, no tonsilopharyngeal congestion

NECK: Trachea is at midline; thyroid gland is non-palpable. Thyroid cartilage moves upward
upon deglutition, with no palpable and tender cervical lymph nodes, no visible pulsation, ROM
unimpaired

BREASTS: No discoloration, nipples are everted, no discharges, no palpable lymph nodes, no

lumps, no tenderness

CHEST and LUNGS:

Inspection: No retractions, no apparent respiratory distress

Palpation: symmetric expansion, no tenderness

Percussion: resonant on all lung field

Auscultation: Clear breath sounds

CARDIOVASCULAR:

Inspection: adynamic heart, no precordial bulging

Palpation: PMI is not measured, adynamic apex precordium, carotid pulse is brisk and sharp, and
synchronous with apex pulsations. No thrills, no heaves

Auscultation: Radial pulse is synchronous with heart sounds, with regular rate and rhythm, no
murmurs

ABDOMEN:
Inspection: Umbilicus everted, no visible veins nor lesions.

Auscultation: Normoactive bowel sounds

Palpation: Firm, non tender upon palpation

GUT: No discharges, no voiding problems.

EXTREMITIES: Symmetric, equal in length and size on both sides, no edema, no cyanosis, no
deformities.

BACK and SPINE: no abnormal deviations,no visible bulging, no redness (-) Inflammation. No
CVA tenderness;

NEUROLOGIC: no neurologic deficit

ASSESSMENT:

(I10.1) Hypertension, stage II 

PLAN:

Laboratory:

1. FBS
2. BUA
3. Lipid Profile
4. NaKCl
5. Creatinine
6. SGPT
7. CBC
8. Urinalysis

Medications:
 1. Losartan 50mg/tab, 1 tab once a day 

Refer to medical records for medical certificate issuance

To come back once with laboratory result

Advise low sat amnd low fat diet

Advise

PMHx:

Non hypertensive

Non diabetic

Family Hx: Hypertension and Diabetes Mellitus

Psychosocial: 

(+) Alcoholic beverage drinker

Smoker, 15 pack years

Usual diet: Fish, Rice and Vegetables, salty and fatty foods

Works as a cargo agent