I.

General Data:
Patient’s Information
Name of Patient: D.C.

Age/Birthday: 62 Y.O. (December 14, 1962)

Sex: Male
Marital Status: single

Address: Oton, Iloilo

Nationality/Religion: Filipino, Roman Catholic

Occupation Utility worker at Iloilo National High School

# of Admission: 2nd

Reliability 94%

This interview happened on January 30, 2023 at 3:30 PM.

This is the case of D.C., 62-year-old, male, single, filipino, roman catholic, a resident of
Oton, Iloilo, who had his 2nd admission at Iloilo Doctors’ Hospital on January 24, 2023.

The informant is the patient himself with 94% reliability.

II. Chief Complaint

“Chest pain”

III. History of Present Illness

4 months prior to admission, the patient started with a dry cough which
developed to a productive cough with whitish phlegm occurring throughout the
day for the rest of the month. Not associated with hemoptysis, difficulty of
breathing, fever, nasal catarrh and fatigue. No medications taken. No
consultation was done.

3 months prior to admission, previous symptoms of cough persisted without

changes in sputum quality. Patient took Tuseran for the cough; temporary relief
was noted. No associated signs such as shortness of breath, hemoptysis, fever,
nasal catarrh, and fatigue. Still no consultation was done.

2 months prior to admission, cough was still persistent with whitish phlegm; still
no associated signs were present. Patient still took Tuseran as needed for cough.
No consultation was done.

1 month prior to admission, previous symptoms of cough still persisted and the
patient experienced continuous epigastric pain which he rated as 6/10 alleviated
by rest. Pain was not alleviated or aggravated by food intake and radiates to the
shoulder and upper back associated with sour belching and episodes of vomiting
approximately one cup per episode in 3 separate days described as clear or
sometimes accompanied with previously ingested food; no nausea, hematemesis
and fever was noted. Patient sought consultation and was prescribed
Omeprazole 40mg/cap 1 capsule once a day which gave temporary relief.
Patient continued taking Tuseran as needed. No labs were requested.

1 week prior to admission, previous symptoms persisted with epigastric pain

progressing to 7/10 not alleviated or aggravated by food intake, and the patient
took Omeprazole which offered temporary relief. Patient continued taking
Tuseran as needed. No associated signs and symptoms. No consultation was
done.

3 days prior to admission, patient said he went out drinking during the festivities
at the Dinagyang festival

2 days prior to admission, the productive cough persisted and the patient
experienced shortness of breath after work. Patient rested and temporary relief
was noted. No associated symptoms such as chest pain, epigastric pain,
orthopnea, dizziness and vomiting. Patient continued taking Omeprazole which
offered temporary relief and the patient just rested. No consultation was done.

1 day PTA,

On the day of admission, the patient experienced a copious productive cough

with tinge of bright red blood and shortness of breath, accompanied by chest
tightness with crushing pain radiating to the left arm and back graded 10/10
which lasted for more than 30 minutes Patient immediately went to the hospital,
thus this admission.
 While in the triage area, the patient claimed to have an attack, lost
consciousness and was defibrillated. After being transferred to the ER, he had
lost consciousness again and was defibrillated.

IV. Past Medical History

Patient’s first admission was St Paul’s Hospital in 1980. He was admitted for a
gunshot wound in the RUQ and RLQ of the abdomen due to a stray bullet.
Surgery was done was admitted for 15 days

The patient has no diabetes, hypertension, or asthma but has an allergy to

seafood.

Patient is fully immunized and fully vaccinated

V. Family HIstory
Patient’s father died of asthma while his mother died of natural causes. He has 1
sibling who died of asthma. No family history of cancer, recent pneumonia and
tuberculosis.

VI. Personal History

The patient works as a utility in Iloilo National High School. A non-smoker, an
occasional binge alcoholic drinker (4-6 bottles per session),and had a history of
using marijuana. His diet consists more of chicken and fish, and less of beef and
pork.

VII. Socio-environmental History

The patient lives in a rural community, in a boarding house with 2 floors made of
mixed wood and concrete. He lives with 4 other people but at the moment he’s
the only one staying on the 2nd floor. The source of water for cleaning is from
deep well and distilled water for drinking. Garbage is picked up every night by
garbage collectors.
VIII. Physical Examination
A. General Survey:
The patient is awake and lying supine with back elevated at 45 degrees,
not in cardiopulmonary distress and coherent but occasionally stops to cough.

ANTHROPOMETRIC

RESULT NORMAL VALUE INTERPRETATION

Height 5’6

Weight 68 kg

BMI 24.1 (18-25 kg/m2) Normal

VITAL SIGNS

RESULT NORMAL VALUE INTERPRETATION

Blood 120/90 mmHg <120 / <80 mmHg Normal

Pressure

Heart Rate 76 60 – 100 bpm Regular and Normal

Respiratory 22 cpm 14 – 20 cpm Tachypneic

Rate

Temperature 36.6 °C 36.5 – 37.5 °C Afebrile

Taken at the right axilla.

SpO2 92% 95-100 Hypoxic

B. SKIN, HAIR AND NAILS
Hair: Upon inspection hair on head is black, long, soft and well distributed. Upon
palpation there were no lesions, lumps, masses, dandruff and infestation noted
on the scalp. Upon palpation no lumps were felt and no tenderness were
observed.
Skin: Upon inspection skin was not yellowish nor cyanotic, fair in color but darker
on sun exposed areas. Upon palpation the skin is warm to touch, rough, not oily
or dry. There was a soft moveable lump about 6 cm length and 3 ½ wide, soft, no
pain and moveable on the right upper back and 2 scars from previous surgery at
the right upper and lower abdomen.
Nails: Upon inspection nails are clean, pink nail bed, lunula is present there was
mild clubbing. Upon palpation capillary refill of less than 2 seconds was noted.

C. HEENT
Upon inspection conjunctiva was pinkish, there were no lymphadenopathies, no
nasal catarrh or discharges. In palpation there were no tender spots or pain in
the face, there was presence of lump on the upper right shoulder.

D. PULMONARY SYSTEM
Upon inspection there were no visible signs of cardiopulmonary distress, no
wheezing, no shortness of breath. Upon palpation there was no lagging, tactile
fremitus was normal. Upon auscultation normal, quiet breathing, no adventitious
breath sounds.

E. CARDIOVASCULAR SYSTEM
Upon inspection, the patient was not in cardiopulmonary distress, there was no
difficulty in breathing. In palpation there were no thrills, no visible strong pulses.
Upon auscultation the Point of Maximal Impulse is at the 5th Intercostal space
medial to the midclavicular line. Heart rate was normal and there were no
murmurs.

F. ABDOMEN
 Upon inspection there were 2 scars noted with the bigger scar located in the
RUQ of the abdomen measuring 6 cm in length and 3 ½ cm in width while the
scar on the RLQ of the abdomen was smaller and faint. No rashes, bruises,
masses or tumors observed. In auscultation, abdominal clicks were normal, no
abnormal sounds were heard. Upon palpation there was no tenderness noted.

G. EXTREMITIES
No cyanosis and edema noted in all extremities.

IX. ANCILLARY TEST RESULTS

ECG
Supraventricular tachycardia with aberrancy
STT wave changes may be due to ischemia and or rate related