CASE

Patient: W. E., a 45 year old male, Filipino, Taxi driver from Davao City

Chief Complaint: Shortness of breath of 1 month duration

History of Present Illness:

1 month prior to admission (PTA):

- Patient started to have shortness of breath, exacerbated when climbing a flight of stairs.
- No consultation was done nor medications taken at this time.

1 week PTA:
- Patient’s symptoms worsened and associated with 2-pillow orthopnea.
- This prompted consultation and hence admitted.

Past Medical History:

(+) hypertension
(-) diabetes mellitus
No previous surgery

Family Medical History:

(+) hypertension – paternal side
(-) diabetes
No known family history of cancer

Personal/Social History:
(+) smoker 1 ½ pack per day since he was 21 years old
Occasional alcoholic beverage drinker

Physical Examination:
General
Awake, alert, in respiratory distress
Survey
HR: 98 BP: 110/80 mmHg Temp: 37.6
Vital Signs
RR: 27 O2 saturation: 92% at room air
Anicteric sclerae, pink palperbal conjunctivae, pupils equally and briskly reactive to light,
HEENT no tonislopharyngeal congestion, several 2 cm diameter palpable lymph nodes at the right
cervical area
Skin No jaundice, no lesions seen
Chest and
Symmetrical chest expansion, decreased breath sounds at the right lower lung field
Lungs
Adynamic precordium, tachycardic and regular rhythm, distinct S1 and S2, no murmurs,
CVS
splits or gallops
Abdomen Soft, non-tender abdomen, normoactive bowel sounds
Extremities No edema, no cyanosis, full and equal pulses
Chest X-Ray:

Chest Ultrasound: