CASE PROTOCOL
General Data: RS, 62 years old, male, Filipino, married, retired veteran, Roman Catholic born on September
17, 1936 in Rizal presently residing at Barangay Holy Spirit, Phase 1, Purok 3, Quezon City, admitted for the
1st time at our institution on April 6, 2016
Chief Complaint: difficulty of breathing
History of Present Illness:
History of present illness started 5 days prior to consult when the patient experienced productive cough
with yellowish sputum, undocumented fever, loss of appetite and occasional shortness of breath. No other
associated symptoms such as nausea and vomiting, chest pain, diaphoresis nor headache. No consult was done,
no medications were taken.
One day prior to consult, still with above signs and symptoms but now with more distressing productive
cough, persistent fever, difficulty of breathing, generalized body weakness and 2 episodes of non projectile, non
bloody, non billous vomiting of previously ingested food after bouts of coughing. Hence prompted patient to
seek consult.
Past Medical History:
The patient is a non hypertensive, non diabetic, non asthmatic.. With previous PTB treatment for 9 months
in 2008, no history of Myocardial Infarction and Stroke. No liver disease, kidney diseases, malignancy or
psychiatric illness. No known allergies to food or medications.
Family History
Father: deceased due to Myocardial Infarction at the age of 50
Mother: deceased due to Breast Cancer of 60. No siblings
There are no other heredofamilial diseases such as diabetes mellitus, asthma, liver disease, kidney diseases, or
psychiatric illness.
Personal and Social History
Patient is a highschool undergraduate, unemployed, married for 40 years. His wife died due to Breast
Cancer. Patient lives in a poorly ventilated, well lit bungalow type of house. Garbage is segregated and
collected three times a week. He has no regular exercise and prefers to eat pork, fried foods and sweets. Patient
is a non-alcoholic drinker. A 60 pack year smoker. No history of sexually transmitted infection or illicit drug
use.
Review of Systems:
Constitutional: (-) weight loss, (-) easy fatigability
CNS: (-) vertigo, (-) syncope, (-) loss of consciousness, (-) paralysis, (-) numbness, (-) paresthesia, (-) loss of
memory, (-) confusion, (-) headache
Skin: (-) itchiness, (-) excessive dryness or sweating, (-) jaundice
HEENT: (-) dizziness; (-) vertigo, (-) blurring of vision, (-) double vision, (-) lacrimation, (-) photophobia, (-)
earache, (-) deafness, (-) tinnitus, (-) change in smell, (-) nose bleeding, (-) nasal obstruction, (-) gum bleeding,
(-) disturbances in taste, (-) sore throat, (-) hoarseness
Neck: (-) pain, (-) limitation of movement
Respiratory System: (-) hemoptysis, (-) wheezing
Cardiovascular System: (-) palpitation, (-) orthopnea, (-) paroxysmal nocturnal dyspnea, (-) cyanosis, (-) easy
fatigability
Gastrointestinal System: (-) dysphagia, (-) diarrhea, (-) constipation, (-) hematemesis, (-) melena, (-)
hematochezia, (-) regurgitation
Genitourinary System: (-) urgency, (-) bladder distension, (-) hematuria, (-) incontinence, (-) genital discharge
Neuromuscular: (-) stiffness, (-) numbness, (-) limitation of movement, (-) pain
Hematopoietic System: (-) bleeding, (-) pallor, (-) easy bruisability
Endocrine System: (-) intolerance to heat and cold, (-) excessive weight gain or loss, (-) polyuria, (-) polydypsia
Pertinent Physical Examination Findings:
General Survey: Patient is conscious, coherent, febrile, in mild cardiorespiratory distress
BP: 110/60 mmHg CR: 105 bpm RR: 29 cpm T: 37.5 C
Wt: 60kg Ht: 5’7” BMI: 20.76 kg/m2
HEENT: Thick black hair, coarse with clean scalp, normocephalic, no mass or tenderness. Temporal arteries
are not visible but palpable with strong, equal pulsation, walls are not thickened. Symmetrical; thin, black and
white and evenly distributed eyebrows, normally set eyeballs, thin black eyelashes, directed outward, no
matting. Pink palpebral conjunctiva, icteric sclera black iris with regular contour, pupils normal in size and
shape, equally reactive to light and accommodation. Symmetrical, no tenderness, patent vestibules, pink
mucosa, septum at midline and intact, turbinates not congested, with discharge, no tenderness over the frontal
and maxillary sinus, normal transillumination test. Lips are pink, moist, symmetrical, no lesion. Buccal mucosa
and gums are pink, smooth, no lesions. The roof, floor and palate are pinkish with no lesion. Tonsils not
enlarged, pinkish pharynx with no lesion or exudates.
Neck: supple, symmetrical, with no neck vein engorgement, no mass, normal muscle development and tone,
trachea in midline, soft, No cervical lymphadenopathies noted.
Lungs/Chest: Symmetrical chest expansion, with supraclavicular and intercostal retractions. Increased tactile
fremitus on the right lower lung field, with dullness on percussion over the same area. With crackles on the
right lower lung field but with no bronchophony, egophony nor whispered pectoriloquy.
Heart: Adynamic precordium, no heaves nor thrusts, no palpable thrills. The apex beat is at the 5th intercostal
space left mid clavicular line. S1 is soft best appreciated at the apex. S2 is accentuated best appreciated at the
base. Tachycardic, regular rhythm, no murmur.
Abdomen: flat, umbilicus is inverted, no superficial blood vessels, no caput medussae, with normoactive bowel
sounds, no epigastric and lumbar bruits, tympanitic, (+) tenderness on the RUQ, palpable liver edge 3 cms
below the right subcostal margin, spleen not palpable.
Extremities: No gross deformities, muscle tones are normal without weakness, full and equal pulses
NEUROLOGIC EXAMINATION:
Cerebrum: Patient is conscious, coherent, fluent, oriented to 3 time, place, and person, has intact immediate,
recent and remote memory. Intact calculation and abstract reasoning.
Cranial Nerves
CN I: can identify the smell of coffee
CN II: J1 on Jager’s chart, Fundoscopy: (+) red orange reflex, AV ratio 2:3, clear media with distinct margins,
with localized narrowing of retinal vessles. No visual field defect.
CN II-III: 2-3 mm pupils equally reactive to light, direct and consensual, adduction and constriction of both
eyes on accommodation
CN III: no ptosis
CN III, IV, VI: intact extraocular muscles
CN V: equal sensation on both sides of the face; can clench teeth on both sides
CN V, VII: (+) bilateral corneal reflex
CN VII: no facial asymmetry, can identify taste of sugar and salt solution
CN VIII: can hear on both ears, no lateralization on Weber’s test
CN IX, X: uvula is at the midline, (+) gag reflex
CN XI: can turn head from side to side, can shrug both shoulders
CN XII: tongue is at the midline, no fasciculations
5/5 5/5 100% 100% ++ ++
5/5 5/5 100% 100% ++ ++
CEREBELLAR:
Can do finger-to-nose test, rapid alternating movements, heel to shin test, and tandem walk.
MENINGEAL SIGNS:
No nuchal rigidity. Negative for Brudzinski sign. Negative for Kernig sign.
PATHOLOGIC REFLEXES:
No Babinski
