Carlos D. Achondo Jr.
2MD-1
General Data:
Joel Bautista, 54 years old, residing at 106 D. Pineapple St., Potrero, Malabon, Roman
Catholic, Married, born on November 30, 1966. Confined at MCU-FDTM Hospital for 2 times.
Admitted on Thursday, November 7, 9:00 PM. 100% reliability with the patient and his wife as
informants.
Chief Complaint:
Pain and swelling of the left arm
History of present illness:
One week prior to admission, the patient already had a small wound on the index finger of
his left arm but he added that the wound was already healing. It did not affect his daily activities
though so he still continued to do household chores such as washing the clothes and doing garden
works. On November 1, he opted to stay in their home instead of visiting the cemetery for he
continued to do the laundry and other household chores. It was noted on that day that his left arm
started to be itchy so he applied a sulfur soap. On November 2, he felt a sudden prickly pain on his
left arm which started to become swollen. On November 3, the pain is already progressing but he
can still bear with it as he continue to apply the sulfur soap. For three days after that, him and his
wife opted to visit their local herbolarios for it was a case of “naengkanto.”
On November 5, he now has insomnia for he can no longer bear the severe pricking and
knife-like pain that radiated in his entire left arm. He took medicines such as:
Amoxicillin 500 mg for which the patient took once only, mefenamic acid 500 mg only once,
Augmentin 625 mg for he took only once also. The medications provided a mild relief but still the
pain recurred.
On November 7, they now decided to go to the ER for the severe unbearable pain. In the
ER, a series of laboratory tests such as Xray, CBC were done on him and the physicians decided to
do operation to prevent the complication of ascending infection. The patient was sent to the OR at
11:00 PM and was returned to the ward the following day already at around 8:00-9:00 AM.
Past Medical History.
He has no known allergy to drugs and foods. Had a history of chickenpox in 1991. History
of mumps, on his elementary years. He claimed to have completed the immunization. Is taking
Metformin and Amlodipine 5 mg for his hyperglycemia and Hypertension. The Metformin was just
prescribed upon admission based on CBG of 180. The hypertension was diagnosed 10 years ago in
the client’s local health unit and was prescribed with the medication. On 2010, the patient has
Carlos D. Achondo Jr. 2MD-1
endoscopy and biopsy of his upper gastrointestinal tract which was found out to have ulceration.
Proton pump inhibitors were prescribed.
Family history.
His mother died because of Leukemia with his brother you already had a bypass surgery
due to a cardiac pathology. Diabetes Mellitus is one of the diseases that seem to run in their family
and his brother also had a history of stroke.
Lifestyle and Social History
The patient is known alcoholic who drinks every night a half-glass full of any alcoholic
beverage (Emperador, Red Horse etc.) He smokes 5-6 sticks per day for 15 years already. He does
basketball every week. Diet is mainly fish and vegetables but has likeness on fatty foods especially
on drinking spree occasions.
Review of Systems
Patient has slight blurring of vision which is not aided by any corrective lenses. He claimed
that he urinates for about 2 liters per day, drinks more than 1 liter per day and usually fonds eating.
Mild paresthesias and numbling were claimed in the extremities. The lower extremities appeared to
have some patchy dark red discoloration.
No other abnormal findings were noted in some systems.
General Survey:
Patient is awake, coherent, oriented to time, person and place. Ambulatory, has big body
habitus, no abnormal and involuntary motor movements noted, good body posture and gait, not in
cardiopulmonary distress, shows appropriate affect consistent with his mood.
Vital Signs: T- 36.3; PR- 95; RR- 13; BP- 150/100
Weight: 87 kg
Height: 5’8
Physical Exam
Carlos D. Achondo Jr. 2MD-1
HEENT
Head: Configuration- normocephalic
Hair- normal texture
Scalp- no lesions, tenderness
Eyes: Sclera- white
Conjunctiva- pink
o Red Reflex: present
o Disc: round, sharp margins, nl color
o Vessels: nl caliber, A/V ratio ~ ½
o Background: abn pigmentation, hemorrhages or
exudates
o Macula: visualized
Ears: External Ear-lesions, masses, tenderness
Auditory Canal- normal
Eardrum- TM’s gray, translucent, with nl light reflex
Nose: Color- pink discharge
Septum- midline
Inferior and Middle Turbinates – normal
Throat and Teeth: Present and in good dentition
Mouth: Tongue: lesions
Gums and Mucosa: swelling, bleeding, infection
Pharynx and Tonsillar Fossa: normal
Openings of Stensen's and Wharton's Ducts: identified
Carlos D. Achondo Jr. 2MD-1
NECK
Active ROM: normal flexion, extension, lateral rotation and tilting
Trachea: midline, mobile
Thyroid: non-palpable or palpable, normal size & consistency, no lesions
Suprasternal Notch: no pulsation
THORAX & BACK
Observation: symmetrical expansion with respiration
Percussion: No spinal tenderness, no CVA (costovertebral angle) tenderness
LUNGS
Percussion and Palpation of Lung Fields- normal resonant percussion
Auscultation- clear, normal vesicular breath sounds
