PTB Case To Edit

General Data:
Patient: GY
Age: 40 years old.
Civil Status: Married
Address: Tuao, Cagayan
Religion: RC
Informant: Patient herself
Admission: 1st
CC: Hemoptysis
HPI:
The patient was apparently well 3 months prior to admission, when she started experiencing
general body weakness. No fever noted nor coughing. And no consultation done.
2months PTC, she had non productive cough and night sweats. Still no consultation was done.
1month PTC, the cough is said to be productive with whitish sputum.She also reported of having
low grade fever, especially at night. She also reported of having chills. No consultations was
made.
Two weeks prior to admission, with the persistence of the productive cough, she also noted of
having poor appetite. And noticed of losing weight. No consultation was sought.
One week prior to admission, patient started experiencing occasional difficulty of breathing
accompanied with chest and back pain. Still with the low grade fever, she opted for a consultation
in RHU. She was treated as a case of pneumonia.
Two days prior to admission, still with productive cough, difficulty of breathing is worsening.
Few hours prior to admission, the above mentioned symptoms persisted now accompanied by 2
episodes of hemoptysis. Patient was admitted to CVMC, hence admission.
Past Medical History

Childhood illnesses: Had chicken pox and mumps.
Adult illnesses: None
Surgical: None
Psychiatric: no history of depression, anxiety and psychosis.
Medications: Ascorbic acid, 500 mg taken once daily
Immunizations: all are unrecalled
Allergies: allergies to seafood
OB History
: Had her menarche at age 13, subsequent regular menstrual period usually last for 3 days,
consuming 3 pads per day. No premenstual syndrome experienced.
:She had her coitarche with her husband at age 21
:OB score of G2P2 (2002), both are delivered to term via NSD. Both are currently alive.
Family History:
Her father died due to old age.
Mother is alive, with HPN
Her only sibling is alive and well.
Her husband has PUD.
With no heredofamilial diseas such as hypertension, diabetes or cancer.
Personal and Social history.
Patient is currently a housewife after resigning from her work as a helper in a private clinic 5
months ago. . She is a college undergrad, and was born and raised in Tuao, Cagayan. She does the
household chore while her husband works as a janitor in the wet market.
She lives in a 2 room bungalow house together with her mother, 2 sons and her husband.
They have pets. And their source of drinking water is through a refilling station.
She used to smoke when she was 17 years old and stopped when she had her marriage at
the age of 24. She admits of being an occasional drinker, with preference to gin and beer. She
denies use of illicit drugs.
She drinks about 4-6 glasses of water everyday and her usual diet consist of vegetables and
meat. She consumes about 3 cups of coffee everyday and usually sleeps at 9 pm and wakes up at
4 AM.
REVIEW OF SYSTEMS
Constitutional: (+) Weight loss; (+) Fatigue; (-) Fever; (-) Chills
Skin: (-) Pale skin, (-) Rashes, (-) Lumps, (-) Itching, Dry skin
Head: (+) Dizziness upon standing, (-) Headache, (-) Syncope, (-) Trauma, (-) Tenderness
Eyes: (-) Eye pain, (+) Blurred Vision, Use of glasses, (-) Redness, (-) Double vision, (-) Lacrimation
Ears: (-) Hearing problem, (-) Earache, (-) Discharge, (-) Tinnitus, (-) Vertigo
Nose and Sinuses: (-) Nose bleeds, (-) Nasal stuffiness, (-) Discharge
Mouth and Throat: (-) Bleeding Gums, (-) Sore throat, (-) Mouth sores, (-) Toothache, (-) Difficulty
swallowing, (-) Hoarseness
Neck: (-) Pain, (-) Stiffness, (-) Lumps
Breast: (-) Pain, (-) Discharge
Respiratory: (+) White sputum, (+) Chest pain (when coughing), (+) Hemoptysis, (-) Wheezing, (+)
Difficulty of breathing
Cardiovascular: (-) Shortness of breath when using only 1 pillow, (-) Easy Fatigability, (-)
Palpitations
GI: (+) Loss of Appetite, (-) Vomiting, (-) Nausea, (-) Diarrhea, (-) Abdominal pain
Renal: (-) dysuria, (-)hematuria, (-) Oliguria, (-) Polyuria, (-) Incontinence
Genitalia: (-) Pain, (-) Swelling, (-) Discharges, (-) Ulcers, (-) Itching
Peripheral Vascular: (-) Leg cramps, No varicose veins
Musculoskeletal: (-) Muscle weakness, (-) Back pain, (-) Stiffness, (-) joint pain, (-) Joint swelling
Neurologic: (-) Paralysis, (+) Numbness on both lower extremities, (-) Seizures, (-) Tremors, (-)
Memory Loss
Hematologic: No mucosal bleeding, No easy bruising
Endocrine: (-) Polydipsia, (-) Polyphagia, (-) Excessive Sweating
Psychiatric: No nervousness, No Anxiety, No Depression, No hallucinations
PHYSICAL EXAMINATION
General Survey:
Patient GY is a pleasant, small built woman, who appears to be her stated age, and is
appropriately dressed for the weather. She is sitting on bed, alert and coherent with ongoing IVF
of PNSS 1L x 31 gtts/min, patent and infusing well at the ® dorsal metacarpal vein. She is
cooperative during the physical examination.
Vital Signs:
Blood Pressure: 110/80 mmHg (Ⓛ arm; Auscultation; while sitting on bed)
Temperature: 37.4°C (Axillary)
Pulse Rate: 84 bpm, Regular
Respiration Rate: 26 cpm (Tachypneic)
Height- 5’3 (1.651 m)

Weight- 56 kg
BMI - 21.8
SKIN : Good skin turgor, no pallor, no cyanosis, no jaundice

Head: Scalp has no lesions. Hair with average texture, black, with streaks of white
Eyes: White sclera; Pinkish conjunctiva, No excessive tearing, no swelling, nor discharges noted.
Ears: No swelling; No redness; No discharges; No tenderness. No hearing aid
Nose: No frontal, maxillary sinus tenderness; No obstruction; No lesions; No exudates; No
inflammation; Septum midline
Mouth & Throat: Gums, buccal mucosa and tongue - moist, no discoloration, no signs of
bleeding; No tonsillitis
Neck: No tenderness; No vein engorgement; Trachea is midline; Lymph nodes palpated are
non-tender; Thyroid non-palpable
Chest & Lungs: Chest has no scars. Respirations non labored, and have regular rhythm, but
increased in rate; no excessive depth, effort of breathing, or unilateral lag. Chest shape is
symmetric with good expansion; no kyphosis. Chest wall movements are symmetrical, with no
retraction of interspaces on inspiration.
(-) chest wall tenderness. Increased tactile fremitus. Lung sounds are diminished at the upper
regions bilaterally; .(+) high-pitched inspiratory wheezes on the upper right lung field after
coughing.
Heart: (-) Precordial lifts or heaves – PMI not visible;
S1- heard best at apex, normal intensity, S2- heard best at base, normal splitting, (-) S3,S4, (-)
Murmurs
PMI at 5th ICS, MCL. No thrills, lifts or heaves felt on palpation
Abdomen: Flat; (-) Scars; Normoactive bowel sounds on all quadrants; (-) bruits; (-) tenderness,
masses, guarding; Liver edge not palpable; Spleen non-palpable; R & L kidneys non-palpable
Extremities: No Lesions; No redness; No deformities; No visible joint swelling; No limitation of
ROM; No tenderness; (-) Edema ; No clubbing of nails; CRT 1 second
NEUROLOGICAL EXAMINATION
Mental Status: Patient GYis awake & alert; oriented to person, place & time
Cranial Nerves:
I: Visual Fields- intact in all fields
II and III: Pupillary Reaction to Light- direct & consensual (normal); Accommodation-normal
(PERRLA/pupils, equal, round, reactive to light, and accommodation for both)
III, IV, VI: EOM- intact (No nystagmus; No diplopia)
V: Positive corneal reflex
VII: Can wrinkle forehead or raise both eyebrows. Symmetric smile
VIII: No hearing difficulty
IX, X: Normal swallowing
XI: Can shrug shoulders and rotate the head against resistance
XII: Midline protrusion of tongue; No atrophy
Motor System:
Normal tone; 5 / 5 strength in all extremities
(Sensory and Reflex: There is normal sensation on right arm, and is also intact on the left. Slightly
decreased sensation on both lower extremities.
Salient Features:
40. y.o,Female. Filipino

Helper in a private clinic,
General body weakness
2 months history cough
Night sweats
Chills
Low grade fever
Chest and back pain
Poor appetite
Weight loss
Hemoptysis
Fever
Tachypneic
(+)Lung sounds are diminished at the upper regions bilaterally
+) high-pitched inspiratory wheezes

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General Data:

Past Medical History

Personal and Social history.

Height- 5’3 (1.651 m)

SKIN : Good skin turgor, no pallor, no cyanosis, no jaundice

40. y.o,Female. Filipino

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