ENDORSEMENT

OCTOBER 19, 2021

PGI JOSEPH I. AGUJA
 IDENTIFYING DATA
• E.C.
• 82 years old
• MALE
• SINGLE
• FILIPINO
• SO. MACARANAS, SAN AGUSTIN BASEY, SAMAR
• Admitted: October 16, 2021 at 10:25 AM
 CHIEF COMPLAINT
• COUGH
 HISTORY OF PRESENT ILLNESS
A week PTA, the patient had an onset of on and off fever with the
highest documented temperature of 38°C. This was associated with
occasional nonproductive cough and colds. Doing TSB and taking a tablet of
Paracetamol 500 mg every 4 hours for fever were done but this only
provided temporary relief. No consult was done.
Interim, above mentioned symptoms were still present. Still no
consultation was done. No hemoptysis, no weight loss, no anosmia, no
ageusia were noted.
3 days PTA, the patient’s symptoms persisted now associated with
productive cough with whitish sputum. Persistence of cough prompted the
patient to seek consult and was subsequently admitted for further
evaluation and management.
Problem #2 Inguinal Pain

Few months PTA, the patient started to notice that his inguinal
hernia was irreducible. No tenderness, no redness on affected site were
noted. No consultation was done.

3 days PTA, the patient had an onset of pain on the inguinal area
with a PRS of 6/10. No dysuria, no flank pain, no change in bowel
movement noted.
Problem #3 Dysuria
During the interview the patient noted complains of dysuria. No
flank pain noted. No hematuria.
 PAST MEDICAL HISTORY
• (-) Diabetes Mellitus
• (+) Hypertension – 2021 : Amlodipine 5mg + Losartan 50mg once a day after breakfast
• (+) Reducible Inguinal Hernia – 2016
• No previous hospitalization, surgery nor Blood Transfusion
• No known allergies to food and medications
 FAMILY HISTORY
HYPERTENSION – unknown
DM - unknown
No other heridofamilial disease
 PERSONAL AND SOCIAL HISTORY
• Retired rice field farmer
• Occasional alcoholic beverage drinker
• Non smoker
• No illicit drug use
• Good functional capacity
 REVIEW OF SYSTEM

 General: No body malaise, no unintentional weight loss

 Skin: No rashes, no itchiness, no lumps, no sores.
 HEENT: No headache, no dizziness, no retro-orbital pain, no anosmia,
no dysphagia, no epistaxis,
 Respiratory: no hemoptysis, no dyspnea
 Cardiac: No chest pain, no easy fatigability, no palpitations, no
orthopnea
 REVIEW OF SYSTEM
 GIT: No abdominal pain, no nausea, no diarrhea, no vomiting, no
hematemesis, no melena, no hematochezia
 GUT: No flank pain, no hematuria, no discharges
 Musculoskeletal: No malaise, no myalgia, No joint pain, no edema
 Psychiatric: no history of depression or treatment in psychiatric
conditions
 Hematologic: no bleeding gums, no easy bruising
 PHYSICAL EXAMINATION
(Done on the 3rd hospital day)
 General: Awake, conscious, coherent, ambulatory,alert,good eye
contact and respond to questions, not in respiratory distress
 Vital signs: AT ER UPON INTERVIEW
BP: 110/90 mmHg BP: 130/80 mmHg
HR: 106 bpm HR: 110 bpm
RR: 22 cpm RR: 24 cpm
Temp: 37.9 C Temp: 38.1 C
O2 sat: 96% O2 Sat: 98%
BL: 158.6 cm
Weight: 66 kg
BMI: 26.2 kg/m^2
WHO classification: Overweight
Asian Classification: Obese I
 PHYSICAL EXAMINATION
(Done on the 3rd hospital day)

 Skin: Brown complexion, with hypopigmentation over the waistline

area, warm to touch with good skin turgor, no jaundice, no lice
infestation
 HEENT: normocephalic, eyebrows symmetrical with fine black hair,
Anicteric sclera, pinkish palpebral conjuctiva, Ears symmetrical, no
lesions, no discharges, Intact nasal septum, pinkish nasal mucosa, No
sinus tenderness
 Neck: supple, no lymphadenopathy, no neck vein engorgement
 Mouth: moist oral mucosa, no dentures, pinkish gums, tongue is
midline, pink moist and nontender, uvula at midline, tonsils are pink
with no swelling and exudates
 PHYSICAL EXAMINATION
(Done on the 3rd hospital day)
 Respiratory: Symmetrical and truncal in shape, Symmetric chest expansion, no
intercostal retraction, unimpaired tactile fremitus, resonance upon percussion of
both lung fields, no dullness, no tenderness. Fine rales were noted over the left
basal lung field. no wheezes, no cough noted
*AT ER: (+) fine rales, bibasal Left > Right.
 Cardiovascular: Adynamic precordium, no visible precordial pulsation, no thrills,
no heaves, S1 louder at apex, S2 louder at base, regular rhythm, synchronous
with radial pulse, no bruit, no murmur, PMI at 5th ICS Left MCL
*AT ER: tachycardic, regular rhythm, no murmurs
 GI: Flabby, symmetrical, no lesions, no mass, umbilicus not everted. Other
regions are soft, nontender and warm to touch, (-) kidney punch sign, No
rebound tenderness, normoactive bowel sounds.
 PHYSICAL EXAMINATION
(Done on the 3rd hospital day)
 GUT: with an irreducible bulging mass over the right inguinal area,
nontender, no redness, no discharge noted, bladder not distended.
 Extremities: symmetrical upper and lower extremities, Full and equal
pulses, no edema, no tenderness, no swelling, no limitation of ROM,
 Neurologic exam: No focal neurologic deficits, GCS 15
 MSE: oriented to person, place and time
 Cerebellum: No ataxia, no nystagmus, no dysdiadokinesia, no
dysmetria
 Cranial nerve testing: unremarkable
 SALIENT FEATURES
Demographics History of Past Medical Family Personal and Review of Physical Exam
Present Illness History History social history Systems

 Male  On and off  Hypertensive none  Retired • Fine rales were

 82 years fever rice field noted over the
old  (+) farmer left basal lung
productive field
cough with • With bulging
whitish mass on the right
sputum inguinal area.
 Inguinal • Vital Signs:
hernia, BP: 130/80 mmHg
irreducible, PR: 110 bpm
right. RR: 24 bpm
 (+) dysuria T: 38.1 C
sPO2: 98% RA
ADMITTING IMPRESSION RECEIVING WARD IMPRESSION

Community Acquired Pneumonia- Community Acquired Pneumonia

Moderate Risk, COVID-19 Suspect - Moderate Risk - resolving,
Inguinal Hernia, Right COVID-19 Negative
T/C BPH Inguinal Hernia, Right
Hypertension stage II Complicated UTI
BPH
Hypertension stage II – controlled
ASIS FOR DIAGNOSIS
COMMUNITY ACQUIRED PNEUMONIA-
MODERATE RISK
 On and off fever
 (+) productive cough with whitish
sputum
 Fine rales were noted over the left basal
lung field
BP: 130/80 mmHg
PR: 110 bpm
RR: 24 bpm
T: 38.1 C
sPO2: 98% RA
ASIS FOR DIAGNOSIS
COMPLICATED UTI
 82 years old
 Male
 On and off fever
 Dysuria
PIVOT
COUGH
Differential Diagnosis: RULE IN RULE OUT
COVID PNEUMONIA • Fever • Intact sense of smell and taste
• Productive cough • No headache
• Rales • No myalgia
• No sore throat
• No diarrhea
• RT-PCR negative
ACUTE BRONCHITIS • Fever • Presence of bibasal rales
• Productive cough

TUBERCULOSIS • Fever • No weight loss

• Cough • No hemoptysis
• No anorexia
• No fatigue
• No night sweats
• Rales on basal fields
• Less than 2 weeks cough
 PROBLEM 1: Cough
CAP - MR
• DIAGNOSTICS
CBC
Chest X-ray
Sputum GS/CS
 RT-PCR

• MANAGEMENT :
 Ceftriaxone 2g IV OD
 Azithromycin 500 mg OD
PATHOPHYSIOLOGY
 PROBLEM 2: Inguinal Mass
Inguinal Hernia
• DIAGNOSTICS
History and Physical
Examination
• MANAGEMENT :
 Refer to surgery for co-
management on possible
herniorrhaphy
 PROBLEM 3: Dysuria
BPH and Complicated UTI
• DIAGNOSTICS
Urinalysis
Urine culture and sensitivity
Ultrasound of KUB
Prostate specific antigen

• MANAGEMENT :
 Dutasteride+Tamsulosin HCl
 Continue Ceftriaxone
 PROBLEM 4:
Hypertension
• DIAGNOSTICS
FBS
Lipid Profile
Creatinine
Serum electrolytes
ECG
• MANAGEMENT :
 Low salt, low fat diet
 Continue maintenance
medication of Amlodipine
5mg + Losartan 50mg
THANK YOU!