1

SUGGESTED IMPROVEMENT FOR HISTORIES:

PLEASE SEPARATE CHIEF COMPLAINT HERE, BEFORE THE S. CHIEF COMPLAINT: FOLLOW-UP (DIZZINESS)

S: Patient was last seen last February 10, 2022, with a chief complaint of on and off

dizziness, non-rotatory in character, lasting for 3-5 minutes and precipitated by sudden change

movements (PLEASE SPECIFY.for example: dizziness was precipitated by sudden change in position from
lying down to sitting position… what side? We can deduce the location of the deranged otoliths if left or
right or both by the location of ‘tumba.. left or right ba? Pareho? May loss of consciousness ba or
syncope? Untog?). This was relieved by lying down and shutting her eyes ( you can also know if the
vertigo is peripheral or central if it is relieved by shutting the eyes or aggravated by closing the eyes)..
There were no

associated signs and symptoms such as nausea, vomiting, headache, LOC, ringing of the

ears, no hearing loss and no aural fullness (para marule out ang Menieres Disease). Patient was sent
home and was prescribed with Betahistine with an unrecalled dose and was given laboratory

requests for work up. Patient was advised to follow-up once with complete laboratory

results hence (place comma here) sought consultation for lab interpretation.

O: GS: Patient was awake, alert, coherent, cooperative and not in cardiopulmonary distress

Vital Signs:

HR: 63 bpm RR: 19 cpm Temp: 36.5 ℃ O2: 98%

BP: 120/70 mmHg Weight: 60 kg Height: 162.5 cm BMI: 22.7 kg/m 2

(Normal) waist circumference? Waist-hip ratio? Pls note the next time

Skin: Patient’s skin was brown in color, smooth, normal skin turgor and mobility, no

pallor, no jaundice. No rashes and lesions

Hair: Patient’s hair was black, fine, long and well distributed all over the body.

Nails: Nail plate was firm, convex, clean, no pits and/or grooves, no spots and/or

discoloration. Nail bed was pale pink in color, no discoloration, and no clubbing.

HEENT: head is oval in chape, no facial asymmetry, (+) Arcus senilis, pupils 3-4mm in

size, equally reactive to light and accommodation, intact extraocular muscles ROM,
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external auditory canal is patent, tympanic membrane is intact, (-) cervical

lymphadenopathy

Chest and Lungs: Symmetrical chest expansions, no visible lesions/mass, clear breath

sounds, no wheezing

Cardiovascular: Adynamic precordium, normal rate, regular rhythm, (-) murmur

Abdomen: Flabby, soft, non-distended abdomen, no tenderness upon palpation

Spine and Extremities: No gross deformities, no tenderness upon palpation of upper

and lower extremities and full range of motion, CRT <2 seconds

Neurological: GCS 15 (E4V5M6), patient is oriented to 3 spheres, time, person and

place

A: Type 2 Diabetes Mellitu; Dyslipidemia; Benign Paroxysmal Positional Vertigo

P: - Medications:

- Metformin 500mg/tab, OD

- Atorvastatin 10mg/tab, OD

- Systane (please PLACE GENERIC NAME HERE AND ENCLOSE BRAND NAME IN PARENTHESES) Balance, 2
drops on both eyes Q4

- Iberet tab, OD (GENERIC NAME AS WELL PLS)

- Ascrobic acid tab, OD (PLS CORRECT THE SPELLING OR TYPO)

- Health Teachings/Advised and Agreed Upon:

- low salt, low fat, low carb diet (CHANGE TO DM DIET)

- Increase oral fluid intake (HOW MANY LITERS PER DAY?)

Laboratory:

- FBS, BUN, Serum Crea, Lipid profile, SGPT, SGOT, Na, K, CBC, Urinalysis

Patient well Advised

Family and community intervention inquired and suggested (PFC Care rendered)

S Chief Complaint: Interpretation of laboratory results

5 days PTC, Patient underwent laboratory work up for her general check up. (PLEASE WRITE HYPHEN OR
DASH)
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4 days PTC, patient consulted a private clinic for laboratory results interpretation and was

diagnosed with UTI (WHAT SPECIFIC UTI? ACUTE UNCOMPLICATED CYSTITIS? COMPLICATED UTI? ACUTE
PYELONEPHRITIS?). Patient was then prescribed with Cephalexin 500mg/tab for UTI (WAS THE PATIENT
COMPLIANT AND COMPLETED TREATMENT? RESISTANCE IS COMMON WITH UNCOMPLETED
ANTIBIOTIC TREATMENT),

Simvastatin 20mg/tab (FREQUENCY? COMPLIANCE?)and Losartan 50mg/tab (FREQUENCY?

During the interim, patient experienced headache, localized on the frontal (BIFRONTAL?) area every

time she takes Cephalexin. This was alleviated by Paracetamol (Biogesic) (DOSE AND FREQUENCY?)and
sleeping.

Patient came in today for a second opinion, with no subjective complaints such as

dysuria, fever, chills, flank pain, urinary frequency, urinary urgency and headache.

Blood Chemistry (05/04/23): (VERY GOOD IN TYPING THE RESULTS) - NEXT TIME PLS ALSO INCLUDE THE
mg/Dl values by using conversion factors); PLEASE HIGHLIGHT THE ABNORMAL VALUES

FBS: 5.73 mmol/L BUA: 515 umol/L TG: 1.65 mmol/L

SGOT: 22 U/L Creatinine: 71 mmol/L HDL: 1.33 mmol/L

SGPT: 17 U/L Cholesterol: 4.88 mmol/L LDL: 2.80mmol/L

BUN: 5.09 mmol/L

Urinalysis (05/04/23):

Color: Yellow Transparency: Hazy Specific Gravity: 1.020

pH: 5.0 Protein: Negative Glucose: Negative

RBC: 1-2 /hpf WBC: 3-5 /hpf Bacteria: Moderate

Hematology (05/04/23)

Hgb: 137 Neutro: 0.58 MCV: 88 MPV: 7.0

Hct: 0.40 Lympho: 0.36 MCH: 30

WBC: 6.4 Mono: 0.05 MCHC: 339

RBC: 4-6 Eosinophil: 0.01 RDW: 14.5

O Patient was awake, conscious, coherent, ambulatory and not in cardiorespiratory

distress

Vitals signs: BP= 130/80mmHg; HR= 76 bpm; RR= 19 cpm; Temperature = 36.6C;
4

O2 sat: 97% RA (PLEASE INCLUDE THE WAIST CIRCUMFERENCE, WASIT TO HIP RATIO NEXT TIME)

Anthropometrics: Weight= 55 kg; Height= 160 cm; BMI= 21.5 (Normal)

Skin: Skin is brown in color, normal skin turgor and mobility, warm to touch, no

jaundice or no edema noted.

HEENT:

Head: Normocephalic, no deformities, no facial asymmetry, no lesions, no

tenderness

Eyes: Anicteric sclera, pink palpebral conjunctivae, pupils are equal, 3mm,

round, reactive to light and accommodation, able to follow six cardinal gazes.

Ears: The ear is brown in color, normal in size, symmetrical, external auditory

canal is patent, tympanic membrane is intact with pearly white color and normal cone

of light

Nose: The nose is symmetrical, septum is in midline, no alar flaring, no nasal

discharges

Mouth: Lips are moist and pink, tongue and uvula at the midline

Chest and Lungs: Symmetrical chest expansion, no retractions, no lagging, with

clear breath sounds, no adventitious breath sound

Cardiovascular: Adynamic precordium, Normal rate, regular rhythm, PMI is at 5th

ICS LML, no murmurs

Abdomen: Flat, brown in color, normoactive bowel sounds, soft, no tenderness and

pain on all quadrants upon palpation,

Extremities: Grossly normal extremities, Full and equal pulses, no edema, CRT <2

seconds

Genitourinary: (-) Costovertebral angle tenderness

Neurologic: GCS 15 (E4V5M6), Oriented to three spheres, time, person and place;

intact memory for recent and remote events

Cranial Nerves:

CN I = Able to smell coffee grounds

CN II CN III = No visual defects. Able (+) Direct and consensual light reflexes
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on both eyes. Pupils equally reactive to Light, and Accommodation.

CN III/IV/VI = intact extra ocular muscle movements, no ptosis

CN V = Able to distinguish different kinds of sensation in the facial area and

demonstrate normal tone and force in the muscle of mastication

CN VII = No facial asymmetry

CN VIII = Able to hear rubbing fingers in both ears. Patient able to maintain

steady gait in an upright posture

CN IX/X = intact gag reflex

CN XI = Good shoulder shrug

CN XII = Tongue is in the midline

Cerebellum: Normal gait, no tremors, no nystagmus, no involuntary movements

Motor Function: Upon inspection, there is no atrophy, hypertrophy, fasciculations

and involuntary muscle movements.

Deep Tendon Reflexes: +2 on triceps, patellar and achilles tendon

A Dyslipidemia [E78.5]; Hypertension stage II [I10]

P Diagnostics

● Repeat Lipid profile after 3 months

Pharmacologic

● Continue present medications:

○ Losartan 50 mg tablet once a day

● To start:

○ Fenofibrates 200 mg/capsule once a day at bedtime

Non-pharmacologic

● Advise and agreed upon BP monitoring and record

● Advised and agreed upon low salt and low fat diet

● advised and agreed upon increase in oral fluid intake

● to come back after 3 months (CHANGE TO to come back once) with laboratory results

● Well advised

Family and community intervention inquired and suggested (PFC Care)

CLINICAL HISTORY

Age: 65 years old

Sex: Male

S: This is a known case of BPH (2022; Tamsulosin 400 mg/tab COMPLIANT?), Hypertension (2012;

Olmesartan 40 mg/tab COMPLIANT?) and Gouty arthritis (2008; Febuxostat 40 mg/tab, COMPLIANT?).
Seen and

examined last on February 27, 2023, came in today for follow-up and reading of latest

laboratory results PLEASE INCLUDE ALL THE RESULTS AND HIGHLIGHT THE ABNORMAL VALUES. The
patient had subjective complaints SINCE WHEN? BLANK PRIOR TO CONSULT such as (+) urinary
frequency,

(+) urgency, (+) nocturia, (+) straining, (-) abdominal pain, (-) joint pains, (-) fever, (-)

Cough

PLS INCLUDE PERTINENT NEGATIVES RELATED TO HIS DIAGNOSIS

BPH-

HPN- CHEST PAIN ETC

GOUTY ARTHRITIS – PAIN ETC

ALWAYS INCLUDE A REVIEW OF SYSTEMS EVEN IF TH EPATIENT IS ONLY FOR FOLLOW UP

O: GS: Patient was awake, alert, coherent, cooperative, ambulatory? and not in cardiopulmonary
distress

Vital Signs:

HR: 71 bpm RR: 20 cpm Temp: 36.5℃ O2: 98% BMI AND INTERPRETATION?

BP: 130/90mmHg Weight: 69 kg

Skin: Patient’s skin was brown in color, smooth, normal skin turgor and mobility, no
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pallor, no jaundice, no rashes

HEENT: symmetrical face, normal facie, no involuntary movements, anicteric sclerae,

pink palpebral conjunctivae, no naso-aural discharge, no cervical lymphadenopathy, OS -

J10, OD - J16

Chest and Lungs: Symmetrical chest expansions, no lagging, no retractions, clear

breath sound

Cardiovascular: Adynamic precordium, no lifts, heaves and thrills, no jugular vein

distention, normal rate and regular rhythm, no murmur

Abdomen: Globular, normoactive bowel sounds, soft, no tenderness upon palpation

Spine and Extremities: grossly normal extremities, (+) tophi (1st MTP), no edema, no

lesions, full range of motion. Capillary refill time <2 seconds.

Genitalia: Not Assessed

Neurologic: Oriented to three spheres; intact memory for recent and remote events; no

anxiety, or agitation

Cranial Nerves:

CN I = Able to smell coffee grounds

CN II CN III = No visual defects. Able to read text from a brochure. Direct and

consensual light reflexes on both eyes. Pupils, Equal, Round, Reactive to Light,

and Accommodation.

CN III/IV/VI = Demonstrated full extra ocular muscle movements, no ptosis

CN V = Able to distinguish different kinds of sensation in the facial ares and

demonstrate normal tone and force in the muscle of mastication

CN VII = Face is symmetrical, with normal eye closure and able to demonstrate

different facial expressions

CN VIII = Able to hear rubbing fingers in both ears. Patient able to maintain steady

gait in an upright posture

CN IX/X = Phonation is normal.

CN XI = Head turning and shoulder shrug are intact

CN XII = Tongue is in the midline and able to move without difficulty. no

fasciculation nor involuntary movement observed

Cerebellum: Normal gait, no tremors, no nystagmus, no involuntary movements

Motor Function: Upon inspection, there is no atrophy, hypertrophy, fasciculations and

involuntary muscle movements.

Laboratory results:

SEROLOGY

PSA - 1.239 ng/ml (Interpretation?

Whole abdomen ultrasound

● Mild to moderate diffuse fatty liver PLS INCLUDE A DIAGNOSIS RELATED TO THIS IN THE DX PART

● Normal ultrasound of the gallbladder, pancreas, spleen, abdominal aorta, kidneys

and urinary bladder

● Enlarged prostate gland (II) with concretions.

A: BPH, Hypertension (Stage I), Gouty Arthritis icd?; NAFLD? IS HE ALCOHOLIC? K75. 8

P: Diagnostics:

Blood Uric acid

Therapeutics:

Febuxostat 40 mg/tab, OD

Olmesartan 40 mg/tab, OD

Tamsulosin 400 mg/tab, OD (MICROGRAMS, NOT MILLIGRAMS)

Silymarin cap 125 mg/cap, OD

Supportive:

Advised strict adherence to maintenance medications

Advised low salt, low fat diet (DASH diet)

Advised for BP monitoring (AM & PM) and record

EXERCISE?

Follow-up after 1 week with BP monitoring results for continuity of care

Patient well Advised

Family and Community Intervention given – inquired and suggested (PFC Care)

--

S: Patient was seen last March 6, 2023 with a chief complaint of difficulty in swallowing,

hoarseness, fever, cough and colds.(CHOOSE ONLY 1 CC, ASK THE PATIENT WHICH IS THE MOST
BOTHERSOME THAT PROMPTED HER TO CONSULT. YOU CAN ALSO DO VERBATIM TERM USED BY THE
PATIENT BUT ENCLOSE IN QUOTATION MARKS)

He was managed as a case of Hypertension Stage II

- controlled; Diabetes Mellitus Type 2, controlled or uncontrolled? Depending on the labs and or
symptoms of 3p’s etc); BPH; S/P Cataract Operation, which eye?, 2016. Laboratory

tests were requested but were not accomplished by the patient (what was the reason?). Patient was
given

medications such as Metformin, Losartan, Amlodipine, Simvastatin, Aspirin and Strepsils dose,
preparation and compliance?

Patient claimed that his symptoms were resolved. The patient came in only for a refill of

maintenance medications. PERTINENT SYMPTOMS RELATED TO HIS DX.CONDITION?

HPN – CHEST PAIN? ORTHOPNEA? ETC USUAL BP? HIGHEST Bp?

DMT2 – 3PS? FOOT SYMPTOMS SINCE COMPLETE FOOT INQUIRY AND EXAM SHOULD BE DONE FOR
EVERY DIABETIC PATOENT COMING IN FOR CHECKUP

ASSOCIATED SYMPTOMS RELATED TO THE CC, DIFFICULTY SWALLOWING- TO SOLIDS OR LIQUIDS?

O: GS: Patient is awake, alert, ambulatory, coherent, cooperative and not in

cardiopulmonary distress

Vital Signs:

HR: 75 bpm RR: 18 cpm Temp: 36.4℃ IS THIS NORMAL TEMP? O2: 97%

BP: 140/70 mmHg Weight: 59 kg

Skin: Patient’s skin was brown in color, has good elasticity, no lesions, no pallor, no
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jaundice.

Hair: Patient’s hair was black mixed with white, fine, fairly abundant.

HEENT: Head is oval in shape, no facial asymmetry, anicteric sclerae, pale palpebral

conjunctivae, pupils 3-4 mm in size, equally reactive to light and accommodation, intact

extraocular muscles ROM, external auditory canal is patent, tympanic membrane is intact,

no cervical lymphadenopathy.

Chest and Lungs: Symmetrical chest expansions, no visible lesions/mass, clear breath

sounds, no wheezing.

Cardiovascular: Adynamic precordium, normal rate with 75 beats per minute, regular

rhythm, no murmur.

Abdomen: Flabby, non-distended abdomen, with normoactive bowel sounds, soft, non-

tender. (+) RLQ surgical scar

Spine and Extremities: No gross deformities, no tenderness upon palpation of upper and

lower extremities and full range of motion, CRT <2 seconds.

Neurological: GCS 15 (E4V5M6), patient is oriented to time, person and place.

Cerebrum:

Conscious, coherent, oriented to time, place, and person. GCS 15(E4V5M6).

Cerebellum: (-) Dysmetria, (-) Dysdiadochokinesia

Cranial Nerves:

I: Not assessed.

II, III: Equal pupillary reaction to direct, consensual light reflex, and accommodation

III, IV, VI: Able to follow the 6 cardinal gazes

V: Able to distinguish different kinds of sensation in the facial area

VII: No facial asymmetry, able to demonstrate different facial expressions

VIII: Able to localize sounds

IX, X: Uvula is at the midline, gag reflex

XI: Able to shrug her shoulders symmetrically

XII: Tongue is in the midline. No fasciculations nor involuntary movements observed.

Motor: Intact range of motion, 5/5 muscle strength, no noted spasticity and rigidity on both

upper and lower extremities.

Sensory: Intact sensation for pain, crude touch, and position sensation on upper and

lower extremities.

DTR: 2+

A: Hypertension Stage II - controlled; Diabetes Mellitus Type 2 , Controlled or Uncontrolled? ; BPH; S/P
Cataract, which eye? Cataract surgery? When?ICD?

Operation, 2016

P: Pharmacologic:

1. Losartan 100mg/tablet; take one tablet once a day

2. Amlodipine 10mg/tablet; take one tablet once a day

3. Simvastatin 20mg/tablet; take one tablet once a day

4. Aspirin 80mg/tablet; take one tablet once a day

5. Metformin 500mg/tablet; take one tablet once a day

6. Multivitamins tab; take one tablet once a day

Health Teachings/Advise:

- Low salt, low fat diet, DM diet

- Continue BP monitoring and record

Patient was well Advised, to come back when there is problem encountered. Change to Follow-up after
one week for continuity of care, because your patient has acute symptoms

Family and community intervention inquired and suggested (PFC Care)

--

S: Patient was last seen in Feb date? 2023 and was managed as a case of Hypertensive stage I,
controlled?

and CKD stage II. Patient came in at our clinic complaining of itchiness of throat. Patient

presents with difficulty swallowing (solids and/or liquids? Since when?), and itchiness of the throat not
associated with fever,
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odynophagia, runny nose, cough, nausea and vomiting (covid? Covid exposure? Travel history?). With no
medications and

consultation done. (INCLUDE CHEWFINDCAB MNEMONIC SINCE THIS IS APPLICABLE TO YOUR PATIENT)

Fhptc (PLEASE DO NOT ABBREVIATE IF NOT STANDARD ABBREVIATION, NOT USED UNIVERSALLY the
patient sought consultation at our clinic due to persistence of her throat

itchiness as well as for refill of her maintenance medications. (WHEN DID IT START? PERTINENT
NEGATIVES? NOT WRITTEN, NOT DONE, AS APPLIED IN LEGAL DOCUMENTS)

O: GS: Patient was awake, alert, coherent, cooperative, ambulatory? and not in cardiopulmonary
distress

Vital Signs:

HR: 75 bpm RR: 19 cpm Temp: 36.4 ℃ O2: 98%

BP: 110/80 mmHg Weight: 47 kg Height: 160 cm BMI: 20.3 kg/m 2

(Normal)

Skin: Patient’s skin was brown in color, smooth, normal skin turgor and mobility, no

pallor, no jaundice,

Hair: Patient’s hair was black, fine, long and thinly distributed all over the body.

Nails: Nail plate was firm, convex, clean, no pits and/or grooves, no spots and/or

discoloration. Nail bed was pale pink in color, no discoloration, and no clubbing.

HEENT: Face was oval, symmetrical, normal facie, no involuntary movements, anicteric

sclera, pink palpebral conjunctiva, no cervical lymphadenopathy, (+) congested

oropharynx

Chest and Lungs: Symmetrical chest expansions, no retractions, clear breath sounds

Cardiovascular: Adynamic precordium, normal rate, regular rhythm, no murmur

Abdomen: Flat abdomen, brown in color, normoactive bowel sounds, non-distended

abdomen, no tenderness upon light and deep palpation

Spine and Extremities: No gross deformities, CRT 2> secs

A: Hypertensive CHANGE TO Hypertension, stage I (I11), CKD stage II secondary to hypertensive kidney
disease(N18), (PLEASE CAPITALIZE ACCORDINGLY, FIRST LETTERS)

Acute Pharyngitis(J02.9), Anemia secondary to CKD(D63.1) Rule out COVID-19 Infection/COVID-19

P: - Medications:

losartan 100 mg 1 tab once a day in the morning. CAPITALIZE FIRST LETTER

Captopril 25 mg 1 tab once a day in the morning

Atorvastatin 10 mg 1 tab once a day before bedtime

Ketoanalogue + Essential amino acid 1 tablet three times a day

Ferrous sulfate + Folic Acid 1 tablet twice a day for 3 weeks

Ascorbic Acid + Zinc 1 tablet once a day

Kamillosan spray 4 sprays 4 times a day

- Health Teachings/Advise:

● To come back if with problems

● Advised low fat and low salt diet

Increase oral fluid intake

Patient well Advised

Follow up after 1 week (Continuity of care)

Family and Community Intervention Given Inquired and Suggested (PFC Care)

Patient was last seen on April 11, 2023 and was managed as a case of CKD stage IIIA,

Hypertension stage 1, and DM type II. Patient came in at our clinic for a refill of

medications. The patient's usual blood pressure is 130/80 with no accompanying

symptoms. No difficulty breathing, headache, nausea and vomiting noted. The patient is

on maintenance medications of Losartan 100mg/ tab OD, Amlodipine 5mg/ tab OD,

Glimepiride 4mg/ tab OD HS, Ketoanalogue + Essential amino acid TID, and Lactulose

20ml OD PRN and had her regular consult at our clinic. COMPLIANT?

PERTINENT NEGATIVES RELATED TO HER DIAGNOSIS/CONDITION?

CHEST PAIN, ORTHOPNEA ETC

POLYURIA POLYDIPSIA ETC

FOOT SYMPTOMS ESPECIALLY SHES ADIABETIC?

MONOFILAMENT EXAM ON PE SHOULD ALWAYS BE DONE FOR COMPLETE FOOT EXAM

IF NO MONOFIKAMENT TOOL, USE NEURO HAMMER TIP

O: GS: Patient was awake, alert, coherent, cooperative and not in cardiopulmonary distress

Vital Signs:

HR: 78 bpm RR: 19 cpm Temp: 36.3 ℃ O2: 98%

BP: 120/80 mmHg Weight: 50 kg Height: 149 cm BMI: 22.5 kg/m 2

(Normal)

Skin: Patient’s skin was brown in color, smooth, normal skin turgor and mobility, no

pallor, no jaundice.

Hair: Patient’s hair was white, fine, long and thinly distributed all over the body.

Nails: Nail plate was firm, convex, clean, no pits and/or grooves, no spots and/or

discoloration. Nail bed was pale pink in color, no discoloration, and no clubbing.

HEENT: Face was oval, symmetrical, normal facie, no involuntary movements, anicteric

sclera, pink palpebral conjunctiva, no cervical lymphadenopathy

Chest and Lungs: Symmetrical chest expansions, no retractions, clear breath sounds

Cardiovascular: Adynamic precordium, normal rate, regular rhythm, no murmur

Abdomen: Flat abdomen, brown in color, normoactive bowel sounds, non-distended

abdomen, no tenderness upon light and deep palpation

Spine and Extremities: No gross deformities, CRT 2> secs

A: Hypertensive stage 1 (I15); DM type II (E11); CKD stage IIIA secondary to hypertensive

kidney disease (N1831) DIABETES? ICD?

P:

- Medications:

Losartan 100mg/ tab once a day in the morning

Amlodipine 5mg/ tab once a day in the evening

Glimepiride 4mg/ tab once a day before bedtime

Ketoanalogue + Essential amino acid thrice a day

Lactulose 20 ml once a day as needed only FOR? PLSINDICATE IN THE DX ALSO.

- Health Teachings/Advise:
15

● Advised low salt and low fat diet DM DIET?

● Advised for regular exercise- Advised moderate intensity exercises 150 minutes per week divided into
3-4 x a week

Follow up when? Alwaysinclude this for mandatory continuity of care

Patient well advised

Family and Community Intervention Given inquired and suggested (PFC Care)

S:

This is a case of Gomez, Emily 56/Female. Patient was last seen in March 2023 and was managed as a
case of Hypertension - Controlled; Bronchial Asthma, not in Acute Exacerbation; Hypertensive
Cardiovascular Disease. COMPLETE CARDIAC DIAGNOSIS? MAINTENANCE MEDS? COMPLIANCE? BP
MONITORING?

PLEASE DO CHEWFINDCAB MNEMONIC FOR PERTINENT SYMPTOMS SINCE THIS IS APPLICABLE TO THE
PATIENT

Patient came in for follow up and interpretation of laboratories. Patient only complained of shortness of
breath upon exertion such as walking and climbing 3-4 flights of stairs. She had no accompanying
symptoms such as fever, dizziness, cough, colds, difficulty of breathing, chest pain, orthopnea, PND, easy
fatigability, nausea, vomiting, and edema. No consultation done, no previous hospitalizations. Patient
was compliant to her maintenance medications which include Levothyroxine (Euthyrox) 50 mg OD,
Calcium Carbonate + Vitamin D (Calmatrix) OD, Telmisartan 80 mg OD. She used to take Metformin OD
but eventually stopped since she claimed that her blood glucose levels normalized.

Usual BP: 140/90 mmHg

Highest BP: 150/100 mmHg

Lowest BP: 130/90 mmHg

Chest AP (April 14, 2023)

Lung fields are clear

Cardiomegaly

Atheromatous aorta

No pleural effusion
16

Blood Chemistry (April 14, 2023)

FBS: 6.17 mmol/L PLEASE CONVERT TO MG PER DL ALSO AND KINDLY HIGHLIGHT THE ABNORMAL
VALUES

Creatinine: 73 umol/L

Total Cholesterol: 7.93 mmol/L

Triglycerides: 3.53 mmol/L

HDL: 1.54 mmol/L

LDL: 4.79 mmol/L

VLDL: 1.60 mmol/L

BUA: 484 umol/L

SGOT: 31 u/L

SGPT: 36 u/L

Sodium: 141.3 mmol/L

Potassium: 4.94 mmol/L

Complete Blood Count (April 14, 2023)

Hgb: 138

Hct: 0.42

WBC: 9.3

RBC: 4.56

Neutrophil: 0.56

Lymphocyte: 0.33

Monocyte: 0.06
17

Eosinophil: 0.04

Basophil: 0.01

MCV: 92

MCHC: 30

RDW: 14.1

MPV: 7.0

Urinalysis (April 13, 2023)

Color: Light Yellow

Appearance: Hazy

Specific gravity: 1.020

pH: 5.0

RBC: 0-2/hpf

WBC: 1-3/hpf

Epithelial Cells: Few

Bacteria: Few

Amorphous urates: Few

Glucose: Negative

Protein: Trace

O:

GS: Patient was conscious, coherent, ambulatory? and not in cardiorespiratory distress

Vital Signs:
18

HR: 88 bpm RR: 20 cpm Temp: 36.6℃ O2: 96%

BP: 130/90 mmHg Weight: 80 kg Height: 149.86 cm BMI: 35.6 kg/m2 ( pls include the
interpretation for Asian bmi and also include as lifestyle related disease in the initial impression; ALSO
INCLDE ADVISED WEIGHT REDUCTION; DOES SHE FULFILL THE DIAGNOSIS OF METABOLIC SYNDROME?
PLS INCLUDE IN THE DX IF YES)

Skin: Patient’s skin is fair in color, smooth, normal skin turgor and mobility, no pallor, no jaundice. No
rashes and active dermatoses.

Hair: Patient’s hair is black, fine, long and well distributed all over the body.

Nails: Nail plate was firm, convex, clean, no pits or grooves, no spots and/or discoloration. Nail bed was
pale pink in color, no discoloration, and no clubbing.

HEENT: Head is symmetrical in shape, no facial asymmetry, pupils are equal and reactive to light,
external auditory canal is patent, intact tympanitic (TYMPANIC) membrane, no cervical
lymphadenopathy, no neck vein distention

Chest and Lungs: Symmetrical chest expansions, no lagging, no retractions, clear breath sounds, no
wheezing

Cardiovascular: Adynamic precordium, normal rate, regular rhythm, no murmur

Abdomen: Flabby, soft, non distended, non tender

Spine and Extremities: No gross deformities, no tenderness upon palpation of upper and lower
extremities, was able to do a full range of motion on both upper and lower extremities, with full and
equal pulses, CRT <2 seconds

Neurological: GCS 15 (E4V5M6), patient is oriented to 3 spheres, time, person and place, able to follow
simple commands, intact memory on recent and remote events, no depression, anxiety, and agitation

Cranial Nerves:

I: Able to identify odour of coffee on both nostrils

II, III: Pupils equally round and reactive to light, able to read text from Jaegers chart

III, IV, VI: Intact extraocular muscles, no ptosis

V: No sensory deficit

VII: No facial asymmetry, with normal eye closure and able to demonstrate different facial expressions

VIII: Intact gross hearing

IX, X: Phonation is normal, uvula is at the midline, (+) Gag reflex

XI: Able to turn head and shrug shoulders

XII: Tongue is at midline when protruded

Cerebellum: Normal gait, no tremors, no nystagmus, no involuntary movements

Motor Function: Upon inspection, there is no atrophy, hypertrophy, fasciculations, and involuntary
muscle movements

Deep Tendon Reflexes: +2 on triceps, patellar, and Achilles tendon

A:

Hypertension - Controlled [I10]; Hypertensive Atherosclerotic Cardiovascular Disease [I11.0]; Bronchial

P:

Pharmacologic:

> Telmisartan (Telzox) 80 mg/tab, 1 tablet once a day

> Atorvastatin (Torvas) 40 mg/tab, 1 tablet once a day

> Fenofibrate (Zinof) 200 mg/tab, 1 tablet once a day for 60 days

> Febuxostat (Atenurix) 40 mg/tab, 1 tablet once a day

> Metformin (Normax) 50 mg/tab, 1 tablet once a day at night

> Empagliflozin (Jardiance) 10mg/tab, 1 tablet once a day in the morning

> Levothyroxine (Euthyrox) 50 mg/tab, 1 tablet once a day

> Calcium Carbonate + Vitamin D (Calmatrix) tab, 1 tablet once a day

> Vitamin B Complex (Vibee) tab, 1 tablet once a day

Non Pharmacologic:

> Low salt, low fat, low purine diet

> Increase oral fluid intake

Advised weight reduction?

> Exercise daily at least 30 mins per day

Diagnostics:

Patient well-advised

Family and community intervention inquired and suggested (PFC Care)

-----

CC: Follow up check up

This is a case of patient _____, 58/F who came in for a follow up check-up

Patient is known to our service and was last seen on April 23, 2023. She is also a case of

Generalized Anxiety Disorder (2017) on Alprazolam (Xanor) but is non-compliant with

medications.

Two weeks prior to consultation (April 19, 2023), the patient experienced right-sided

flank pain, 4/10 on pain scale, radiating to the thighs. QUALITY OF PAIN? SHOOTING PAIN? DULL ACHING
PAIN? NUMBNESS? WEAKNESS?

She reported to have self medicated

with one dose Naproxen (Flanax) 550 mg SURE WITH THE DOSE? tablet which afforded no relief. She
sought

consultation at our clinic for the first time and was prescribed with Tramadol +

Paracetamol (Dolcet) 37.5mg/ 325 mg tablet and Vitamin B complex (DOSE OR FREQUENCY?)

. Urinalysis and blood

chemistry tests were also requested and the patient was advised to come back once with

results. (WHAT ARE THE RESULTS?) PLS LIST DOWN

During the interim, the patient reported relief of pain and had the requested laboratory

tests done at the laboratory of choice.

1 week prior to consultation, she came back for a follow up check up on April 23,

2022. Results of the urinalysis revealed urinary tract infection (WHAT KIND OF UTI ACCORDIGN TI THE
CPG? ACUTE UNCOMPLICATED CYSTITIS? PYELONEPHRITIS?) hence the patient was

prescribed with 1 dose of Fosfomycin 3g/sachet. (COMPLIED?) T

he blood chemistry test also revealed

an impaired fasting glucose result of 114 mg/dl. Requests for a repeat urinalysis and CBC

were given. She was advised to follow up once with the results of the tests hence the

follow up.

PERTINENT NEGATIVES FOR UTI AND GAD? LIST DOWN ALL

NO PALPITATIONS, NO TREMORS ETC

NO FEVER, NO CHILLS, ETC

O: GS: Patient is conscious, coherent, cooperative, able to answer questions (SINCE SHE HAS GAD, A
SHORT MINIMENTAL STATE EXAM WOULD BE APPROPRIATE. ORIENTED TO 3 SPHERES?).
AMBULATORY?

Patient

appears clean, relaxed and well-nourished, with an erect and coordinated gait.

Vital Signs:

HR: 67 bpm RR: 18 cpm Temp: 36.5℃ O2: 98% at room air

BP: 110/70 mmHg Weight: 52 kg Height: 150cm BMI: 23.2 kg/m 2 (BMI INTERPRETATION? ASIAN)

Skin: Brown in color, warm to touch with good skin turgor. No pallor, jaundice, edema, no
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cyanosis, no rashes, and no active dermatoses seen.

HEENT: Head is in midline,normocephalic, anicteric sclera (SCLERAE WHEN PLURAL), pink palpebral
conjunctiva, (CONJUNCTIVAE WHEN PLURAL)

non-sunken eyeballs, ears have no deformities, no masses, no tragal tenderness on

palpation, nose is in the midline, no deformities, no nasoaural discharge, lips are pinkish

in color, moist, no cleft lip/cleft palate, no neck vein distention, no cervical

lymphadenopathy. MASSES?

Chest and Lungs: Symmetrical chest expansions, no lagging, clear OR VESICULAR breath sounds, no

wheezes, no crackles

Cardiovascular: Adynamic precordium, normal rate, regular rhythm, no murmur

appreciated

Abdomen: Soft, flabby abdomen, normoactive bowel sounds (HOW MANY?), tympanitic on all
quadrants,

non tender all quadrants upon palpation, no costovertebral angle tenderness.

Spine and Extremities: Grossly normal extremities, no edema, no cyanosis, CRT &lt; 2

seconds

Neurological: GCS 15 (E4V5M6), oriented to time, place, and person.

Cranial Nerves:

CN I -Able to smell the scent of coffee granules and ethanol

CN II/CN III - Equal pupillary reaction to direct and consensual light reflexes on

both eyes

CN III/IV/VI - Demonstrated full extra ocular muscle movements, no ptosis

CN V - Intact sensory functions on the face

CN VII - No facial asymmetry

CN VIII - Able to localize sound

CN IX/X - Uvula is at the midline, (+) gag reflex

CN XI - Able to shrug shoulders

CN XII - Tongue is at the midline when protruded, no fasciculations

Cerebellum: Normal gait, no involuntary movements

Motor Function: Upon inspection, there is no atrophy, hypertrophy, fasciculations and

involuntary muscle movements, intact range of motion, 5/5 muscle strength on all

extremities

Sensory: Intact sensation for pain, crude touch, and position sensation on upper and

lower extremities.

A: Urinary Tract Infection (ICD? WHAT TYPE OF UTI ACCDG TO LATEST CPG?)

Generalized Anxiety Disorder

LIFESTYLE RELATED DISORDER? AND ICD

P: Diagnostics:

- For repeat of urinalysis (WHEN?)

- For whole abdominal ultrasound (WHY? TO CHECK FOR?)

Therapeutics:

- Ofloxacin 200 mg/ tab, BID x 7 days

Non Therapeutics:

- Low salt, low fat diet, INCREASE ORAL FLUID INTAKE

- Mild to moderate exercise (HOW LONG? 150 MINUTES PER WEEK OF MODERATE INTENSITY
EXERCISES DIVIDED INTO 3-4 TIMES PER WEEK)

- Advised follow up to Neuropsych (WHAT HOSPITAL? GIVEN REFERRAL FORM? TO WHICH HOPSITAL?)

- Advised follow up once with lab results

- Well advised

FAMILY AND COMMUNITY INTERVENTION INQUIRED AND SUGGESTED (PFC CARE)

Age/Sex: 58/F

LABORATORY REQUEST

1. Urinalysis WHEN?
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