CPC Case

CASE 1: Acute cough in Adult

General Data: Mr. JA, a 57 year old, male, married, carpenter, Catholic from Cebu City.
Chief complaint: productive cough
History of Present Illness:
One week prior to consult, he had low grade fever, sore throat and rhinorrhea. NO meds taken.
NO consult done. These symptoms spontaneously resolved after 3 days.
5 days PTC, he noted productive cough with yellowish phlegm. Condition tolerated. No meds
taken.
Day of consult, spasmodic coughing occasionally productive of yellowish, purulent sputum
persisted. Hence, he came for consult. There is no history of chills, chest pain or dyspnea, and anosmia.

Past Medical History:

NO history of previous hospitalization.
NO Hypertension, Diabetes nor asthma
NO history of any psychiatric illness.

Family History:
There is diabetes in maternal side and hypertension in paternal side. All siblings were apparently
well. No other heredofamilial diseases noted.

Personal/ Social History:

He works as a carpenter for 30 years. He has 3 children .He lives with his wife and children in
rented 2 storey house. He is a 25 pack year smoker and occasional alcoholic drinker. His diet consists of
fish and vegetables. He occasionally plays majong with friends.

Review of Systems: Unremarkable

Physical Examination:

General Survey: A healthy looking male who coughs frequently during examination
Vital Signs: BP: 125/ 80, PR 70/min , Temp 37.5C, RR 20
Anthropometrics: weight: 58kg Height : 5’6”
EENT: normal except for slight nasal congestion
Cardiac: normal
Chest and Lungs: Normal except on auscultation, there are occasional inspiratory rhonchi that diminish
after coughing

The rest of the physical examination findings are unremarkable

CASE 2: HEADACHE

General Data: Ms. V , a 22 year old, female, single, supervisor in a call center, Catholic from Cebu City.
Chief complaint: headache
History of Present Illness:
5 months PTC, patient noted intermittent headache described as constricting, originating from
the occiput and radiating to the frontal area in a band like manner lasting for less than 10 min . Pain
score 6/10. NO other accompanying symptom.
3 months PTC, recurrence of the headache with same character described above with pain score
6-7/10. She Self -medicate with Ibuprofen which offered temporary relief. She had several consults but
no relief noted.

Past Medical History:

NO history of previous hospitalization.
NO Hypertension, Diabetes nor asthma
NO history of any psychiatric illness.

Family History:
No other heredofamilial diseases noted.

OB History: G0, 1 sexual partner, menarche at 13, coitarche at 20, no OCP use
LMP 8/18/2020 regular monthly 3-5 pads/day , 4 days duration , no dysmenorrhea

Personal/ Social History:

She works as supervisor in a call center and was just recently promoted 5 months ago. She is a 2
pack year smoker and occasional alcoholic drinker. She lives in a rented room in the city. She prefers to
eat chicken and pork. She recently broke up with her boyfriend for 2 years.

Review of Systems: Unremarkable

Physical Examination:

General survey : awake, coherent, oriented to three spheres

Vital signs : T = 37.4oC; BP = 100/60 mmHg; HR = 78 / minute; RR = 20 / minute; O2 saturation = 97%
HEENT: anicteric sclerae, pink palpebral conjunctivae; no cervical lymphadenopathy;; no anterior neck
mass
Chest and Lungs : equal chest expansion; no retractions; clear breath sounds, no crackles, no rales, no
wheezes
CVS: adynamic precordium; normal rate and regular rhythm, distinct S1 and S2, no S3 gallop, no
murmurs
Abdomen : flat abdomen; (-) direct epigastric tenderness; normoactive bowel sounds; no organomegaly
Peripherals: no cyanosis; no edema; with strong bilateral pulses
neurologic exam / fundoscopy: essentially normal
Case 3 Difficulty in Breathing
A case of 2-year old, female, child, Catholic, Filipino, residing at Tapilon, Daanbantayan,
Cebu.

Chief Complaint: difficulty of breathing

History of present illness

About a year prior to consult, the patient had onset of nocturnal dyspnea which was
triggered by his on and off productive cough, accompanied with whitish to yellowish phlegm
and coryza. No fever, no headache, no hemoptysis, no chest pain was noted. Consult was done
and was given Coamoxiclav Oral Suspension and Salbutamol Syrup which provided temporary
relief.
One month prior to consult, cough and colds recurred. Nocturnal dyspnea was noted for
2 to 3 episodes per week. And occasional dyspnea was noted by the mother which usually occur
when the weather condition changes. More often, decoction of “Calabo” herbal plants for
cough and liniments (Efficascent Oil) or Vicks was applied on the chest during asthma attacks.
Symptoms persisted thus prompted this consult.

Past Medical History

The patient has no previous hospitalizations, and no known allergies to any food or
medications.

Prenatal, Natal & Post-Natal History

Prenatal started at 3 months AOG regularly at the Barangay Health Center. The mother
had episodes of asthma attacks throughout the course of pregnancy. Multivitamins and
Salbutamol were her medications. She delivered the patient full term via spontaneous vaginal
delivery at Daanbantayan District Hospital by a Midwife and no complications were noted. Her
birth weight was 6kg and she was the 3rd of 4 siblings.
She was exclusively breastfed up to 1 year old and weaned at 8 months. The patient had
her complete primary immunization at Tapilon Barangay Health Center. Her developmental
milestone is at par with age.

Family History
Her mother and a brother is known to be asthmatic. No family history of diabetes,
tuberculosis, heart or kidney disease.
Review of Systems
General (-) weight loss
Skin (-) pruritus
HEENT (-) headache (-) dizziness
Respiratory (-) hemoptysis
Cardio Vascular (-) chest pain (-) palpitations
GIT (-) abdominal pain
GUT (-) dysuria
Musculo Skeletal (-) musculoskeletal pain
Neurologic (-) loss of consciousness
Physical Examination
 Examined awake, responsive, cooperative, ambulatory, not in respiratory distress
 Vital Signs:
o BP = 90/60 mmHg
o HR = 80 bpm
o RR = 46- 50 cpm
o T = 36.5C

o Wt = 10 kg
o Ht = 79cm

o WFA = 82.44 % (1st Degree

Malnutrition)
o WFH = 90% (Mild Wasting)
o HFA = 84.04% (Severe Stunting)
 Skin: no lesions, warm, good turgor
 HEENT: Normocephalic, anicteric sclerae, pinkish palpebral conjunctivae, no alar
flaring, (+) clear nasal discharges
 Neck: no lymphadenopathies
 C/L: equal chest expansion, no chest retractions, no rales, (+) wheeze
 CVS: adynamic precordium, distinct heart sounds,normal rate, regular rhythm,
no murmur
 Abdomen: globular, NABS, tympanitic in all quadrants, no tenderness upon
palpation,
non-palpable spleen and liver
 Extremities no edema, full equal pulses, no cyanosis
 Neurologic Examination:
 Cerebrum: Oriented to time, place and person
 Cranial Nerves: Intact
 Cerebellum: (-) Nystagmus
 Motor: 5/5 in all extremities
 Sensory: Intact
 Reflexes:

 Meningeal Sign: (-) Brudzinski sign, (-) Kernig sign,

Case 4. Fever and Facial Edema

PATIENT INFORMATION

The is a case of Z.E.C., 7 years old, female, single, Filipino, Roman Catholic, currently
residing at Landing, Catarman, Lilo-an, Cebu, which came in due to fever and facial edema.

Approximately 2 weeks PTA, noted onset of sore throat. No other associated symptoms
noted. No consultation done. No medication taken.

Approximately 3 days PTA, noted onset of undocumented fever which was associated
with facial edema, subauricular mass, and loss of appetite. (-) tea colored urine (-) bipedal
edema Condition persisted thus decided to seek admission.

Prenatal History:

Mother was 42 year old at the time of pregnancy, with an OB Score of G10P9009.
Prenatal started at around 28 weeks of gestation. No illnesses incurred during pregnancy, and
no medication taken.

Natal History:

Patient was delivered via NSVD at a lying-in clinic, attended by a midwife. Cephalic
presentation, birth weight of 6 lbs., and no complications. Birth rank: 10th

Postnatal History:

Immunization was done at a local health center. Vaccines given were: BCG vaccine, 3
doses of Hepatitis B vaccine, 3 doses of DPT vaccine, 3 doses of OPV, 1 dose of Measles
vaccine, and 3 doses of HiB vaccine. Patient was purely breastfed for 1 year. Previous
hospitalization was last 2016 due to PCAP at MMC. No known familial illnesses. No known
allergies.

Past Medical History: unremarkable

Family History: No known heredofamilal diseases

Review of Systems

General survey: Usual weight, no chills, no headache, no body malaise, undocumented fever.

Skin: No changes in color, (+) small scars at the lower extremities

HEENT: No coryza, no clogged nose, no ear discharge, with sore throat last 2 weeks

Respiratory: No cough, no dyspnea, no orthopnea

Cardiovascular: No chest pains, palpitations, syncope, cyanosis

Gastrointestinal: There is loss of appetite for the past 3 days, no abdominal pain, and no
vomiting, no changes in bowel movement and caliber of stools

Urinary: No changes in urine output, No urinary frequency, incontinence, dysuria nor hematuria

Genital: Not inquired

Peripheral vascular: No varicosities, no claudication, no numbness, no cyanosis or pallor

Muskuloskeletal: No limitation of movements, no muscle weakness

Neurologic: Unremarkable

Psychiatric: No hallucinations, mood changes or nervousness

Hematologic: No bleeding episodes, No bruising

Endocrine: No heat or cold intolerance, excessive thirst or hunger

Extremities: No edema, CRT < 2 seconds

Physical examination (upon admission):

General survey: Patient was awake, coherent, oriented, ambulatory, not in respiratory distress

Vital signs:

BP: 100/60 mmHg

 Heart rate: 115 rpm
Respiratory rate: 24 cpm
Temperature: 37.9°C
O2 saturation: 98 %
Weight: 19.7 kg

Skin: brown complexion, (+) multiple purpuric rash at the upper extremities, (+) multiple small
scars at the lower extremities, warm, good turgor

HEENT: (+) facial edema, (-) enlarged tonsils , (+) moist lips and tongue, (+) subauricular mass,
approximately 2x2 cm in size, (+) multiple LAD

Chest and lungs: Symmetrical chest expansion, Clear breath sounds

Cardiovascular: Adynamic precordium, distinct S1 and S2, no murmur, PMI at the 5 th ICS left
MCL.

Abdomen: Flat, no changes in colorations, no visible blood vessels, normoactive bowel sounds,
soft, no tenderness

Genitourinary: No costophrenic angle tenderness.

Extremities: Unremarkable, no edema, strong pulses and no limitations of movement, no

deformities.

Neurologic: essentially normal, no neurologic deficit

MMSE: Awake, alert, oriented, cooperative, sits on the hospital bed during interview