Saint Louis University

School of Medicine
Department of Medicine

MEDICINE CLINICS
POMR

Submitted to:

Dr. Justina Calibuso

Submitted by:
Ramos, Jeffrey
Reyes, Aldrin Paul
Romaguera, Leah Ann
Sab-it, Audrey

Date Submitted:
March 31, 2017
GENERAL DATA:
R.L., 50-year old male, born on November 28, 1966, married, Filipino, works as a broadcaster, presently
residing in Bakakeng, Baguio City. The informant is the patient with a percentage reliability of 90%

Chief Complaint: Fever at night of seven days duration

History of Present Illness:

Seven days prior to consult the patient experienced fever (thermometer was used; however, he cannot
recall the temperature) which occurred at night and low back pain which was described as mildly disturbing, but
with no radiation. He took celecoxib for two consecutive days to relieve the low back pain and took one tablet of
paracetamol. However, these symptoms disappear the next morning and recur during the following night. Five
days prior to consult, this same pattern of febrile episodes persisted. The patient also stated waking up the next
morning with his clothes (sweaters and pajamas) soaked in his own sweat. In addition, the patient recounted 3
episodes of bleeding when he blew his nose (this was not due to having colds, instead a mere practice that he
does when he feels unwell). Four days prior to consult he developed unproductive cough and sore throat which
he treated by drinking a lot of water. He claimed that it offered him relief. One day prior to consult, the night
fever (38.3 C) persisted, hence prompted the consultation.

Past Medical History:

The patient was diagnosed to be hypertensive after having a BP of 200/120 last February 22, 2017 at the
University of Baguio clinic and was prescribed with maintenance medication Losartan initially at 100mg then
trimmed down at 50mg OD. He said that aside from religiously taking Losartan, he also checks his blood
pressure each morning and every night using a digital sphygmomanometer. He observed a decline in his blood
pressure until it stabilized to about 120/80. His BP for the past two days was 100/70 thus, he discontinued taking
Losartan.
Aside from prescribing him with Losartan, he was also advised to lose weight. He did this by modifying
his diet consisting of vegetables, fruits, fish and chicken (no rice, no salty food, no red meat nor soda). He also
took Organogold, a supplement with the regimen of 3x a day for 9 days which he perceived to have benefited
him. He claimed to have successfully lose weight, shedding about 10-13 pounds from February up to this month.
As mentioned above, because of his decreased BP upon follow-up, his doctor lowered the dosage of
losartan to 50mg OD every other day.
The patient had also experienced a tingling sensation on his left extremity and was advised by a doctor
to take Vitamin B-complex which relieved the symptoms. The patient reported that he has insomnia; he finds it
hard to fell asleep and when he does he eventually wakes a few hours after. He said that it coincided with his
move to his father’s house. The patient’s last hospital confinement was in 1992 because of Hepatitis A infection
at the SLU hospital. The patient said that he had completed all childhood vaccinations because his parents were
very particular about it and he had a flu vaccine three years ago. The patient cannot recall his childhood illness
except for chicken pox.

Family History:
His mother died due to an unrecalled complication of hypertension while his father, 74 years old is alive,
but has hypertension. His father underwent cataract surgery last March 23, 2017. He has a brother which is well
and not suffering from any illness. No family history of diabetes, cancer or other heredo-familial disease.
No family member living with the patient manifested same signs and symptoms.

Social and Environmental History:

The patient has smoking history of 12-pack years. He claimed to be an occasional alcohol drinker,
consuming an average of seven bottles per drinking event. He drinks more than 8 glasses of water a day, from a
local water refilling station. He lives in a 2-storey house with flush type toilet with his father and daughter. He
has two other children, living with their mother. No other member of his household experiences the same
symptoms. He takes care of two dogs, a cat, and a fish. History of travel revealed travel to La Trinidad, Benguet
two weeks ago. He denied any exposure to sick people. Their garbage is collected weekly.
Review of Systems:
General: Intentional weight loss about 10-13lbs, no fever, no anorexia, no weakness
Skin: no cyanosis, no pallor, no rash
HEENT: no headache, no colds, no sneezing, no sore throat, no dysphagia, no odynophagia, no dryness, no
hoarseness of voice, no ear discharge
Respiratory: unproductive cough, no dyspnea
Cardiac: no chest pain, no palpitations, no orthopnea, no paroxysmal nocturnal dyspnea
GIT: no abdominal pain, no vomiting, no diarrhea, no constipation
GUT: no dysuria, no hematuria, no dribbling, no hesitancy, no incontinence, no oliguria
Musculoskeletal: no joint pains, no muscle pains

Physical Examination:
General Survey: conscious, coherent, ambulatory, oriented to time, place and person, not in cardiopulmonary
distress
Temperature: 36.2C, RR: 17cbpm, PR: 81bpm, BP: 150/110 mmHg, Weight: 79 kgs Height: 5’4”
Skin: fair skin color, acyanotic, warm to touch with good skin turgor, <2 seconds capillary refill, no petechiae or
maculopapular rashes
HEENT: Evenly distributed hair on the head, no tenderness, no nodules; anicteric sclerae; moist and pinkish
nasal mucosa, no nasal discharges, no sinus tenderness; pink and moist lips, tonsils are not enlarged and not
inflamed without any exudates; no palpable cervical lymph nodes; JVP 2 cm above sternal angle; no carotid
bruit; thyroid not enlarged and no nodules palpated
Chest and Lungs: symmetrical chest wall expansion, no retractions, resonant, equal tactile fremiti, vesicular
breath sounds, no crackles or wheezes
Heart: PMI at the 5th LICS, MCL, no heaves or thrills, regular rhythm, S1 louder at the apex, S2 louder at the
base, no S3 or S4, no murmurs
Abdomen: globular, inverted umbilicus, normoactive bowel sounds, tympanitic, non-tender, no organomegaly,
no CVA tenderness
Extremities: no gross deformities, no wounds, no joint swelling, ++ dorsalis pedis and posterior tibial pulses
DRE: not indicated
Neurologic Exam: intact CN II, CN III

PROBLEM LISTS
 Fever and Low Back Pain
 Hypertension

Problem
 FEVER, LOW BACK PAIN
S: The patient experienced fever and low back pain. 4 days PTC, he had nosebleed whenever he blow his nose. 3
days PTA, he developed cough and itchy throat

O: General Survey: conscious, coherent, ambulatory, oriented to time, place and person, not in cardiopulmonary
distress
Temperature: 36.2C, RR:17cbpm , PR: 81bpm, BP: 150/110 mmHg Weight: 79 kgs Height: 5’4”
Skin: fair skin color, acyanotic, warm to touch with good skin turgor; no petechiae or maculopapular rashes
HEENT: Evenly distributed hair on the head, no tenderness, no nodules; anicteric sclerae; moist and pinkish
nasal mucosa, no nasal discharges, no sinus tenderness; pink and moist lips, tonsils are not enlarged and not
inflamed without any exudates; No palpable cervical lymph nodes; JVP 2 cm above sternal angle; no carotid
bruit; thyroid not enlarged and no nodules palpated
Chest and Lungs: symmetrical chest wall expansion, no retractions, resonant, equal tactile fremiti, vesicular
breath sounds, no crackles or wheezes
Abdomen: globular, inverted umbilicus, normoactive bowel sounds, tympanitic, non-tender, no organomegaly,
no CVA tenderness
Extremities: <2 seconds capillary refill, with good skin turgor, no gross deformities, no wounds, no joint
swelling
Neurologic Exam: intact CN II, CN III
A: Dengue fever
Ddx:
Dengue
Rule in Rule out
Fever (-) rash
Low back Pain (-) loss of appetite
Epistaxis for 3 days (-) body malaise
(-) headache

Chikungunya
Rule in Rule out
Low back pain (-) rash
Fever (-) loss of appetite
(-) body malaise
(-) headache

Influenza
Rule in Rule out
Fever No nasal discharge
Cough No myalgia
Itchy throat No headache
Body pain No red, watery eyes

P:
Diagnostics:
 Complete blood test to rule out bacterial infection (elevated WBC occurs in bacterial infection and
decrease WBC and platelet count may occur in viral infection)
 Culture of specimens like blood sample, nasal swabs to determine the causative agent
Treatment:
 Bed rest
 Increase fluid intake
 Paracetamol 500mg every 4-6 hrs to relieve fever and body pain

 HYPERTENSION
S: 50-year-old male, diagnosed hypertensive on February 2017, taking losartan 100 mg then 50 mg OD, former
smoker 12-pack years, consumes alcoholic beverages occasionally, with family history of hypertension, no chest
pain, no palpitations, no orthopnea, no paroxysmal nocturnal dyspnea

O: General Survey: The patient is conscious, coherent, ambulatory, oriented to time, place, and person, not in
cardiopulmonary distress
Temperature: 36.2C, RR: 17cbpm, PR: 81bpm, BP: 150/110 mmHg, Height: 5 feet 4 inches Weight: 79
kilograms (BMI:30.9, Obese Class 1)
Heart: PMI at the 5th LICS, MCL, no heaves or thrills, regular rhythm, S1 louder at the apex, S2 louder at the
base, no S3 or S4, no murmurs
Extremities: no gross deformities, no wounds, no joint swelling

A: Hypertension Stage I

Hypertension Stage I
Rule-in Rule Out
BP: 150/110 No chest pain
Taking maintenance medication for HPN (Losartan) No palpitations

BMI: 30.9 Obese I No orthopnea

Familial History of HPN No paroxysmal nocturnal dyspnea

Former Smoker
Occasional alcohol drinker
++ dorsalis pedis and posterior tibial pulses

P:
Dxtics:
- 12-leads ECG to determine presence of cardiomegaly and ischemic changes
- CXR-PA – to determine presence of cardiomegaly or congestion
- FBS, lipid profile – determine risk factors such as DM and dyslipidemia
- Creatinine – assess kidney function since patient is hypertensive
- Urinalysis – assess kidney function since patient is hypertensive

Txtics:
a. General measures: low fat, low salt diet
b. Specific measures: Losartan 50 mg 1 tab OD; Amlodipine 10 mg 1 tab OD;
c. Patient education: weight loss