Republic of the Philippines
Bicol University - College of Medicine
Daraga, Albay
IDENTIFYING DATA:
B.G., 57 y/o male, Married, Driver, Roman Catholic from Bogtong, Legazpi City.
INFORMANT: Patient and wife
RELIABILITY: 95%
CHIEF COMPLAINT: ”May nana sa leeg”
HISTORY OF PRESENT ILLNESS:
10 months prior to consult, the patient experienced weakness, fatigue, lower back pain,
dysuria with turbid urine, and was not able to walk. He went for a check-up but was not
admitted. The following weeks, the patient had continuous check-ups but still wasn't admitted
to a hospital.
9 months prior to consult, the symptoms worsened; the patient experienced nausea, vomiting,
and edema in his lower extremities was present. Pain was relieved by hot compress, however,
it persisted almost everyday until the patient fainted and was rushed to the hospital.
He was diagnosed with CKD Stage 5 and advised to undergo hemodialysis. His hemodialysis
was initially scheduled twice a week, but when his condition improved, the frequency of the
procedure was changed to once a week every Thursday. He was also prescribed unrecalled
medications and underwent catheterization to manage his dysuria. Patient was in-and-out of
confinement in the hospital.
7 months PTC, the unrecalled prescribed medications were replaced with Ferrous Sulfate +
Folic Acid 1 tablet twice a day, Carvedilol 6.25mg ½ tablet twice a day, Atorvastatin 40 mg 1
tablet once a day, Dutasteride + Tamsulosin 1 tablet once a day, Empagliflozin 10 mg 1 tablet
once a day, Clopidogrel 75 mg 1 tablet once a day, and Erythropoietin.
The patient was consistent in his hemodialysis appointments, however, the patient was
sometimes non-compliant to his medications due to financial constraints. During which he
immediately experiences worsening symptoms.
A day prior to consult, the patient went to his regular hemodialysis session. That night, the
patient experienced fever and noticed an abscess on his central venous catheter on the left
side of his neck, hence prompting him to seek consult in BHRMC.
PAST MEDICAL HISTORY
(+) Cardiovascular Disease
(+) Obstructive uropathy
(+) Benign Prostatic Hyperplasia
PERSONAL AND SOCIAL HISTORY
The patient is a driver and starts to work from 7 in the morning until 7 in the evening. His sleep
pattern ranges between 7-8 hours but experience an occasional difficulty in sleeping. He is
currently living with his wife and bears no children. He is an alcoholic drinker that can consume
1 liter of Redhorse everyday and a smoker with 20.5 pack-years.
FAMILY HISTORY
Hypertension, Diabetes Mellitus – Paternal and Maternal side
ROS:
General
(+) weight change, (+) fever, (+) fatigue, (+) weakness
Cardiovascular
(-) Chest pain, (-) Palpitations, (-) Orthopnea, (-) Edema
Gastrointestinal
(-) Dysphagia, (-) Abdominal Pain, (-) Tenderness
Peripheral Vascular
(-) Varicose veins
Genitourinary Urinary
(-) Dysuria
(-) Discharge
Skin
(+) Hyperpigmentation
HEENT
(+) Headache, (+) Dizziness, (+) Pus – left side of neck
CVS
(+) Hypertension, (+) Dyspnea
GIT
(+) changes in appetite, (+) nausea
Peripheral Vascular
(+) Peripheral Edema
Musculoskeletal
(+) Muscle pain (Upper right limb), (+) Arthritis
Neuro
(+) Syncope, (+) Tingling (Upper right limb), (+) Numbness (Upper right limb)
Psychiatric
(+) Lethargy
PHYSICAL EXAMINATION
Height: 5 feet
Weight: 43.3 kg (Dry Weight)
BMI: 18.5 (Normal)
HISTORY-TAKER:
Einreb Broqueza
Alexis Buela
Jhuna Marie Buenaflor
Jie Leo Ben Buergo
Sean Bufete
Mary Grace Buitizon
Date: September 11, 2024
Time: 2:40pm