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PANGILINAN RUBEN ca

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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Pangilinan, Ruben Address: 1950 D F Muñoz St. Paco, Manila Date of Admission: April 4, 2008 Admitting Diagnosis: Community Acquired Pneumonia, Moderate Risk Erythematous lesion 2° to CAP, t/c Psoriasis Physicians-in-charge: Drs. Gutierrez/Dimaandal/Areja Clerks-in-charge: Liwag/Lopez Clinical Abstract This is a case of a 55 y/o male from Paco, Manila who came to OMMC due to difficulty of breathing. History of Present Illness

Hospital#: 1819562 Age/Sex: 55/M

Past Medical History No TB No Diabetes mellitus No hypertension No bronchial asthma No allergies No coronary artery disease Family History No heredofamilial disease Personal and Social History

Review of Systems General: no weight loss, no loss of appetite HEENT: no dizziness, no headache, no tinnitus, no discharge, no congestion Gastrointestinal: no diarrhea, no constipation Genitourinary: no dysuria, no hematuria, no oliguria Hematology: no easy bruisability, no bleeding tendencies Endocrinology: no polyuria, no polyphagia, no polydipsia, no heat/cold intolerance Physical Examination General: conscious, coherent, not in cardiorespiratory distress Vital Signs: BP: 110/70 mmHg HR: 100bpm RR: 21 cpm Temp: 36.8°C Skin: No pallor, no cyanosis HEENT: pink palpebral conjunctivae, anicteric sclerae, no mass, no cervical lymphadenopathies, no neck vein distention CHEST AND LUNGS: symmetrical chest expansion, no retractions, equal breath sound on both lungs HEART: adynamic precordium, PMI at 5th ICS left midclavicular line, tachycardic,no murmur ABDOMEN: flat, soft, normal abdominal bowel sounds, non tender, normoactive bowel sounds EXTREMITIES: appreciate full pulses, no edema DRE: no skin lesions, good sphincter tone, no mass, no tenderness, bowel stool on tactating finger. Assessment: Community Acquired Pneumonia, Moderate Risk Erythematous lesion 2° to CAP, t/c Psoriasis

Plan: for ADMISSION Laboratory Requested: CBC with PC Blood typing EGD BUN, Crea, Na, K FBT CXR UTZ, whole abdomen TG, TC, LDL, HDL FBS Chest X-ray


				
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