Transcript Year Outcome

• Corazon Padua-Uy is a 54/F, married,
unemployed, from Tondo Manila
• Hypertensive since 1989
• Diagnosed with diabetes mellitus in 2008
History of Present Illness
• 2 yrs prior to visit
– Non-healing wound of 2 months duration on her
right ankle prompted consult at a private doctor in
Cavite
– Capillary blood glucose taken, diagnosed with
diabetes
– No medications given, lost to follow-up
– Several non-healing wounds, no consult done
– No other symptoms
History of Present Illness
• 1 year prior to visit
– nocturia
• 10 months prior to visit
– Woke up with heaviness of left leg
– Rushed to Ospital ng Maynila where she was
diagnosed with mild stroke
– Sent home with medications and lab orders but she
was non-compliant
– Had 3 sessions of physical therapy, which she claimed
helped her to walk with less difficulty
History of Present Illness
• 7 months prior to visit
– Four episodes of chills precipitated by hunger
– Polyphagia
– Consulted at Canossa Health Center where
capillary blood glucose was measured
– Diagnosed with DM
– Given meds:
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Metformin 500mg BID
Glicazide 80mg BID
Enalapril 10mg OD
Amlodipine
– Joined DM club
• Regular checkups at the Canossa Health center
• Helped the patient become more compliant with her
medications
• Financial constraints prevent her from being compliant
History of Present Illness
• 3 months prior to visit
– Frothy urine
– Polydypsia
• 2 months prior to visit
– Chest pain described as “kirot”, usually felt in the
afternoon, no known aggravating or relieving
factors, duration of 5-10 minutes
– Episodes of feeling of pins and needles on the left
hand
History of Present Illness
• 1 month prior to visit
– Episodes of dyspnea at rest
– 2-pillow orthopnea
– Edema of left leg which resolved after 2 wks
Review of Systems
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(-) weight loss, fever
(+) BOV since 2002
(+) hearing loss
(-) cough, colds
(+) Left abdominal pain
Bowel movement of once/week since 2000
(-) melena/hematochezia
(-) frothy urine
(-) gross hematuria
(-) loss of sensation
(+) weakness of left leg
Past Medical History
• Hypertension: 1989, currently taking aspirin
80mg OD and enalapril 10mg OD
• (-) thyroid disease, TB, asthma, drug and food
allergies
Family Medical History
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Hypertension: mother and siblings
Cardiovascular disease: father and siblings
Asthma: sibling
Stroke: sibling
Leukemia: child
Menstrual and Gynecologic History
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Menarche: 17 yrs old, RMI
Menopause: 48 yrs old, (-) HRT
Coitarche: 18 yrs old w/ 1 NPSP
(+) OCP use for 3 years (1981-1984)
OB History
• G8P6(6024)
Year
Outcome
1976
M, FT, SVD at local hospital, currently alive
1977
F, FT, SVD at local hospital, died at 11 mos due to leukemia
1979
M, FT, SVD at local hospital, currently alive
1980
Abortion at 4mos
1981
M, FT, SVD at local hospital, currently alive
1984
F, FT, SVD at home assisted by midwife, currently alive
1985
abortion
1988
F, FT, SVD at local hospital, died at 11 mos due to measles
Personal and Social
• Elementary school graduate
• Previously worked as a vendor in a canteen
until 1989 when the canteen closed
• Husband is a carpenter, and still does minimal
contractual work
• Smoker for 27 years (13.5 pack/yr), stopped
when diagnosed with diabetes
• Occasional alcohol drinker, stopped in 2009
due to diabetes
Timeline
Diagnosed with
hypertension
1973
Got married, moved
from Paho to Tondo,
worked in a canteen
1987
Moved to Block 2
1989
Lost employment due
to closure of canteen
2000
Moved from
block 2 to
current home
Timeline
Non-healing
wound
2008
Diagnosed
w/DM in
Cavite
nocturia
Stroke
Polyphagia, chills
diagnosed w/ DM
2009
Frothy urine,polydypsia,
edema, chest pain
present
Physical Exam
• General: conscious, coherent, NICRD
• Ht:150cm, wt: 94kg, waist-hip ratio: 0.86
• Vital signs:
BP:180/100
HR: 70
RR: 24
Physical Exam
• HEENT: pupils 2-3mm EBRTL, anicteric sclerae, pink
conjunctivae, (-)nasal/ear disharge, (-) CLAD, normal JVP
• Chest: distinct heart sounds, (-) murmurs, PMI at L 5th ICS
• Lungs: equal chest expansion, clear breath sounds,
normal tactile fremiti, resonant on percussion
• Abdomen: (-) lesions, normoactive bowel sounds (+)
tenderness on LUQ, tympanitic on percussion, normal
liver span, intact Traube’s space
• Extremties: (-) cyanosis, (-) clubbing, (+) pitting edema on
L leg, good capillary refill
Physical Exam
• Neurologic exam
CN: intact (CN I not tested)
Sensory: intact
Motor: weakness of left leg