General Data:

Mrs. H.J, 79 y/o, Widow, Fil., born in Sampaloc Manila,retired o!"t employee,
#at$olic,cons%lted &or t$e &irst time at '() Hospital
* +eliability: 9,*
#$ie& #omplaint: memory loss
-wo years )-., $er son relates t$at t$e patient /%st $asn"t been t$e same since $er $%sband
died. S$e owns a ba0ery w$ic$ s$e started wit$ $er spo%se. (ow $er son does most o& t$e
/ob. S$e persistently resists acceptin any $elp and s$e ar%es wit$ anyone w$o tries to
$elp $er. Her son $as been noticin $er ba is always &%ll o& bills s$e $as not been
payin. S$e $as been &orettin appointments and o&ten &orets t$e names o& c%stomers
w$o re%larly come to t$eir ba0ery. S$e seems to repeat $ersel&, as0in t$e same 1%estion
o!er and o!er2 3W$at day is it today4 Ha!e 5 eaten l%nc$ already 4Some e!enins s$e
doesn"t bot$er to coo0 or eat dinner. S$e nelects to ta0e a bat$ and c$ane $er clot$in.
S$e was pre!io%sly metic%lo%s o& $er appearance and $yiene. S$e %sed to be !ery
orani6ed especially reardin &inancial matters b%t now $er son does most o& t$e
&inancial manaement o& t$eir b%siness. -$e patient"s son is a&raid s$e mi$t $a!e a
problem wit$ $er memory.
Medications: none
.lleries: 728 &ood/dr%/s0in allery
Smo0in H9: non2smo0er
.lco$ol/Dr% 'se: 728
).S- H5S-:+;
General St ate o& Healt$: )atient percei!es $ersel& as !ery $ealt$y.
#$ild$ood 5llnesses: %nrecalled
.d%lt 5llnesses:
Medical: 728 H9 o& )-<, H)(, #.D, DM, .st$ma, +enal Diseases, cancer
)syc$iatric: 728
S%rey: (o pre!io%s s%rery
:< Gyne: G=)=7=2>2>2=8
F.M5?; H5S-:+;:
728 H)( mot$er
728 #.D, DM, .st$ma, +enal Diseases, cancer
)@+S:(.? A S:#5.? H 5S-:+;
<orn and raised in Manila, Bnis$ed collee , retired o!"t employee. S$e li!es wit$ $er
son. .t $ome, s$e pre&ers to do t$ins on $er own.. Sleeps mostly d%rin t$e day . S$e wa0es %p
at aro%nd C a.m., wal0in aro%nd t$e $o%se or watc$es early -D prorams.
+@D5@W :F S;S-@MS
General. 's%al wei$t ,> 0. 728 recent wei$t c$ane, wea0ness ,&ati%e, &e!er
S0in. (o ras$es or ot$er c$anes.
Head, @yes, @ars, (ose, -$roat 7H@@(-8:
Head:(o $istory o& $ead in/%ry.
@yes:&arsi$ted
@ars: no tinnit%s/ !ertio/ in&ections.
(ose: (o cold $ay &e!er/ sin%s tro%ble.
-$roat: no bleedin o& %ms no soret$roat
(ec0. (o l%mps, oiter, pain. (o swollen lands.
<reasts. (o l%mps, pain, disc$are.
+espiratory. 728 co%$ , no w$ee6in. (o #E+ done pre!io%sly
#ardio!asc%lar. (o 0nown $eart disease or $i$ blood press%reF
last blood press%re last year<)G ==>/7> mmH. 728 dyspnea ,,728 c$est pain, 728 ort$opnea/
palpitations. (o pre!io%s @#G done
Gastrointestinal. .ppetite oodF no na%sea, !omitin, indiestion,bowel mo!ement abo%t once
dailyF no diarr$ea or bleedin. (o pain, /a%ndice, allbladder or li!er problems.
'rinary. (o &re1%ency, dys%ria, $emat%ria, or recent Han0 pain
)erip$eral Dasc%lar. no $istory o& p$lebitis nor le pain.
M%sc%los0eletal. Mild, ac$in, low2bac0 pain, o&ten a&ter a lon sittinF no radiation down
t$e les, relie!ed by lyin down. (o ot$er /oint pain.
(e%roloic. (o &aintin, sei6%res, motor or sensory loss.
Hematoloic. no easy bleedin, no anemia.
@ndocrine. (o 0nown t$yroid tro%ble, temperat%re intolerance. Sweatin a!erae. (o symptoms
or $istory o& diabetes.
)syc$iatric. Denies symptoms s%c$ as depressed mood, mar0edly diminis$ed interest or
pleas%re in all acti!ities o& t$e day, insomnia nor $ypersomnia, &eelins o& wort$lessness,
rec%rrent s%icidal ideationF denies treatment &or psyc$iatric disorders
)H;S5#.? @E.M5(.-5:(
General S%r!ey
Mrs. H.J, medi%m b%ilt, &emale, is pleasant and cooperati!e. S$e tells yo% s$e does not
0now w$y $er son bro%$t $er to see yo%. S$e state s$e &eels &ine and responds 1%ic0ly
to 1%estions. . Her color is ood and s$e lies Hat wit$o%t discom&ort and is not in cardio2
respiratory distress.
Dital Sins.
<)G ==>/7> mmH H+G 79 beats/min. ++ G I>/ breat$s/min. -emperat%re J7.C
o
#.
painG none
S0in. )alms cold and moist, b%t color ood.. (ails wit$o%t cl%bbin, cyanosis.
Head, @yes, @ars, (ose, -$roat 7H@@(-8.
Head: Hair o& a!erae te9t%re. Scalp wit$o%t lesions, normocep$alic/atra%matic
@yes: Dis%al Belds &%ll by con&rontation. #on/%ncti!a pin0F
sclera w$ite. )%pils C mm constrictin to I mm, ro%nd, re%lar, e1%ally, reacti!e to
li$t. @9traoc%lar mo!ements intact.
F%ndoscopy: Disc marins s$arp, wit$o%t $emorr$aes, e9%dates. (o arteriolar
narrowin or .2D nic0in.
@ars: Wa9 partially obsc%res ri$t tympanic membrane 7-M8F le&t canal clear, -M wit$
ood cone o& li$t. .c%ity ood to w$ispered !oice. Weber midline..# K <#.
(ose: M%cosa pin0, sept%m midline. (o sin%s tenderness.
-$roat Mo%t$: :ral m%cosa pin0. Dentition ood.-on%e midline, no lesions -onsils .
(ot conested.)$aryn9 wit$o%t e9%dates.
(ec0. (ec0 s%pple. -rac$ea midline. -$yroid ist$m%s barely palpable, lobes not &elt.
(o cer!ical lymp$adenopat$y
-$ora9 and ?%ns.
wider t$an deep. Symmetric e9pansion,e1%al tactile &remit%s, resonant, clear !esic%lar
breat$ so%nds
#ardio!asc%lar. J%%lar !eno%s press%re = cm abo!e t$e sternal anle, wit$ $ead o& e9aminin
table raised to J>L. #arotid %pstro0es bris0, wit$o%t br%its. .pical imp%lse discrete and
tappin, barely palpable in t$e ,t$ le&t interspace Mcm lateral to t$e midsternal line. Good
S=, SIF no SJ or SC.. (o m%rm%rs.
<reasts.. (o massesF nipples wit$o%t disc$are.
.bdomen.&lat. <owel so%nds normonacti!e.(o tenderness or masses. ?i!er span 7 cm in ri$t
midcla!ic%lar lineF ede smoot$, palpable = cm below ri$t costal marin 7+#M8. Spleen
and 0idneys not &elt. (o costo!ertebral anle tenderness 7#D.-8.
Genitalia. @9ternal enitalia wit$o%t lesions nor disc$are
+ectal. +ectal !a%lt wit$o%t masses.ood sp$incter tone brown stool %pon remo!al o& tactatin
&iner
@9tremities. Warm and wit$o%t edema. #al!es s%pple, nontender.
)erip$eral Dasc%lar. (o edema at bot$ an0les. )%lses 7I N G bris0, or normal8:
+adial Femoral )opliteal Dorsalis )edis )osterior -ibial
+- IN IN IN IN IN
?- IN IN IN NI IN
M%sc%los0eletal. (o /oint de&ormities. Good rane o& motion in $ands, wrists,elbows, s$o%lders,
spine, $ips, 0nees, an0les.
(e%roloic.
Mini2 Mental Stat%s @9am: IJ
#ranial (er!es.5OE55 intact.
Motor: Good m%scle b%l0 and tone. Strent$ ,/, t$ro%$o%t
+apid alternatin mo!ements 7+.Ms8, point2to2point mo!ements intact. Gait
stable, H%id.
Sensory: )inpric0, li$t to%c$, position sense, !ibration, and stereonosis intact.
+omber neati!e.
+eHe9es:
<iceps -riceps <rac$ial )atellar .c$illes )lantar
+- IN IN IN IN N IN 7 28<abins0y
?- IN IN IN IN IN 7 28<abins0y
-$e Mini2Mental Stat%s @9amination
Points
:rientation
(ame: season/date/day/mont$/year J/,
(ame: $ospital/&loor/town/state/co%ntry ,/,
+eistration
5denti&y t$ree ob/ects by name and as0 patient to repeat >/J
.ttention and calc%lation
Serial 7sF s%btract &rom =>> 7e.., 9JOMPO79O7IOP,8 C/,
+ecall
+ecall t$e t$ree ob/ects presented earlier >/J
?an%ae
(ame pencil and watc$ I/I
+epeat Q(o i&s, ands, or b%tsQ =/=
Follow a J2step command 7e.., Q-a0e t$is paper, &old it in $al&, and place it
on t$e tableQ8
J/J
Write Qclose yo%r eyesQ and as0 patient to obey written command =/=
.s0 patient to write a sentence =/=
.s0 patient to copy a desin 7e.., intersectin pentaons8 >/=
Total I>/J>
5.W$at are t$e pertinent data o& t$e case presented 4
55.W$at are t$e pla%sible di&&erential dianoses o& t$e case4
.. W$at is t$e c$ie& complaint or t$e main problem o& t$e patient4
W$at syndromes are associated wit$ t$e c$ie& complaint4 W$at o& t$ese
syndromes does t$e patient present wit$4 J%sti&y yo%r answer.
<. How do yo% approac$ a patient wit$ a s%c$ a complaint4
@stablis$ a Dianostic .pproac$ to be able to de!elop a complete, &ramed
di&&erential dianosis.
555. )rioriti6e yo%r di&&erential dianoses
..W$at is t$e leadin $ypot$esis, w$at are t$e acti!e alternati!es and is t$ere a m%st
not miss dianosis4. J%sti&y yo%r c$oices o& di&&erential dianoses
=. ?eadin Hypot$esis: disease w$ere its typical te9tboo0 presentation is
mani&ested by t$e patient
I. M%st (ot Miss Dianosis: Disease t$at s$o%ld not be missed beca%se
delay in its treatment leads to mortality and morbidity
J. .lternati!e Dianosis: Disease t$at is a common ca%se o& t$e complaint
and it is an easily treatable disease
<. Gi!e t$e salient &eat%res o& eac$ di&&erential dianosis. 7de&inition,
pat$op$ysioloy, epidemioloy, clinical cl%es to its dianosis8
5D. -est yo%r Hypot$esis
W$at dianostic test/s wo%ld con&irm yo%r dianosis4
+e&erences:
Harrison"s )rinciples o& 5nternal Medicine
#ecil -e9tboo0 o& Medicine
<ates G%ide to )$ysical Dianosis
Raplan and Sadoc0"s Synopsis o& )syc$iatry
Goodman Gillman"s )$armacoloic <asis o& -$erape%tics
$ttp://www.bc%idelines.ca/alp$abetical.$tml
$ttp://bestpractice.bm/.com/best2practice/monorap$/7=>/dianosis.$tml