Blood Red Karl Bolintiam Bianca Cruz Clifford De la Cruz Francine Lu Harmony Que

General Data NameSan Jose, Tagumpay Sr. Soriano Age and Sex56/M Date of BirthOct 23, 1955 Marital StatusMarried

Chief Complaint Epistaxis

History of Present Illness

250 ml =

Review of Systems General. No fever, has been losing weight and feels weak. Skin. No rashes or other changes. Head, Ears, Nose, Throat. No history of head injury. Ears: No difficulty in hearing, no tinnitus, no vertigo. Throat: no gum bleeding, no reported dental pains or problems. Neck. No swollen glands. Respiratory. Has occasional cough, No wheezing, dyspnea. Cardiovascular. No chest pain, syncope, or orthopnea. Gastrointestinal. No dysphagia, heartburn. No pain, jaundice, gallbladder or liver problems. Urinary. No hematauria, flank pain, difficulty urinating. Genital. No penile infections. Peripheral Vascular. No edema. Musculoskeletal. No muscle pain, joint pain, nape pain. No joint swelling. Neurologic. No seizures. No motor or sensory loss. Hematologic. No easy bleeding. No anemia. Endocrine. No symptoms and history of diabetes.

Past Medical History (+) Pneumonia 2010 (-) Hypertension (-) DM (-) History of TB (-) Asthma (-) Allergies

Family History (+) DM

Personal Social 10 pack year smoker Occasional alcoholic beverage drinker Worked as a driver (private) but felt that he is becoming unhealthy, has been losing weight, occasional coughing and weakness therefore the patient quit 2009

Physical Exam Patient is stable (vitals) Decreased breath sounds on the right Have wheezes all over

Impression PTB Benign anterior epistaxis, Bilateral, Inactive (ENT diagnosis also)

Pathophysiology

Differentials Community Acquired Pneumonia Rule InRule Out

Differentials Esophageal varices Rule InRule Out

Differentials COPD Rule InRule Out

Differentials Pulmonary Mass Rule InRule Out

Differentials Blood dyscrasia Rule InRule Out

ED Plan of Management Plain NSS O2 via nasal canula Tranexamic Acid Ice chips ENT: NaCl Nasal Spray (Salinase) and Petroleum Jelly both nostrils 2x a day Patient is for standby intubation

Diagnostics CBC, Na, K, Crea, PT, APTT, PBS, CXR, RL-ECG, fiber-optic bronchoscopy, urinalysis, sputum AFB, sputum GS ICS This is what is written on chart

Chest Xray findings Pneumonia with probable atelectasis on the right postero-lateral segment Degenerative osseous changes in thoracic spine