1. Preeti Prerna M. Vaswani
Admitting Conference
Preeti Prerna M. Vaswani

2. General Data F.P. 76 years old Male Married Iglesia ni Cristo
Sampaloc, Manila

3. Chief Complaint
Hypogastric Pain

4. History of Present Illness
Frequency, dysuria, turbid urine
Hypogastric pain
Generalized weakness
Loss of appetite
3 days PTA
Admission

5. Past Medical History Polycythemia Vera - 2004 (+) BPH - 2008
(+) PTB – completed treatment in 2009
(-) DM, HPN, asthma, thyroid disease, allergies
No previous surgery

6. Family History
(-) HPN
(-) DM
(-) Asthma
(-) Cancer

7. Personal and Social History
Smoker – 2.5 pack years
Occasional alcoholic beverage drinker
No illicit drug use

8. Review of Systems General: No weight loss
Skin: No itchiness, no jaundice
Eyes: No blurring of vision, eye pain or itchiness, no excessive lacrimation, no redness
Ear: No deafness, no discharge, no tinnitus
Nose: No epistaxis, discharge
Throat: No sore throat
Mouth: No bleeding gums, no oral sores
Neck: No neck stiffness, no masses
Cardiac: No chest pain, no palpitations
Abdominal: No abdominal pain, no diarrhea, no vomiting
Musculoskeletal: No myalgia, arthralgia
Endo: (-) polyuria, (-) polyphagia, (-) polydipsia; no heat/cold intolerance
Neuro: No seizure, no headache
Psychiatric: no depression

9. Physical Examination
Conscious, coherent, ambulatory, not in cardiorespiratory distress
BP 100/70 mmHg PR 84, regular RR 20 cpm, T 37.0°C
Warm dry skin, no active dermatoses, no jaundice
Pink palpebral conjunctiva, anicteric sclerae

10. Physical Examination
No nasoaural discharge, turbinates not congested, moist buccal mucosa, nonhyperemic posterior pharyngeal wall
Supple neck, (-) palpable cervical lymph nodes, no masses, no tenderness
Symmetrical chest expansion, unimpaired transmission of tactile fremiti, resonant on percussion, clear and equal breath sounds

11. Physical Examination
Adynamic precordium, AB 5th LICS MCL, S1>S2 at apex, S2>S1 at base, no murmurs, no S3 or S4, no heaves, no lifts, no thrills
Flabby abdomen, normoactive bowel sounds, palpable liver edge, liver span 17cm R MCL, palpable spleen, 15cm below subcostal area, 2.5 cm past midline, tenderness on palpation of hypogastric area, no CVA tenderness
DRE: Prostate enlarged, smooth, no nodules
Pulses full and equal, no cyanosis, no clubbing, no edema

12. Neurologic Examination
Awake, alert, follows commands, oriented to person, place, time
Pupils 2-3mm, ERTL, (+) direct and consensual reflex intact, EOMs full and equal, no ptosis, V1V2V3 intact, (+) corneal reflex, can clench teeth can raise eyebrows equally, can close eyes against resistance , can smile, can frown, can puff cheeks, no facial asymmetry, intact gross hearing, can shrug shoulders and can turn head side to side against resistance, (+) gag reflex, tongue midline on protrusion
Motor: 5/5 on both UE and LE; no tremors, no fasciculations, no atrophy
Cerebellar: Can do APST/ FTNT with ease
DTRs ++ on both UE and LE
No sensory deficit
(-) Babinski, (-) nuchal rigidity

13. Assessment Polycythemia Vera Benign Prostatic Hyperplasia
T/c Complicated Urinary Tract Infection

14. Plans CBC Urinalysis Urine culture and sensitivity Ultrasound KUBP
Uric Acid

15. Plans Ciprofloxacin, 500mg/tab, 1 tab BID for 14 days Hydroxyurea
Allopurinol
NaHCO3