West Visayas State University College of MedicineDepartment of
Family and Community MedicineClinical Clerkship Community
Rotation
Rotation: Census Date: CC Alonsabe/ CC Araneta/ CC Atotubo/CC
AguilarPatientAgeSexAssessmentImpressionManagement
What was done?What should have been done?
Name: Donguines, LeahAddress: Dumangas, IloiloBirthday:
10-21-74Clerk in Charge:CC Atotubo41FChief Complaint:Generalized
skin rash, pruriticHPI: 2 days PTC, patient developed generalized
pruritic rash while working in the field. Pruritus was noted to be
aggravated by perspiration. Patient applied cassava starch to the
affected areas with relief of pruritus. Patient scratched the area
with breaks in the skin.DOC, lesions and pruritus persistedPMH: (-)
previous hospitalizations(-) FDA, BA, HTN, DMFHx:
unremarkablePSHx:NANS, farmerPhysical Exam:Anicteric sclera,
pinkish conjunctiva, NCLAD, NNVESymmetrical chest expansion, clear
breath sounds, adynamic precordium, normal cardiac rate and rhythm,
soft nontender abdomen(+) hyperpigemented lesions, generalized(-)
redness, pruritus(+) signs of healingAtopic DermatitisLoratadine 10
mg/tab, 1 tab OD x 7 days
Prednisone 20 mg/tab, 1 tab BID x 5 days
Health education done
Advised Hydrocortisone ointment 1% Use 1% ointment 2-3 times
daily.
Loratadine 10 mg/tab, 1 tab OD x 7 days
Health education and hypoallergenic diet
Maintain hygiene
Name: Dumancas, Reynaldo Jr.Address: Dujmangas, IloiloBirthday:
05-27-77Clerk in Charge:CC Atotubo38MChief Complaint:Skin lesions
on the neck, chest and back, pruriticHPI: 1 year PTC, onset of
popular lesion, nontender, erythematous, pruritic when exposed to
perspiration.7 months PTC, increase in the number of lesions in the
neck and back. Other lesions appear nodular and abscess formation
was noted.PMH: (+) Gouty Arthritis; takes Colchicine and
PrednisoneFHx: unremarkablePSHx:2 pack year smoker, stopped 3
months agoOccasional alcoholic drinker, stopped 2 years
agoDriverPhysical Exam:Anicteric sclera, pinkish conjunctiva,
NCLAD, NNVESymmetrical chest expansion, clear breath sounds,
adynamic precordium, normal cardiac rate and rhythm, soft nontender
abdomen(+) papulonodular lesion in the neck and back(+) abscess and
pustules in the back(+) hyperpigmented areas and scarring in the
neck and backSoft tissue infectionCloxacillin 50 mg/tab, 1 tab QID
x 7 days
For referral to Department of Surgery
Laboratory and diagnostic tests: CBC, FBS, Se. Uric Acid,
Urinalysis, Fecalysis
AdvisedCloxacillin 50 mg/tab, 1 tab QID x 7 days
Incision and drainage of abscess
Daily wound dressing
Laboratory and diagnostic tests: CBC, FBS, Se. Uric Acid
Name: Gayas, LanceAddress: New Lucena, IloiloBirthday:
01-20-15Clerk in Charge:CC Atotubo6 monthsMChief Complaint:White
patches on the buccal area x 3 daysSkin rash in the back area x 1
weekDiaper rashHPI: 1 week PTC, development of maculopapular rash
at the back with scaling and dryness noted. No management was
done.3 days PTC, development of whitish plaques in the buccal
mucosa.1 day PTC, development of maculopapular rash in the
buttocksPMH: No previous admissions(-) FDA, BAFHx:
UnremarkablePSHx:Exclusively breastfed up to 6 monthsStarted solid
food 3 days agoImmunizations up to dateDevelopment at par with
agePhysical Exam:Active, good cry, good suck, Anicteric sclera,
pinkish conjunctiva, NCLAD, NNVESymmetrical chest expansion, clear
breath sounds, adynamic precordium, normal cardiac rate and rhythm,
soft nontender abdomen(+) white plaques in the buccal mucosa(+)
maculopapular rash in the back and buttocksOral thrushAtopic
dermatitisNystatin Oral Suspension1 mL QID x 10 days
Hydrocortisone 1% cream, apply once a dayHydrocortisone ointment
1% Use 1% ointment 2-3 times daily.
Nystatin Oral Suspension1 mL QID x 10 days
Advise hypoallergenic diet
To come back anytime if with problems
Name: Madoginog, SamanthaAddress: Maasin, IloiloBirthday:
1-21-13Clerk in Charge:CC Atotubo2FChief Complaint:Skin lesion in
the nose, chin and waistHPI: 1 week PTC, Patient experienced cough,
productive with post tussive vomiting. They consulted PP and was
prescribed with Co-Amoxiclav and Prednisone for 7 days. Cough
resolved and when medications were completed, onset of apthuous
lesions in the tongue appeared.3 days PTC, lesion in the nose and
chin appeared. Folks applied calamine on affected area. Cough
returned, productive with whitish phlegm.PMH: (-) previous
hospitalizations(+) BA, last attack- 7-15-15FHx: (+) BA, HTN, DM,
CA (lung)(+) TB exposurePSHx:Acive, good family and peer relations,
development at par with age, no exposure to smoking, complete
immunizations, exclusive breastfeeding for the first weeks and
mixed feeding thereafterPhysical Exam:Anicteric sclera, pinkish
conjunctiva, NCLAD, NNVESymmetrical chest expansion, clear breath
sounds, adynamic precordium, normal cardiac rate and rhythm, soft
nontender abdomen(+) multiple lesions and scarring in the
extremities(+) apthuous lesions in the tongue(+) oneycomb lesion in
the chin and nose, crusting notedPCAP BImpetigoCefaclor 250mg/5mL,
3 mL BID x 7 days
Cetirizine 5mg/5mL, 3 mL BID x 5 days
Mupirocin ointment, apply TID
Hypoallergenic diet
AdvisedCefaclor 250mg/5mL, 3 mL BID x 7 days
Cetirizine 5mg/5mL, 3 mL BID x 5 days
Mupirocin ointment, apply TID
Hypoallergenic diet
Advised
Name: Suniega, KristineAddress: Cabatuan, IloiloBirthday:
10-04-04Clerk in Charge:CC Atotubo10FChief Complaint:Skin lesions
in the upper extremitiesHPI: 2 days PTC, patient developed
vesicular lesions, pruritic and spread gradually. Folks applied
antifungal ointment with relief. Lesions developed and became
pustular.DOC, persistence of lesions with increased amount of
pustules.PMH: (+) Skin AsthmaPrevious skin infection treated with
Cloxacillin and Cotrimazole cream, relieved (Nov 2014)FHx: (+) HTN,
DM, BAPSHx:NANS, no exposure to smokePhysical Exam:Anicteric
sclera, pinkish conjunctiva, NCLAD, NNVESymmetrical chest
expansion, clear breath sounds, adynamic precordium, normal cardiac
rate and rhythm, soft nontender abdomen(+) pustular lesion at the
right arm(+) abscess formationAtopic Dermatitis with secondary
Bacterial InfectionAdvised admission but mother refused; risks and
consequences explained.
Co-Amoxiclav 400mg/5mL, 5mL TID x 7 days
Cetirizine 5 mg/5mL, 5mL BID
Mupirocin ointment, apply TID
Hypoallergenic diet
Follow up on Monday, July 27, 2015
AdvisedAdvised admission but mother refused; risks and
consequences explained.
Co-Amoxiclav 400mg/5mL, 5mL TID x 7 days
Cetirizine 5 mg/5mL, 5mL BID
Mupirocin ointment, apply TID
Hypoallergenic diet
Follow up on Monday, July 27, 2015
Advised
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