CHAPTER III

CLIENT PRESENTATION
This is the case of patient D.M.G, an eighty-two year-old male, Filipino, and a Roman
Catholic. He currently lives in Paranaque City with his daughter; though, he has a house in
Quezon province. He stands 165 cm tall and weighs 55kg.
The patients relstives stated a past history of Diabetes Mellitus for more than 5 years
with no CBG monitoring and not on Lantus. He also had a history of melena and head trauma
last 2011 or 2012. He has no history of past surgeries. Patient was also noted to have no allergy
to any foods and drugs. Prior to admission, the patient has the following medications: Ferrous
Sulfate, Metformin, and Levocetirizine. Patient is dependent on all his activities of daily living,
assisted by his caregiver. Family history reveals that there was no significant disease noted
within the family.
The caregiver of the client was interviewed for information since the client wasnt able to
answer questions. The patient was reported that he does not smoke, drink, and use drugs. He
graduated on a college in Batangas. He worked at the Air force of the Philippines, as a
bodyguard, and also worked under Marcos in Malacanang as a technician. He was married with
four children, two sons and two daughters.
He was accompanied by his caregiver when he was admitted in a tertiary hospital
in Paranaque City during the first week of February, 2015 due to a chief complaint of
pneumonia. His caregiver was interviewed for data assessing, diagnosing, planning,
implementing and evaluating. According to his caregiver, during first week of February, patient
was admitted for severe cough and fever, managed as a case of pneumonia with levofloxacin
500mg/ tab OD for seven days and co-amoxiclav 625mg/tab three times daily for seven days.
Patient was discharged well and stable. Four days prior to admission in our institution, patient
was noted to be drowsy with decreasing appetite and fever with productive cough with yellowish
sputum. Persistence prompted consult.

The patient is a known diabetic with no prior history of stroke. Premorbid, the patient is
ambulatory with assistance and needs assistance in all activities of daily living. Three months
prior to admission, his caregiver noted that the patient tends to drag his foot when walking. No
consult was done and no medications taken. Since then, it was noted that the patient deteriorated,
became bedridden with very minimal food intake. There were episodes that the patient would
choke on his food and medications. Three weeks prior to admission, the patient was admitted at a
hospital in Paranaque and was managed as a case of pneumonia and started on antibiotics. He
was discharged after 5 days. Since then, the patient remained bedridden with poor intake and
very minimal verbal output. Persistence of above symptoms with persistence of cough and fever
prompted admission at our institution.
Upon admission, vital signs were monitored: Blood Pressure (BP) of 120/80 mmHg,
Respiratory Rate (RR) of 22 cycles per minute, Temperature of 37.2 degrees Celsius, Pulse Rate
(PR) of 86 beats per minute.
Last March 6, 2015, physical assessment was performed and revealed: he is awake,
conscious and comfortable with vital signs of: blood pressure 110/70, pulse rate of 70,
respiratory rate of 22 and temperature of 37.1 degrees celsius. He is bed bound, unable to
ambulate, has right sided weakness and able to move upper extremities and minimally on lower
extremities. His looks and clothes are appropriate for his age. He wasnt able to speak but able to
follow some commands. He had a warm skin, atraumatic head, anicteric sclera, pink palpebral
conjunctiva, briskly reactive 2mm pupil, non-erythematous auditory canal, moist buccal mucosa,
no lymph nodes palpable, with rhonchi on both lungs, symmetrical chest expansion, no chest
retractions, spontaneous and unlabored breathing, adynamic precordium, abdomen soft, nontender and non-distended, full pulses, no peripheral edema, normoactive bowel sounds, no
regurgitation, non-distended bladder. Patient was also noted to be negative of the
following: unusual pigmentation, acne, headache, dizziness, lacrimation, aural discharge, nasal
discharge, epistaxis, toothache, sore throat, orthopnea, cyanosis, fainting, chest pain, diarrhea,
constipation, abdominal pain, jaundice, polyuria, polydipsia, polyphagia, tremors, cold/heat
intolerance, convulsions, and pallor. The client was found to be positive of the following: rashes
on face, chest and gluteal area, visual impairment and hearing difficulties, cough with whitish
sputum, dysphagia, 1x1cm grade 1 sacral bedsore and is on diaper.

On February 24, 2015, the patient was admitted under the service of Dr. M.K. Upon
assessment, the patient was noted to be drowsy, unresponsive, with bibasal rales more on the left,
positive distended neck veins, 5x6 cm grade 1 sacral ulcer, with dry, flaky skin on both left
extremities and had no edema. Since the client wasnt able to swallow, he was inserted with
nasogastric tube with an osteorized feeding of 2000kcal/day divided into 6 equal feedings. He
was started on IVF plain NSS to run at 60ml/hour then was adjusted for 40ml/hour. For
diagnostics, he was prescribed: sputum gram stain culture and sensitivity, chest X-ray(portable),
CBC, serum Sodium, Potassium, Creatinine, BUN, CBG, 12-lead ECG, urinalysis, blood culture
and sensitivity and Arterial Blood Gas. For the arterial blood gas, the client had a PH of 7.46,
pCO2 of 35mmhg, HCO3 of 24.9 mmol/L PO2 of 85 and an oxygen saturation of 97%. He had a
low serum sodium of 124.7 mmol/L, Potassium of 3.8mmol/L, BUN of13.46mg/dl, Creatinine of
0.95mg/dl and a CBG of 134mg/dl. Due to low Sodium, the client was diagnosed with
hyponatremia. For the complete blood count, he had low hemoglobin of 11.3g/ dl, low
hematocrit of 34%, low RBC of 3.57x10^6/ uL, high white blood cells of 13.4x10^3/uL, high
segmenters of 90% and low lymphocytes of 6%. For the 12-lead electrocardiogram, the client
had a PR interval of 122ms, QRS duration of 86 ms, QT interval of 346ms and an OT dispersion
of 100ms. For the chest x-ray, left pericardial infiltrates were seen. For the sputum gram stain
culture and sensitivity, the result was an occasional gram (+) cocci in pairs, rare gram (+) bacilli
and rare gram (-) rods. Pus cells was 25-30/ LPF and epithelial cells was 6-8/LPF. Thus, the
client was diagnosed with community acquired pneumonia. The client was prescribed with
medications of Piperacillin-Tazobactam 45 grams per intravenous every eight hours, Paracetamol
300mg per intravenous every 4 hours as needed for fever of 37.8 degrees Celsius and
above, Acetylcysteine 600mg/ tablet once a day at bedtime per NGT dissolve in a half glass of
water, Azithromycin 500mg per intravenous once a day and Salbutamol + Ipratropium
nebulization every eight hours as needed for difficulty of breathing. He was referred for chest
physiotherapy two times a day, care of pulmonary lab. The client was suctioned for secretions
using oral airway and was positioned on high back rest. He was on bedsore precaution; therefore,
he was provided turning schedule and Calmoseptine cream was applied every diaper change.
On February 25, 2015, the client was drowsy, with productive cough of whitish sputum,
with bibasal rales, with distended neck veins, with 5x6 cm grade 1 pressure ulcer, with dry and
flaky skin on both lower extremities, and no edema. He was diagnosed with pneumonia,

malnutrition, dehydration, and to consider CVA with deficits. MRI of the brain with MRA with
contrast was prescribed. Intravenous fluid of plain NSS was maintained at 40ml/hr. Salbutamol
per nebulization, 1 nebule every eight hours was started while Combivent was discontinued.
Silver Sulfadiazine (Flammazine) cream and zinc oxide Calmoseptine cream two times a day
was applied to decrease pressure ulcer. Donepezil (dricept) 5 mg/tab, 1 tablet once a day at
bedtime per NGT and Levodopa/ carbidopa 25/100 gram per 1 tablet, one half tablet two times a
day per NGT was started. Chest physiotherapy was done and was able to suction oral secretions.
On February 26, 2015, the client was easily arousable, has grumpy voice, has good grip
bilaterally, moves right leg spontaneously, follows commands, noted weakness on right upper
and lower extremities, has bilateral rhonchi, with productive cough of whitish sputum, has pupils
of 3mm briskly reactive to light, primary gaze was midline, has brisk bilateral corneal, no facial
asymmetry, with gross hearing intact, with normoflexive deep tendon reflex and no babinski
reflex. Chest physiotherapy was not done. Intravenous fluid of plain NSS was maintained at 40
ml/hour. Citicoline 1gram per tablet, 1 tablet once a day per NGT and Atorvastatin 40 mg per
tablet, one tablet daily at bedtime was started. Sputum AFB smear was done with no acid fast
bacilli seen. MRI /MRA of the brain with contrast was done with a conclusion of acute infarct,
right high parietal subcortical with chronic infarcts in both centrum semiovale, left thalamus and
right cerebellum, and metabolic encephalopathy secondary to hyponatremia. The client was
scheduled for lumbar tap and see if there is improvement.
On February 27, 2015, the client was not in distress, with noisy breathing, snores loudly,
was able to follow commands, was able to lift both upper extremities spontaneously, with pupils
of 2mm briskly reactive to light, with bibasal rhonchi, and with productive cough of whitish
sputum. Intravenous fluid of plain NSS was maintained at 40ml/ hour. The patient self-removed
NGT and was able to reinsert. Sputum AFB smear was done with no acid fast bacilli seen. Chest
physiotherapy was done. Consent for lumbar tap was pending.
On February 28, 2015, the client has rashes on face, with productive cough of copious
whitish sputum, no fever, not dyspneic, follows some commands, with rales on both lungs, with
grade 2 sacral ulcer positive of fresh blood. Chest physiotherapy was not done. Lung flute was
prescribed but cannot be done since client cannot cooperate. Consent for lumbar tap was still

pending so purpose of lumbar tap was explained again to relatives. Azithromycin dose was
completed, nine of three doses was given. Theophylline 250 grams per tablet once daily to be
given in the morning was started.
On March 1, 2015, the client was oriented to person, has minimal verbal output, follows
commands, has productive cough of whitish sputum and has bibasal rales. Chest physiotherapy
was done. The client was referred to rehab. Complete blood count was done with a result of low
hemoglobin (10.2g/dl), low hematocrit (24.4%), low red blood cells (3.33x10^6/uL) and low
lymphocytes (13%) while the segmenters (72%) and monocytes (12%) were high. Clinical
chemistry was also done with a result of low Sodium of 132mmol/L. Consent for lumbar tap was
signed so lumbar tap was done on the client, obtaining free- flowing cerebrospinal fluid. IgG in
CSF was 59mg/dl which is high from normal. CSF protein (45.4mg/dl) and glucose
(85.2mmol/L) were also found to be high from the normal range. After the procedure, the client
was placed flat on bed and on NPO for 6 hours. Intravenous fluid of plain NSS was maintained
for 20ml/ hour.
On March 2, 2015, the client was asleep but arousable to tactile stimuli, with minimal
verbal output and follows some voice commands. He has pupils at 2mm both reactive, with
sacral pressure ulcer and dysphagia, with occasional bibasal rales, with productive cough of
copious whitish phlegm, no signs of deep vein thrombosis, and all extremities withdraw to pain
with left upper extremity moves spontaneously than the right. He was claimed to be more alert
by relatives. Glycosylated hemoglobin was taken with HbA1c % of 5.8 and HbA1c # of 39.00
and estimated glucose of 118.70 mg/dl. Capillary blood glucose monitoring was discontinued.
Piperacillin-tazobactam per intravenous with 18 doses given for seven days was completed. Coamoxiclav 475mg/5ml 10ml per NGT three times a day, Nystatin 10ml three times a day per oral
swab, Clopidogrel 75mg/tablet, 1tablet once a day per NGT and Budosenide 500mg per ampule
via nebulization every 12 hours was started. Intravenous access was shifted to heplock with
intravenous fluid of plain NSS to consume. The client is for physical therapy, speech therapy and
chest physiotherapy today. The client was treated at bedside for physical therapy and was
examined to have 3-4/5 gross muscle grade on major muscles of both upper and lower
extremities.

On March 3, 2015, the client was awake and comfortable. He was examined with stable
vital signs, bilateral rales, with productive cough of whitish sputum, regular cardiac rhythm and
non-tender abdomen, and was able to follow simple commands with unintelligible words.
Intravenous fluid of plain NSS at 20ml per hour was maintained. Levodopa/ Carbidopa dosage
was increased to 25/100 per tablet; 1 tablet two times a day per nasogastric tube. Chest
physiotherapy was done on client. He was treated at bedside for physical therapy and was able to
tolerate nine minutes of sitting with dangling legs. He was referred to physical therapy for
conditioning exercises and stroke management. The client was also seen for speech and language
therapy. He was alert and cooperative with good pursing and puckering of lips, good tongue
mobility, good comprehension, with good fluency and was able to tolerate swallowing 3
tablespoon of thickened water without aspiration.
On March 4, 2015, the client was more awake and spontaneously moves all extremities,
nods to questions, able to follow commands, able to lift each extremity, has spasticity on passive
range of motion of extremities, has rhonchi on both lungs, and with productive cough of whitish
phlegm. The client was placed on a two point restraint with consent signed since he was able to
remove nasogastric tube two times. Clorhexidine oral solution by swab two times a day was
started. Chest physiotherapy and physical therapy was done. The client was able to tolerate
sitting on bedside chair and was able to tolerate swallowing three tablespoons of pureed mango
and thickened fluid with no aspiration.
On March 5, 2015, the client was asleep, arousable to verbal and tactile stimulation,
moves extremities minimally on command, with productive cough of blood tinged whitish
phlegm, and bilateral rhonchi. He has revised sleeping pattern wherein he is awake at night and
asleep in the morning. Theophylline and --------- was discontinued. Chest physiotherapy was
done. The client may have gelatin and oatmeal/porridge per orem with strict aspiration
precaution. He was brought down to the rehab gym for physical therapy.
On March 6, 2015, the client was able to open eyes to verbal and tactile stimulation,
follows some commands, lift upper extremity and minimally for both lower extremities, and
tolerate transfer to bedside chair. He has productive cough of whitish sputum, bilateral rhonchi,
and no dyspnea. Chest physiotherapy was done. The client was brought down to rehab gym for

physical therapy. Trial feeding was discontinued. Modified barium swallow was prescribed to
rule out aspiration. Co-amoxiclav and nystatin doses for five days were completed.