SILLIMAN UNIVERSITY MEDICAL SCHOOL

SUBMITTED TO: Dr. Emmanuel Katada

SUBMITTED BY: Cristobal Phylicia ,
Cruz, Bea Celina
de la Pea, Nesil M.
de Leon, Jan Gil
de Los Santos Rosheil Mae,
Ditti, Fatima Al Zahra
Divinagracia, Joshua
DATE SUBMITTED: November 16, 2015
DATE AND TIME OF HISTORY TAKING/PE: November 13, 2015, 5 pm
PLACE OF HISTORY TAKING/PE: Silliman University Medical Center
REPRESENTATIVE CASE
IDENTIFYING DATA:
Source of History: Patient
Reliability: 100%
CHIEF COMPLAINT: Abdominal Pain
HISTORY OF PRESENT ILLNESS:
PAST MEDICAL HISTORY:
Medical History:
Surgical History:
Psychiatric History:
FAMILY HISTORY:
PERSONAL AND SOCIAL HISTORY:
REVIEW OF SYSTEMS
General Survey: No weightloss, loss of appetite, no fever or weakness.
Skin: No rashes and no change in skin color, no lumps
HEENT: No headache and nausea, no seizures, no visual changes, no tinnitus, no vertigo, no hearing loss, absence of nasal discharges and no
hoarseness of voice
Neck: No pain or swollen glands. No lumps, pain or stiffness.
Respiratory: No shortness of breath, no cough, no hemoptysis, no wheezing
Cardiovascular: No dyspnea, no high blood pressure. No orthopnea, no palpitations.
Gastrointestinal: (refer to HPI)
Genitourinary: No oliguria, no dysuria and nocturia, no frequency, no hematuria, no flank pain, no vaginal or pelvic pain, no discharges
Musculoskeletal: No muscle or joint pain, stiffness and back pain
Neurologic: No history of fainting, seizures, motor or sensory loss, good intact memory
Psychiatric: No history of depression, no change of mood
Hematologic: No symptoms of bleeding, absence of bruises
Endocrine: No polyuria and polydipsia, no history of thyroid trouble, no heat or cold intolerance, no excessive sweating
PHYSICAL EXAMINATION
General Survey: Patient in semi-fowlers position, conscious, coherent and not in respiratory distress.
Vital Signs: BP: 150/80 mmHg; PR: 75 bpm; RR: 28 bpm, shallow without use of accessory muscles Temp: 37.9 oC
Skin: Palms are warm and moist. No clubbing and cyanosis. No lesions. Slightly dry. Good skin turgor and mobility. Normal capillary refill rate.
HEENT: No lesions in the scalp, normocephalic. No visual field defects. Pupils equally round and reactive to light and accommodation (PERRLA).
Extraocular movements are intact, anicteric sclera, pink conjunctiva; Fundoscopic exam: (+) orange light reflex; both ear canals are clear
tympanic membrane with good cone of light, hearing acuity good to whispered voice. Nasal mucosa is pink with septum in the midline, no
discharges. No sinus tenderness. Oral mucosa is pink and dentition is good with midline tongue.
Neck: Trachea is midline, no lymphadenopathies
Breasts: Not examined
Pulmonary: Lungs resonant. Breath vesicular with no added sounds. No tenderness palpated.
Cardiovascular: No heaves, lifts, or thrills. Apical impulse at 5th intercostal space MCL. No murmur.
Abdomen: Normal active bowel sound. Not palpated (post-op patient)
DRE: Not examined
Genitalia: Not examined
Extremities: No joint deformities, warm to touch, pitting pedal edema noted. Non-pitting edema on left hand edema (IV site)
CNS:
Mental status: Alert and cooperative. Thought coherent. Oriented to person, place, and time.