You are on page 1of 12

IDENTIFYING DATA: Jenny Omisol, 44 years old, Female, Married, Roman Catholic, residing in Dalipuga, Iligan City.

Admitted for the first time at Mindanao Sanitarium and Hospital last January 23, 2012. INFORMANT: Patient RELIABILITY: 95 percent CHIEF COMPLAINT: pain on the left flank of the abdomen HISTORY OF PRESENT ILLNESS: One month prior to admission, patient experienced non-radiating stabbing pain on the left flank of the abdomen. She also experienced intermittent high grade fever. Patient sought consult to a physician and was diagnosed with nephrolithiasis. Four days prior to admission, patients symptoms persisted and she was advised by her physician for a surgery for removal of the stone thus this admission. PAST MEDICAL HISTORY: Last November 2011, Patient was admitted in Mindanao Sanitarium and Hospital and was diagnosed with Nephrolithiasis. She was given medication but did not provide relief. FAMILY HISTORY: No heredofamilial diseases as claimed by the patient such as asthma, hypertension, diabetes, and cancers. PSYCHOSOCIAL HISTORY:

REVIEW OF SYSTEMS GENERAL: (-) weight loss, (-) fever, SKIN: (-) pruritus, (-) bruising HEAD: (-) headache EYES: (-) change in visual field, (-) blurring, (-) excessive tearing EARS: (-) tinnitus, (-) discharge NOSE: (-) epistaxis, (-) discharge THROAT: (-) difficulty swallowing, (-) hoarseness RESPIRATORY: (-) chest pain, (-) cough, (-) dyspnea CARDIOVASCULAR: (-) chest pain and tightness GASTROINTESTINAL: (-) diarrhea GENITOURINARY: (-) urgency, (-) hematuria ENDOCRINE: (-) heat and cold intolerance, (-) polyuria MUSCULOSKELETAL: (-) joint pain, (-) muscle weakness PSYCHIATRIC: (-) anxiety

PHYSICAL EXAMINATION GENERAL SURVEY: respiratory distress VITAL SIGNS: BP: 100/60 mmHg PR: 81bpm RR: 21bpm T: 36.50 C H: 55 W: 80 kg well-developed, well-nourished, ambulatory, coherent, oriented, and not in

SKIN: warm to touch, good skin turgor, no lesions and rashes HEAD: normocephalic, no lumps EYES: pinkish conjunctivae, anicteric sclerae, pupils equally reactive to light and accommodation EARS: no discharges and tenderness NOSE AND SINUSES: nasal septum midline, no discharges and congestion, no flaring of the alae nasi MOUTH AND THROAT: moist oral mucosa NECK: supple, no lymphadenopathy and neck vein engorgement BREAST: no lumps, no nipple discharge CHEST AND LUNGS: Inspection: equal chest expansion, no retractions Palpation: equal tactile fremitus Percussion: resonant lung fields Auscultation: bronchovesicular breath sounds HEART: Inspection: PMI is at the 5th intercostal space left midclavicular line Palpation: no heaves, no thrills Percussion: Cardiac Area of Dullness not enlarged Auscultation: regular rhythm, no murmurs ABDOMEN: Inspection: slightly globular, no scars Auscultation: normoactive bowel sounds Percussion: tympanitic Palpation: no rigidity, no organomegaly, tenderness on the left lower quadrant, positive left costovertebral angle tenderness

EXTREMITIES: strong equal palpable peripheral pulses, no edema

PRIMARY IMPRESSION: Nephrolithiasis

DIFFERENTIAL DIAGNOSIS: 1.) Urinary Tract Infection The symptoms of UTI are primarily dysuria with accompanying urinary urgency and frequency. A sensation of bladder fullness or lower abdominal discomfort is often present. The patient may present with fever, flank pain and costoverterbral angle tenderness. 2.) Diverticulitis The clinical presentation of diverticulitis depends on the location of the affected diverticulum, the severity of the inflammatory process, and the presence of complications. Left lower quadrant pain is the most common presenting complaint. Patient may also present with fever.

PROGRESS NOTES: January 24, 2012 / 6:00 AM S: (+) left flank pain (-) fever (-) hematuria O: conscious, coherent, not in respiratory distress HEENT: anicteric sclerae, pinkish conjuctivae Chest/Lungs: clear breath sounds Heart: regular rhythm, no murmurs Abdomen: flabbing Extremities: equal strong palpable peripheral pulses A: Neprolithiasis P: D5LR 1L at 30 gtts/min Tramadol 50mg q 8hrs PRN for pain

IDENTIFYING DATA: Kent Nillama, 13 years old, Male, grade 5 student, Roman Catholic, presently residing in Kolambugan, Lanao del Norte. Admitted for the first time at Mindanao Sanitarium and Hospital last January 23, 2012. INFORMANT: Mother RELIABILITY: 95 percent CHIEF COMPLAINT: pain and swelling on the left forearm HISTORY OF PRESENT ILLNESS: Four hours prior to admission, Patient was playing basketball together with his friends. And while playing, He accidentally fell with his hands outstretched first on the ground. His forearm becomes painful, especially if he moves it, which prompted the mother of the patient for admission. PAST MEDICAL HISTORY: No previous chronic illnesses and hospitalizations. FAMILY HISTORY: No heredofamilial diseases as claimed by the patient such as asthma, hypertension, diabetes, and cancers.

PSYCHOSOCIAL HISTORY: Patient is the youngest of nine siblings. His mother, Minda, 54 years old, is a plain housewife. His father, 54 years old, works as an overseas worker. He is a grade 5 student at Kolambugan, Lanao del Norte.

REVIEW OF SYSTEMS GENERAL: (-) weight loss, (-) fever, SKIN: (-) pruritus, (-) bruising HEAD: (-) headache EYES: (-) change in visual field, (-) blurring, (-) excessive tearing EARS: (-) tinnitus, (-) discharge NOSE: (-) epistaxis, (-) discharge THROAT: (-) difficulty swallowing, (-) hoarseness RESPIRATORY: (-) chest pain, (-) cough, (-) dyspnea CARDIOVASCULAR: (-) chest pain and tightness GASTROINTESTINAL: (-) diarrhea GENITOURINARY: (-) urgency, (-) hematuria ENDOCRINE: (-) heat and cold intolerance, (-) polyuria MUSCULOSKELETAL: (+) pain and swelling in the left forearm, (-) muscle weakness

PSYCHIATRIC: (-) anxiety PHYSICAL EXAMINATION GENERAL SURVEY: respiratory distress VITAL SIGNS: BP: 110/80 mmHg PR: 98/min RR: 22/min T: 37.8 degrees Centigrade H: W: 44.5 kg well-developed, well-nourished, ambulatory, coherent, oriented, and not in

SKIN: warm to touch, good skin turgor, no lesions and rashes HEAD: normocephalic, no lumps EYES: pinkish conjunctivae, anicteric sclerae, pupils equally reactive to light and accommodation EARS: no discharges and tenderness NOSE AND SINUSES: nasal septum midline, no discharges and congestion, no flaring of the alae nasi MOUTH AND THROAT: moist oral mucosa NECK: supple, no lymphadenopathy and neck vein engorgement CHEST AND LUNGS: Inspection: equal chest expansion, no retractions Palpation: equal tactile fremitus Percussion: resonant lung fields Auscultation: bronchovesicular breath sounds HEART: Inspection: PMI is at the 4th intercostal space left midclavicular line Palpation: no heaves, no thrills Percussion: Cardiac Area of Dullness not enlarged Auscultation: regular rhythm, no murmurs ABDOMEN: Inspection: slightly globular, no scars Auscultation: normoactive bowel sounds Percussion: no abnormal areas of tympany and dullness Palpation: no rigidity, no organomegaly

EXTREMITIES: strong equal palpable peripheral pulses, no edema, there is swelling on the left forearm, erythematous and tender to touch

PRIMARY IMPRESSION: Fracture on the distal third of the Left forearm DIFFERENTIAL DIAGNOSIS: 1.) Galeazzi Fracture Dislocation is an injury pattern involving a radial shaft fracture with associated dislocation of the distal radioulnar joint (DRUJ); the injury disrupts the forearm axis joint which is thought to be caused by a fall that causes an axial load to be placed on a hyperpronated forearm. Pain and soft-tissue swelling are present at the distal-third radial fracture site and at the wrist joint. This injury is confirmed on radiographic evaluation. 2.) Monteggia Fracture Dislocation is a dislocation of the proximal radioulnar joint in association with a forearm fracture. These injuries are relatively uncommon, accounting for less than 5% of all forearm fractures. Monteggia fractures are primarily associated with falls on an outstretched hand with forced pronation. Patients present with elbow pain with swelling, deformity, crepitus and paresthesia or numbness. 3.) Colles Fracture is a fracture of the distal radius in the forearm with dorsal displacement of the wrist and hand. The fracture is sometimes referred to as a dinner fork or bayonet deformity due to the shape of the resultant forearm. Symptoms of a broken wrist includes pain especially when flexing the wrist, tenderness, swelling, bruising, and deformity of the wrist causing it to look crooked and bent.

PROGRESS NOTES:

IDENTIFYING DATA: Virginia B. Sasam, 57 years old, Female, Roman Catholic, residing in Buru-un, Iligan City. Admitted for the first time in GTLMH last January 28, 2012 at 3:30 PM. INFORMANT: Patient RELIABILITY: 95% CHIEF COMPLAINT: fracture of the left leg HISTORY OF PRESENT ILLNESS: NOI: allegedly fell from a motorcycle (passenger) POI: Buru-un, Iligan City DOI: January 29, 2012 TOI: 10:45 AM PAST MEDICAL HISTORY: No previous chronic illnesses or hospitalizations. FAMILY HISTORY: Patients father had Hypertension. No other heredofamilial diseases as claimed by the patient such as Diabetes, Asthma, Arthritis, Tuberculosis, Heart disease, and Cancers. PSYCHOSOCIAL HISTORY: Patient is married to Claudio Sasam, 62 years old, who is a retired NPC operator. She sells Filipino delicacies like puto and cochinta as a source of income. She have four children, namely: Jujie, 33 yo, Clyde, 31 yo, Kimi, 26 yo, and Claudio, Jr., 24 yo. Patient does not smoke cigarette nor drink alcoholic beverages.

REVIEW OF SYSTEMS GENERAL: (-) weight loss, (-) fever, SKIN: (-) pruritus, (-) bruising HEAD: (-) headache EYES: (-) change in visual field, (-) blurring, (-) excessive tearing EARS: (-) tinnitus, (-) discharge NOSE: (-) epistaxis, (-) discharge THROAT: (-) difficulty swallowing, (-) hoarseness RESPIRATORY: (-) chest pain, (-) cough, (-) dyspnea CARDIOVASCULAR: (-) chest pain and tightness GASTROINTESTINAL: (-) diarrhea GENITOURINARY: (-) urgency, (-) hematuria ENDOCRINE: (-) heat and cold intolerance, (-) polyuria MUSCULOSKELETAL: (-) muscle weakness

PSYCHIATRIC: (-) anxiety PHYSICAL EXAMINATION GENERAL SURVEY: respiratory distress VITAL SIGNS: BP: 160/90 mmHg PR: 88 bpm RR: 19 bpm T: 36.3 degrees Centigrade H: W: Patient is well-developed, well-nourished, conscious, coherent, and not in

SKIN: warm to touch, good skin turgor, with multiple abrasions on the left leg HEAD: normocephalic, no lumps or masses, there is an abrasion wound at the left maxillary area 2cm x 2cm EYES: pinkish conjunctivae, anicteric sclerae, pupils equally reactive to light and accommodation EARS: no discharges and tenderness NOSE AND SINUSES: nasal septum midline, no discharges and congestion, no flaring of the alae nasi MOUTH AND THROAT: moist oral mucosa, no cyanosis NECK: supple, no lymphadenopathy and neck vein engorgement CHEST AND LUNGS: Inspection: equal chest expansion, no retractions Palpation: equal tactile fremitus Percussion: resonant lung fields Auscultation: clear breath sounds HEART: Inspection: PMI is at the 5th intercostal space left midclavicular line Palpation: no heaves, no thrills Percussion: Cardiac Area of Dullness not enlarged Auscultation: regular rhythm, no murmurs ABDOMEN: Inspection: flat, no scars Auscultation: normoactive bowel sounds Percussion: no abnormal areas of tympany and dullness Palpation: soft, nontender, no rigidity, no organomegaly EXTREMITIES: strong equal palpable peripheral pulses, no edema

abrasion wound at the medial proximal third of the forearm 5cm x 2cm multiple abrasions at the lateral aspect of the palmar area 1cm 2cm

IMPRESSION: TREATMENT PLAN: PROGRESS NOTES:

IDENTIFYING DATA: Reynaldo Roxas, 69 years old, Male, widower, Iglesia Ni Cristo, residing in Barangay Poblacion, Iligan City. Admitted for the first time in GTLMH last January 29, 2012 at 8:30 in the morning. INFORMANT: Patient RELIABILITY: 95% CHIEF COMPLAINT: mass at the left occipital area of the head HISTORY OF PRESENT ILLNESS: Eight years prior to admission, patient noted a growing mass on his left occipital area. The mass is soft and nontender, with no accompanying symptoms felt by the patient. Patient decided to have the mass removed because it becomes inconvenient for him when he wears his helmet, thus prompting him for admission. PAST MEDICAL HISTORY: No previous chronic illnesses and hospitalizations. FAMILY HISTORY: Patients father was Hypertensive and has Arthritis. There are no other heredofamilial diseases as claimed by the patient such as Diabetes, Tuberculosis, Asthma, Heart disease, Kidney disease, and Cancers. PSYCHOSOCIAL HISTORY: Patient is a retired government employee. REVIEW OF SYSTEMS GENERAL: (-) weight loss, (-) fever, SKIN: (-) pruritus, (-) bruising HEAD: (-) headache EYES: (-) change in visual field, (-) blurring, (-) excessive tearing EARS: (-) tinnitus, (-) discharge NOSE: (-) epistaxis, (-) discharge THROAT: (-) difficulty swallowing, (-) hoarseness RESPIRATORY: (-) chest pain, (-) cough, (-) dyspnea CARDIOVASCULAR: (-) chest pain and tightness GASTROINTESTINAL: (-) diarrhea GENITOURINARY: (-) urgency, (-) hematuria ENDOCRINE: (-) heat and cold intolerance, (-) polyuria MUSCULOSKELETAL: (-) muscle weakness PSYCHIATRIC: (-) anxiety

PHYSICAL EXAMINATION GENERAL SURVEY: respiratory distress VITAL SIGNS: BP: 160/90 mmHg PR: 85/min RR: 20/min SKIN: warm to touch, good skin turgor HEAD: normocephalic, noted a soft mass at the occipital area of the head about 5cm x 3 cm x 4cm EYES: pinkish conjunctivae, anicteric sclerae, pupils equally reactive to light and accommodation EARS: no discharges and tenderness NOSE AND SINUSES: nasal septum midline, no discharges and congestion, no flaring of the alae nasi MOUTH AND THROAT: moist oral mucosa, no cyanosis NECK: supple, no lymphadenopathy and neck vein engorgement CHEST AND LUNGS: Inspection: equal chest expansion, no retractions Palpation: equal tactile fremitus Percussion: resonant lung fields Auscultation: bronchovesicular breath sounds, fine crackles on the left lower lobe HEART: Inspection: PMI is at the 5th intercostal space left midclavicular line Palpation: no heaves, no thrills Percussion: Cardiac Area of Dullness not enlarged Auscultation: regular rhythm, no murmurs ABDOMEN: Inspection: slightly globular, no scars Auscultation: normoactive bowel sounds Percussion: no abnormal areas of tympany and dullness Palpation: soft, flabby, nontender, no rigidity, no organomegaly EXTREMITIES: strong equal palpable peripheral pulses, no edema T: 37.2 degrees Centigrade H: W: 98.9 kg well-developed, well-nourished, ambulatory, coherent, oriented, and not in

IMPRESSION:

DIFFERENTIAL DIAGNOSIS:

PROGRESS NOTES: January 30, 2012/ 8:00 AM S: (-) fever O: BP 140/90 mmHg, PR 64bpm, RR 20bpm, T 37O C FBS - 131.5mg/dl, Creatinine 1.10 g/dl CT Scan : small soft tissue mass, subgaleal aspect, left occipital area, no intracranial extension. No osseous involvement. Blood Type: A+, HGT 112mg/dl, HBsAg nonreactive A: P: CP clearance Schedule for surgery for excision of the mass Request for biopsy of the mass Cefuroxime 750 mg IVTT q 8hrs. ANST Tramadol 50 mg IVTT q 4hrs. Captopril 25 mg sublingual

You might also like