RAMOS, CRISS RAYMOND P.

MED II-B
CLASS NUMBER 37
GENERAL DATA:
July 2, 2010
This is the case of patient X, a 44 year-old female, Filipino and is a resident of Lower Brookside, Baguio
City, Philippines. The patient is a Roman Catholic. The patient is separated from his husband. She is
currently working as a sales lady at Center Mall. She has 5 living children, 4 of which dont live with her
already. The patient was born on ________ and was born in Lingayen, Pangasinan. She was previously
confined for the delivery of her 5
th
child. The informant is the patient herself and has 80% reliability.
CHIEF COMPLAINT: Insomnia
HISTORY OF PRESENT ILLNESS:
2 months PTC, the patient started to have difficulty sleeping. Her usual sleeping time is 9:00 pm and
when she tries to sleep beyond that time, shell be in a lot of trouble trying to sleep. The patient has
verbalized that she has been consuming energen prior to sleeping. She feels cold at night so she wanted
to drink something warm. Since she does not want to drink coffee she opted to have energen.
Whenever she is not able to have a substantial amount of sleep, she experiences head ache. She feels
this pain along the nape area, characterized as dull and is not radiating to any other part of the body.
She has rated the pain as 5/10. She said that she takes relief by drinking water. She takes in vitamin C
and Ferrous Sulfate. She also associates her difficulty to sleep with her constant thinking. A lot of things
bother her mind. She feels weak whenever she isnt able to sleep but generally would not affect in her
ADLs.
PAST PERSONAL MEDICAL HISTORY:
The Patient was born via NSD, with no known allergies, and she had received vaccines when she was
young but failed to remember them. She had UTI about 5 months ago. She sought consult at the Baguio
General Hospital and details of it cant be recalled. She was confined at a hospital (cant remember) for
her 5
th
delivery. The first 4 children were born via Normal Spontaneous Vaginal Delivery at their home
supervised by a midwife. She has history of injury and that was when she was a child. She acquired
bruises on the left arm and on the forehead. She occasionally drinks alcohol, doesnt drink coffee and
tea and doesnt smoke.
OB-GYNE HISTORY
The patient had her menarche at the age of 17 with a 2-day duration. Her menstrual flow was said to be
moderate and has an OB scoring of G6P5 (5-0-1-5). Her first 4 children were all delivered via Normal
Spontaneous Vaginal Delivery. LMP was second week of June 2010.
SOCIAL AND ENVIRONMENTAL HISTORY:
The patient is living in a rented room shared by her son and niece. They have a common toilet for all
occupants; they segregate their garbage and are collected by a garbage truck. Their direct source of
drinking water is through water delivery. There are no pets inside the house. The patient finished college
and earned a secretariat degree. She ran her own business before and is now working as a sales lady at
Baguio Center Mall. The patient does not take any drugs, alcohol or smoke tobacco. Her diet is usually
composed of vegetables and avoids meat. She is fond of eating wheat bread instead of the usual Filipino
heavy meal. She seldom completes the required 8 hour sleep since she experiences insomnia.
FAMILY HISTORY:
The patients father died of complications of hypertension at the age of 68; her mother died of
complications of diabetes at the age of 58. Their family has a history of hypertension and diabetes. The
Patient has _ siblings and all are alive and well. All her children are all doing fine in their own endeavors.

















REVIEW OF SYSTEMS:
1. General: ( ) fatigue, ( ) weight gain, ( ) fever, ( ) chills, ( ), night sweats, ( ) dizziness
2. Skin: ( ) rash, ( ) itching, ( ) moles, ( ) sores, ( ) hives, ( ) pigmentation
3. Head and Neck: ( ) headache, ( ) trauma, ( ) pain, ( ) stiffness, ( ) swelling
a. Eyes: ( ) pain, ( ) diploplia, ( ) scotoma, ( ) visual dysfunction, ( ) dryness, ( ) redness, ( )
tearing, ( ) use of corrective lenses
b. Ears: ( ) difficulty hearing/deafness, ( ) tinnitus, ( ) pain, ( ) discharges, ( ) vertigo/dizziness
c. Nose: ( ) epistaxis, ( ) dryness, ( ) pain, ( ) discharge, ( ) obstruction, ( ) smell dysfunction,
( ) sneezing
d. Mouth: ( ) soreness, ( ) pain, ( ) ulcers, ( ) hoarseness, ( ) dryness, ( ) gum and dental
problems
4. Breast: ( ) discharge, ( ) lump/mass, ( ) pain, ( ) bleeding, ( ) infection
5. Respiratory: ( ) cough, ( ) dyspnea/shortness of breath, ( ) sputum, ( ) hemoptysis, ( ) cyanosis,
( ) wheezing/asthma, ( ) occupational exposure, ( ) tuberculosis/PTB exposure, ( ) past PPD, ( )
previous chest x-ray.
6. Cardiac: ( ) chest pain/discomfort, ( ) orthopnea, ( ) dyspnea, ( ) paroxysmal nocturnal
dyspnea, ( ) palpitation, ( ) undue fatigue, ( ) edema, ( ) cyanosis, ( ) syncope, ( ) hypertension,
( ) past heart diseases, ( ) exercise limit
7. Vascular: ( ) intermittent claudication, ( ) leg cramps, ( ) ulcers, ( ) varicose veins
8. Gastrointestinal: ( ) anorexia, ( ) nausea/retching, ( ) vomiting, ( ) dysphagia, ( ) hematemesis,
( ) indigestion, ( ) melena, ( ) hematochezia, ( ) heart burn, ( ) abdominal pain, ( ) abdominal
distention, ( ) jaundice, ( ) diarrhea, ( ) constipation, ( ) change in bowel movement habits, ( )
hernia, ( ) haemorrhoids, ( ) use of laxative
9. Renal and Urinary: ( ) dysuria, ( ) hematuria, ( ) incontinence, ( ) nocturia, ( ) urinary
frequency, ( ) dribbling, ( ) kidney stones
10. Gynaecological: (+) menarche (age) 17 y/o, (+) cycle regular, (+) duration of menstruation 2
days, ( ) abnormal bleeding, ( ) vaginal discharge, ( ) itching, ( ) dysmenorrhea/pelvic pain, ( )
dyspareunia, ( ) contraceptive use, ( ) history of venereal diseases, (+) number of pregnancies 6,
(+) number and type of deliveries: 5 and all are delivered via NSVD, ( + ) abortions: Miscarriage
of the 6
th
child, ( ) birth control method, ( ) menopause (age)
11. Male Genitalia: ( ) pain, ( ) swelling, ( ) urethral discharge, ( ) hernias, ( ) testicular pain, ( )
masses, ( ) history of venereal disease, ( ) erectile dysfunction/potency, ( ) sexual habits, ( )
ulcers
12. Musculoskeletal: ( ) muscle pain, ( ) joint pains, ( ) cramps, ( ) weakness, ( ) stiffness, ( )
history of trauma, ( ) swelling, ( ) limitation of motion, (+) backache
13. Haematological: ( ) anemia, ( ) excessive bleeding, ( ) easy bruising, ( ) past transfusions
14. Endocrine and metabolic: ( ) heat/cold tolerance, ( ) weight change, ( ) thyroid problem, ( )
excessive sweating, ( ) polydipsia, ( ) polyphagia, ( ) hair change
15. Nervous System: (+) headaches, ( ) syncope, ( ) seizure, ( ) weakness, ( ) head trauma, ( )
stroke, ( ) sleep disorder, ( ) coordination problem, ( ) sensory disturbance, ( ) motor problem,
( ) tremors, ( ) memory
16. Psychiatric/Emotional: ( ) anxiety, ( ) depression, ( ) loss of control/violence, ( ) nervousness,
( ) memory change, ( ) suicide attempts, ( ) substance abuse