FAR EASTERN UNIVERSITY -DR.

NICANOR REYES MEDICAL FOUNDATION

MEDICAL CENTER
Regalado Ave., Corner Dahlia Street, West Fairview Quezon City 1118
Telephone Number: 427-02-13

DEPARTMENT OF INTERNAL MEDICINE

CLINICAL HISTORY
February2,2015

Informant:Patient
Reliability:85%

GeneralData:Nerizon,LinaSilagan,63yearsold,female,married,Filipino,IglesianiCristo,bornonOctober7,
1951,currentlyresidingatBlock8Lot2EcolsSt.,QuezonCity,admittedforthe1 sttimeatFEUNRMFMedical
CenteronFebruary2,2015.
ChiefComplaint:Abdominalpain
Historyofthepresentillness:
Thehistoryofthepresentillnessstarted9dayspriortoadmissionwhenthepatientexperiencedsudden
onsetofleftupperquadrantabdominalpainradiatingtotherightflanktotheback,describedassharpprickingpain
withapainscaleof6/10.Noassociatedsignsandsymptomslikefever,chestpain,dysuria,nauseaandvomiting.No
consultationwasdone.Nomedicationstaken.
6dayspriortoadmission,stillwiththeabovesignsandsymptoms,butnowwithapainscaleof9/10.The
patienttookMefenamicacid500mgpertabletODbuttonoavail.Noassociatedsignsandsymptomslikefever,
chestpain,dysuria,nauseaandvomiting.Noconsultationwasdone.
Until5dayspriortoadmission,duetothepersistenceoftheabovesignsandsymptoms,herdaughter
decidedtosoughtconsultatapublichospital.Laboratorytestsweredonebutresultswereunknowntothepatient.
Shewasadvisedtoundergobloodtransfusionbutthepatientdecidedtogohomethesameday.Shewasgivena
takehomemedicationslikeOmeprazole40mg/tabletOD,Rebamipide10mg/tabletOD,andFerroussulfateOD.
Fewhourspriortoadmission,stillwiththeabovesignsandsymptoms,patientoptedtogotoourinstitution
toseekconsult.Patientwasthensubsequentlyadmitted.
PastMedicalHistory:
PatientwasdiagnosedHypertensive20yearsago.HighestBPwas200/100withausualBPof130/90.
MedicationstakenwasAmlodipine5mg/tabletOD.
NohistoryofDiabetesmellitus,kidney,lung,andliverdisease.Nohistoryofmalignancy.
Noknownallergiestoanyfood;shehasallergytoSenecod.
Noprevioushistoryofaccidents,traumaandpsychiatricdiseases.
FamilyHistory:

Father:Diedatanunrecalledageandcause.
Mother:Diedatanunrecalledageandcause.
Patientiseldestamong2siblings.Allareapparentlywellaccordingtothepatient.
NootherheredofamilialdiseasessuchasBronchialAsthma,DiabetesMellitus,Thyroid,Lung,Liverand
RenalDiseases.
Personalandsocialhistory:
Patientisanelementarygraduate,unemployed,marriedfor42yearsinawelllit,wellventilatedtwostorey
house.Patientisanonsmoker,andnonalcoholicbeveragedrinker,withnohistoryofillicitdruguse.Patientis
fondofeatingvegetablesandfishbuthasnoregularformofexercise.WatersupplyisfromMayniladanddrinks
purifiedwater.Garbagecollectionistwicedaily.
ReviewofSystems:
o Constitutionalsymptoms:(+)weightlossof6kgs,(+)decreaseinappetite()bodyweakness,()fatigue,()
fever
o Skin:()itchiness,()excessivedryness,()changeincolor
o Head:()headache,()dizziness,()vertigo
o Eyes:()pain,(+)blurringofvision,()doublevision,(+)useofeyeglasses
o Ears:()earache,()deafness,()eardischarge
o NoseandSinuses:()changesinsmell,()nosebleeding,()nasalobstruction,()nasaldischarge
o MouthandThroat:()toothache,()gumbleeding,()sorethroat,()disturbanceintaste
o Neck:()pain,()limitationofmovement,()presenceofmass
o Respiratory:()difficultyofbreathing,()shortnessofbreath,()cough,()sputumproduction
o Cardiovascular:()substernalpain,()palpitations,()easyfatigability,()orthopnea
o Gastrointestinal:()abdominalpain,()nausea,()vomiting
o Genitourinary:()dysuria,()hematuria,()incontinence,()urinaryfrequency,()urgency;
o Extremities:()edemaonLeftupperextremities()swellingofjoints,()stiffness
o Nervous:()headache()vertigo,()syncope
o Hematologic:()bleedingtendency,()pallor,()easybruising
o Endocrine:()intolerancetoheatandcold,()polydipsia,(+)weightchange,()polyuria,()polyphagia

PhysicalExaminationuponAdmission:
GeneralSurvey:Patientisconscious,coherent,ambulatory,notincardiorespiratorydistresswiththefollowingvital
signs:
BP:140/80mmHg
CR:91bpm
RR:20cpm
Temperature:36.50C
Skin:fairincolor,normaldegreeofelasticity,mobilityandthickness;nailbedsarepale,nailplatesaresmooth,no
lesion;nailfoldsarenormallooking.

Head:Hairisblackwithwhite,evenlydistributed,normocephalic,nomass,notenderness;temporalarteriesare
visiblebutpalpable,withstrongequalpulses
Eyes: Eyebrows are black, thin evenly distributed, no erythema and no lesions noted; palpebral fissures
symmetrical;eyelashesarethin,withoutwarddirectionofgrowth,nomatting,Noexophthalmos,enophthalmoson
botheyes.Palepalpebralconjunctivae,anictericsclera,lensareclear;irisareblackwithregularcontours,pupilsare
23mmequallyreactivetolightandaccommodation.
Ears:Auriclesaresymmetricalandnontender;auditorycanalsarepatent,nodischarge.
Nose: Nose is symmetrical, patent vestibules, mucosa is pink, septum midline and intact, turbinates are not
congested,nonasaldischarge,notendernessoverthefrontalandmaxillarysinuses
MouthandOralCavity:Lipsarepink,moist,buccalmucosaandgumsarepinkishmoistandsmooth.Tongueisat
midline.Hardandsoftpalateispinkish,nolesions,uvulaisatmidline.Tonsilsnotenlarged;pinkpharyngealwalls,
noexudates
Neck:supple,symmetrical,noneckveinengorgement,nomass,normalmuscledevelopmentandtone,tracheain
midline,nopalpablelymphnodes.
Lungs/Chest:skinisbrownincolor,novisiblemass,noabnormallydilatedbloodvessels.Bonythoraxiselliptical
andsymmetrical,normalmuscledevelopment.Symmetricalchestexpansion,noretractions,clearbreathsounds,no
lagging,equaltactilefremitusonalllungfields,notenderness,noadventitiousbreathsounds.
Heart: Adynamicprecordium, normal rate,regular rhythm,normal S1andS2,noextraheart sounds,pointof
maximumimpulseat6thICSleftmidclavicularline,()murmur
Abdomen:Flat,umbilicusisinverted,nosuperficialbloodvessels,novisiblemass,hyperactivebowelsounds,soft,
nomass,notenderness.Negativecostovertebraltenderness.
Extremities:Nogrossdeformities,fullandequalpulsesonbothextremities,()edema()cyanosis
Neurologicexam:
Cerebrum:Patientisconscious,coherent,orientedtotime,placeandpersonwithGCS15(E4V5M6)
Cerebellum:Nonystagmus,nodysmetria,andnodysdiadochokinesia
Cranialnerves
CNI:intactsmell
CNII:23mm,bothequallyreactivetolightandaccommodation
CNIII,IV,&VI:intactsixcardinaldirectionsofgaze
CNV:Canclenchteeth
CNVII:nofacialasymmetry
CNVIII:intactgrossbilateralhearing
CNIXandX:Uvulaisatmidline,(+)gagreflex
CNXI:canshrugshoulders

CNXII:tongueisinthemidline

Pathologicreflexes:()Babinski
Signsofmeningealirritation:()Nuchalrigidity,()Brudzinski,()Kernigs
Assessment:
UpperGIBleeding
Plan:
Diet:NPOtemporarilyexceptRebamipide
IVF:D5NSSx80cc/hr
Diagnostics:
CBC,FBS,PT,PTT,Bloodtyping,Na,K,Crea,SGPT,SGOT,
Fecalysis,Urinalysis
12LeadECG
CXR(PAview)
Therapeutics:
Rebamipide100mg/tablet1tabletTID
Pantoprazole40mgTIVOD30minutesbeforebreakfast
Transfuse3unitsPRBCproperlytypedandcrossmatched
GiveDiphenhydramine50mg/ampTIV1amp30minutespriortoBT
SOPwhileonBT
Takenoteofcolorandsizeofstools
RefertoGastroserviceforcomanagementandevaluation(forcolonoscopyandEGDandanemiasecondary)

JIICGanir
CoJIICDePerio
Lacuin
Taghavi