Date of Interview: February 05, 2015

History taken by: Causapin, Angelie, G.

Informant: Patient
Percent reliability: 80%

IDENTIFYING DATA: Lina S. Nerizon, 63 y/o, Female, Married, Filipino, Housewife, Iglesia
Ni Cristo, born on October 7, 1951, Presently residing at B8 L2 Ecols St., Quezon City,
Admitted for the 1st time at FEU-NRMF Medical Center on February 02, 2015
CHIEF COMPLAINT: Abdominal Pain
HISTORY OF PRESENT ILLNESS:
9 days PTA, patient experienced sudden hypogastric pain with radiations to the back
producing a belt like distribution, has sharp pricking quality and a 6/10 score in terms of
pain scale. No associated signs and symptoms like fever, chest pain, dysuria, nausea and
vomiting. No medications taken. No consult done.
6 days PTA, there was persistence of the above signs and symptoms, but pain had
progressed from a score of 6/10 to 9/10. Patient took Mefenamic acid 500mg per tablet
OD but afforded no relief. Patient was noted to be pale looking. No associated signs and
symptoms like fever, chest pain, dysuria, nausea and vomiting. No consult was done.
5 days PTA, still with the persistence of the above signs and symptoms, finally her
daughter decided to seek consult East Ave. hospital. Routine laboratory tests were done
but results were unknown to the patient except that she had low hemoglobin levels that
were not specified. Patient was advised to undergo blood transfusion but the patient did
not consent and decided to go home. She was then given the following upon discharge:
Omeprazole 40mg/tablet OD, Rebamipide 10mg/tablet OD, and Ferrous sulfate OD.
Few hours PTA, still with the above signs and symptoms, patient opted to go to our
institution to seek consult and hence, the admission.
PAST

MEDICAL HISTORY:
Experienced the common childhood illness: Chickenpox, measles
Unrecalled immunizations received
1994: Diagnosed with hypertension. Highest recorded BP: 200/100 and usual BP:
130/90. Maintenance medication is Amlodipine 5mg/tablet OD
Unrecalled: Diagnosed with Chronic bronchitis. Given DOXYPHILIN and
CLOMOCYL?? OD
No history of DM, kidney and liver diseases
No known food allergy
Has drug allergy to Senecod
No history of any accident or trauma
No history of blood transfusion
No history of any psychiatric illness

FAMILY HISTORY:
Parents are both deceased
o Father: Deceased at an unrecalled age and cause
o Mother: Deceased at an unrecalled age and cause

2 siblings: Both apparently well

Patient is youngest among the eldest among the 3
No known familial history of cancer, DM, kidney diseases, thyroid, lung and renal
disease
All 8 children are apparently well

PERSONAL AND SOCIAL HISTORY:

Patient is an elementary graduate, housewife, married for 42 years. Lives in a well
lit, well ventilated two-story house. She is a non-smoker, and non-alcoholic
beverage drinker, with no history of illicit drug use. Patients diet usually consists of
vegetables and fish. No regular form of exercise. Water supply is from Maynilad
and drinks purified water. Garbage collection is twice daily.
OBSTETRIC AND GYNECOLOGIC HISTORY:
Menarche at 12y/o
Subsequent menses were regular with:
o unrecalled interval lasting for 3-5days using PASADOR??
G9P8 (8018)
o All delivered NSD assisted by a manghihilot
Ligation: Unrecalled
REVIEW OF SYSTEMS:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

Constitutional symptoms: (+) weight loss of 6 kgs, (+) decrease in appetite (-) body
weakness, (-) fatigue, (-) fever
Skin: (-) itchiness, (-) excessive dryness, (-) change in color
Head: (-) headache, (-) dizziness, (-) vertigo
Eyes: (-) pain, (+) blurring of vision, (-) double vision, (+) use of eye glasses
Ears: (-) earache, (-) deafness, (-) ear discharge
Nose and Sinuses: (-) changes in smell, (-) nose bleeding, (-) nasal obstruction, (-) nasal
discharge
Mouth and Throat: (-) toothache, (-) gum bleeding, (-) sore throat, (-) disturbance in taste
Neck: (-) pain, (-) limitation of movement, (-) presence of mass
Respiratory: (-) difficulty of breathing, (-) shortness of breath, (-) cough, (-) sputum
production
Cardiovascular: (-) sub-sternal pain, (-) palpitations, (-) easy fatigability, (-) orthopnea
Gastrointestinal: (-) abdominal pain, (-) nausea, (-) vomiting
Genitourinary: (-) dysuria, (-) hematuria, (-) incontinence, (-) urinary frequency, (-)
urgency;
Extremities: (-) edema on Left upper extremities (-) swelling of joints, (-) stiffness
Nervous: (-) headache (-) vertigo, (-) syncope
Hematologic: (-) bleeding tendency, (-) pallor, (-) easy bruising
Endocrine: (-) intolerance to heat and cold, (-) polydipsia, (+) weight change, (-) polyuria,
(-) polyphagia

NOTE:
Medications given sa East Ave: Doxiphilin and Clomocyl. Check niyo net ung names.
Nalabas lang doxycycline and clomocycline.