GROUP 2

Members:
RHEA ANGELIE ISLA AHILDEV, DEVADHAS PREMALATHA
MARAH KRYZZIA PURIFICACION RUSHNOL JADE TUPAC
CASEY JON VEA

HISTORY

NAME: Mr. A.L AGE: 44 SEX: MALE CIVIL STATUS: MARRIED

ADDRESS: Tuao, Cagayan

BIRTHDAY: 01/13/1974 RELIGION:ROMAN OCCUPATION:

CATHOLIC Musician/Band pianist
DATE/TIME OF ADMISSION: April 27, 2018
ADMITTING DIAGNOSIS

CHIEF COMPLAINT: Epigastric pain, General weakness

HISTORY OF PRESENT ILLNESS:

2 months prior to admission, after drinking alcoholic beverages with his band
members, he felt severe epigastric pain characterized as 6/10 and radiating through the
whole abdomen. The patient stated that for the past weeks he noticed that he has
decreased appetite, easy fatigability and distention of abdomen. He also noticed blood
in his stool and decrease in urination. However, the pain episodes were still bearable,
hence the patient decided to take a rest to relieve the pain.

One month prior to admission, the patient notice that he has had abdominal
swelling and pedal edema. He said that he had difficulty of breathing and easy
fatigability when performing his daily routine. He also noted a more frequent episode of
abdominal pain than usual.

April 27, 2018, on the day of admission, upon waking up in the morning, the
patient experienced greater intensity of abdominal pain, difficulty of breathing and
confusion. Here, his wife decided to bring him in Cagayan Valley Medical Center for a
check-up. Upon arrival, his vital signs was monitored and was given oxygen treatment,
hence admitted. Upon admission, he has noticeable abdominal swelling and jaundice.

PAST MEDICAL HISTORY:

The patient was diagnosed with hypertension but can no longer recall when he
was diagnosed. Moreover, the patient has no history of any hospitalization and has not
undergone any surgical procedure.
FAMILY HISTORY:
The patient’s father died because of hypertension and weak lungs. Her mother is alive
and with diabetes. With history of diabetes, hypertension and no history of
cardiovascular diseases. Moreover, there is no family history of psychiatric illnesses.

PERSONAL AND SOCIAL HISTORY:

The patient was born and raised in Tuao, Cagayan. He is the eldest and all his
four siblings are alive and well. He is married and has six children. He works as a band
pianist and also serves in the church as the choir’s pianist. The patient started smoking
and drinking alcohol at the age of 20 years old. The patient usually drinks alcoholic
beverages 2x a week or more depending in the schedule of their gig. His diet is mainly
composed of meats and fats.

REVIEW OF SYSTEMS:
GENERAL Weight loss, anorexia
SKIN Yellow, dry and scaly
HEAD,EYES,EARS,
NOSE,THROAT
NECK
RESPIRATORY
HEART
GI epigastric pain,
GU
MUSCULOSKELETAL

PHYSICAL EXAM
GENERAL:
BP: 120/90 mmHg
HR: 113 bpm
T: 37 C
RR: 25 bpm
O2 Sat: 93%
SKIN (+) jaundice, dry, scaling, clubbing of nails
HEAD,EYES,EARS, Icterus
NOSE,THROAT
NECK
RESPIRATORY
HEART dyspnea
GI Jaundice, dullness, ascites
GU Oliguria
MUSCULOSKELETAL
NEUROLOGIC

IMPRESSION: liver cirrhosis