Cagayan State University- Carig Campus

College of Medicine and Surgery

Medicine Ward 1
History Taking

Group 3 members:
AFALLA, JOYCE ANNE
ALFONSO, HANNAH FEBE RUTH
CONAG, RICH MARK
MARCUS, IDA PRISCILLA
MALLILLIN, CHRISTINE JOY
PARONG, MA. STEPHANIE

Date of Assessment: April 20, 2017 (1:30pm)

Date and time of Admission: April 17, 2017
Ward: AC
Name: Mr. RA
Age: 46 y/o
Sex: Male
Marital Status: Single
Occupation: Construction worker
Religion: Roman Catholic
Present Address: Alcala, Cagayan
Source of information: Patient
Reliability: The patient exhibits 100% reliability. The patient was conscious and was able to answer all
questions clearly.

Chief complaint: epigastric pain, Bloody vomitus, Bloody stool

PRESENT ILLNESS

September 2016, 7 months prior to admission, Mr. RA felt severe abdominal pain on the epigastric
area which he rated 8/10, 10 being the highest. He attempted to relieve it by eating and resting but
symptoms lasted for more than 8hours so he decided to go to Alcala District Hospital. He also mentioned
that he was passing out black tarry stool once a day for 3 days. Upon check-up that day he was given
medications to which he could not remember during the course of the interview.

April 16, 2017, one day prior to admission, after his drinking spree with his friends with an estimate
of 750 ml of liquor intake that day, Mr. RA complained of severe abdominal pain in the epigastric region. He
thought that it was just a simple stomach ache and can be relieved it by resting and sleeping. Symptom
subsided eventually.
 6 hours prior to admission, Mr. RA was awaken by severe abdominal pain in the epigastric region
which he rated to be 8/10, 10 being the highest. He also reported to have vomited 5 times that morning
with vomitus is with streak of fresh blood about 3ml. He said that he also said that a day before he passed
out had fresh blood on his stool. This prompted her sister to rush him to Alcala Hospital and upon
admission he was immediately referred to CVMC due to lack of facilities for further evaluation.

On April 17, 2017 (9am), upon admission to CVMC, the resident on duty immediately gave him IV
fluids and omeprazole as medication. He was also advised to be on soft diet. His blood pressure was
recorded as 110/90and a series of laboratory tests was requested like CBC

Past Medical History:

Childhood Illness:

Mr. RA said that he had no history of asthma or allergies to certain foods. When asked further, he
could not recall any childhood illnesses other than the occasional fever, cough and colds which he
managed through over the counter drugs like paracetamol and the like.

Adult Illness:

Patient relayed that during his younger adult years (about 25 years and above) he had episodes of
severe abdominal pain which he would usually think of as ulcer but undeniably never attempted to have
hospital checkup nor took medications for it except for over the counter drug like mefenamic acid to relieve
pain. This is usually precipitated whenever he drinks liquor. He have no noted history or current record of
diseases like TB, DM or Hypertension.

Family History:

Mr. RA is single and lives with his sisters family. According to him, both of their parents have died
when he was still little due to car accident. No other noted diseases like heart, lung or kidney disease,
cancer, epilepsy, hypertension and PTB.

Personal and Social History:

Mr. RA was born and raised in Alacala, Cagayan and works as a construction worker. He is single
and lives with his sisters family. Mr. RA is a regular alcoholic drinker about once or twice a week with
friends at work to shy away exhaustion or let him sleep and also consumes a pack of cigarettes per day.

REVIEW OF SYSTEMS

HEENT:
Eyes: (-) poor vision, yellow sclera
Ears: Optimum hearing function
Nose: No nasal stuffiness

RESPIRATORY:
(-) dry cough (-) productive cough (-) soft crackles

CARDIAC:
(-) chest pain (-) palpitations

VASCULAR:
(-) sign of phlebitis.

G.I.:
Irregular bowel movement with black tarry stool on third day of hospitalization

G.U.:
No pain during urination

MUSCULOSKELETAL:
(+) muscle weakness and easy fatigability, (-) arthritis and gout

NEUROMUSCULAR:
No history of seizures and memory changes

PSYCHIATRIC:
No history of depression

HEMATOLOGICAL:
(-) Anemia

DERMATOLOGIC:
(-) rashes, (-) allergies, dry and dull skin

PHYSICAL EXAM

General Survey: The patient is thin

State of awareness: Conscious, awake
Body movements: Voluntary and purposeful
Speech: Coherent with slight hoarseness of voice
Mood & Affect: Actions are congruent with emotions

Vital Signs:
Temperature: 37 C
Pulse rate: 85 bpm, Regular
Respiratory Rate: 16cpm, Regular
 Blood Pressure: 110/90 mmHg

SKIN: No lesions.

HEAD, EYES, EARS, NOSE:

Head: Normocephalic, fine hair
Eyes: optimal vision
Ears: good hearing
Nose: moist nasal mucosa

ABDOMEN/RECTUM: Rounded abdomen. Bowel sounds are hyperactive. There is moderate tenderness
in the epigastrium. Rectal examination revealed black, tarry stool.

CHEST: Lungs are clear to auscultation and percussion. No murmur is appreciated. Peripheral pulses are
present but are rapid and weak.

Impression:

Upper Gastrointestinal Bleeding secondary to Chronic Gastric Ulceration