History No.

: 3
Name of Patient: MJG Group No.: 2
Informant: mother Preceptor: Dr. R. Cortez
Reliability: 60% Date of Interview: 23 October 2017
Historian: KVDD Date Submitted: 20 November 2017

General Data:
MJG, 21 years old, single, female, Roman Catholic, student, Filipino, born on XXXX xx, 1996 in Quezon City,
currently residing in Bahay Toro, Quezon City, admitted for the first time at Quezon City General Hospital on August 15,
2017.

Chief Complaint
Epigastric pain

History of Present Illness

4 days PTA, the patient experienced abdominal pain, colicky in character, 7/10, localized over the epigastric area,
non-radiating, with no aggravating and relieving factors, associated with on & off undocumented fever, body malaise,
nausea and vomiting. No medications given. Consulted at QCGH ER, diagnosis was Dyspepsia and was given
Omeprazole, buscopan and metoclopramide which afforded temporary relief of symptoms.

Few hours prior to admission, there was increased in the severity of abdominal pain and patient noticed yellowish
discoloration of her skin, still with associated fever, body malaise and vomiting. Due to the persistence of the symptoms,
patient was brought to Quezon City General Hospital and was consequently admitted.

Past Medical History:

Patient claims to have complete childhood immunization. She did not receive any adult immunization. She had
Measles and Chickenpox when she was a child. She is non-hypertensive, non-diabetic and non-asthmatic. She denies
any history of previously hospitalized. She has no known allergies to food or drugs. She is given injectable contraceptives.

Family Medical History:

Father is 52 years old, known hypertensive. Mother is 49 years old, healthy and free from illness. Patient is only
child. No reported heredofamilial diseases such as hypertension, CAD, elevated cholesterol level, stroke, diabetes, thyroid
disease, kidney disease, cancer and asthma.

Personal and Social History:

Patient is highschool graduate and currently unemployed. She has been living with her common law husband for
3 years. They have a 3 year old daughter. She is non-alcoholic drinker, non-smoker and denies history of illicit drug use.
She consumes 3 meals per day consisting of rice, fish and vegetables. She is fond of eating green mangoes and street
food such as fish ball. She consumes 1 cup of coffee every day. Occasionally she consumes soft drinks. She considers
household chores as her exercise. She usually sleeps for 8 hours. They are currently living in a studio type of house with
1 bed room and 1 bathroom made with light materials, with 2 windows and 1 door. Household consists of 8 members.
Water is supplied by Maynilad. Drinking water is from the water refilling station. Garbage is collected twice every week.
Patient has 1 pet dog. Vectors such as cockroaches and rats are present in the house.

Ob-Gyn History:
She had her menarche at 15 years old consuming 5 fully soaked pads lasting for 7 days. She has regular 28 to
30-day menstrual cycle. Her LMP is August 15, 2017.
G1P1 (1-0-0-1)
G1 – full term, 2014, female, lying clinic, midwife assisted, no fetomaternal complication
Injectable contraceptives
Review of Systems:
Constitutional: (-) weakness, (-) easy fatigability, (-) fever, (-) chills,
(-) loss of appetite, (-) weight loss
Skin: (-) itchiness, (-) dryness, (-) jaundice, (-) rashes, (-) lumps,
Head: (-) headache, (-) dizziness/ vertigo,
Eyes: (-) pain, (-) blurring of vision, (-) double vision, (-) lacrimation,
(-) photophobia, (-) use of eyeglasses
Ears: (-) earache, (-) deafness, (-) tinnitus, (-) ear discharge
Nose and Sinuses: (-) change in smell, (-) nose bleeding, (-) nasal obstruction,
(-) nasal discharge, (-) pain around paranasal sinuses
Mouth and Throat: (-) toothache, (-) gum bleeding, (-) disturbances in taste,
(-) sore throat, (-) hoarseness
Neck: (-) tenderness, (-) stiffness, (-) mass
Respiratory: (-) dyspnea, (-) chest pain, (-) hemoptysis, (-) wheezing,
Cardiovascular: (-) substernal pain, (-) palpitation, (-) dyspnea, (-) orthopnea,
(-) paroxysmal nocturnal dyspnea, (-) edema, (-) cyanosis,
(-) syncope, (-) easy fatigability
Gastrointestinal: (-) abdominal pain, (-) nausea, (-) vomiting, (-) dysphagia,
(-) diarrhea, (-) constipation, (-) hematemesis, (-) melena,
(-) hematochezia, (-) regurgitation
Genitourinary: (-) dysuria, (-) urinary frequency, (-) urgency, (-) hesitancy,
(-) polyuria, (-) hematuria, (-) incontinence, (-) genital pruritus,
(-) urethral discharge
Musculoskeletal: (-) muscle weakness, (-) backache, (-) muscle pain, (-) joint stiffness,
(-) joint pain, (-) joint swelling,
Neurologic: (-) paralysis, (-) tremors, (-) memory loss, (-) seizures
Hematologic: (-) bleeding tendency, (-) pallor, (-) easy bruising,
Endocrine: (-) polydypsia, (-) polyphagia, (-) heat and cold intolerance, (-) excessive weight gain or loss, (-)
excessive sweating
Psychiatric: (-) nervouseness, (-) anxiety, (-) depression, (-) hallucination

Physical Examination:
General Survey: Patient is lying supine, conscious, coherent, oriented to time place and person, uncooperative, well
kempt, looks appropriate for his age, and with light-medium body built, ambulatory and not in cardio-respiratory distress
with the following vital signs:
BP: 110/70 mmHg CR: 91 bpm RR: 18 Temp: 36.8 C

SKIN: Skin is dark in color with jaundice. Hair is black in color, and well distributed. The nail beds are pinkish in color,
no lesions, no clubbing, no cyanosis, no swelling.

Hair: Black in color, abundant, well-distributed

Cranium: Normocephalic, symmetrical; no deformities, temporal arteries not visible

HEENT: Icteric Sclerae, pinkish lips

Face; Oval, symmetrical; no facies; patient can move facial muscles with ease, good facial profile. CARDIO – Adynamic
precordium

CHEST – Symmetrical Chest expansion, no retractions

ABDOMEN – slightly globular abdomen

SPINE – not assessed

EXTREMITIES; No gross deformities