Group No.

: A10 Date of Interview: March 1,2024

EVIZA, KIMBERLY F.

MEDICAL HISTORY

PATIENT PROFILE

The patient is a 25 year old female, single , Filipino , Christian from Valenzuela City who was admitted for the first time in
our institution on February 27,2024.

She is a 2nd year college student, and the second-born child among six siblings. She has an easy going and
cooperative personality. She lives with her five other siblings, mother and grandmother in an apartment building in a
densely populated community. They have a regular supply of water and electricity. And the patient’s mother pays for the
hospital bills. The patient has an interrupted sleep of less than five hours due to abdominal pain.She also consumes meat,
vegetables, rice with a less fat diet. She also exercises once a week.

Source and Reliability The patient and her mother with good reliability

Chief Complaint Abdominal pain of 3 week duration

HISTORY OF THE PRESENT ILLNESS

The patient was apparently well until 19 days prior to admission,she woke up with an acute sharp epigastric pain of
10/10 radiating in all abdominal quadrants towards the upper back. She also reported generalized body weakness as the
pain was persistent throughout the day. The patient took Gaviscon (10mL) since she had a known history of
gastroesophageal reflux disease (GERD) but there was no relief. There was also a noted yellowing of sclera and urine.

18 days prior to admission, the abdominal pain of 10/10 and generalized body weakness persisted.The patient
consulted a local clinic and was prescribed Mefenamic Acid (500 mg every 8 hours), which slightly alleviated the pain to
8/10 for 2-3 hours only. In the interim the patient took the prescribed pain reliever.

16 days prior to admission, the patient went to a health center since the pain of 10/10 persisted along with the
generalized body weakness, and was prescribed Omeprazole (110 mg once a day for two weeks). The patient discontinued
after one intake of medication due to non-relief of symptoms. In the interim, the patient did not take any medication.

14 days prior to admission, abdominal pain of 10/10 persisted with the generalized body weakness, and the yellowing
of sclera progressed. She also noted a change in stool of ash gray/green in color, with mushy consistency, passed stool
twice a day. The patient went to a local hospital where ECG and chest x-ray was ordered, the CBC result was normal, while
mild scoliosis was noted in the x-ray. The patient was requested to undergo whole abdomen ultrasound and was prescribed
Tramadol (37.5 mg every 8 hours), the pain was relieved to 5/10 but only for 2-3 hours.The patient noted an itching
sensation but continued to take the medication. In the interim, the patient took Tramadol for abdominal pain and had
undergone an abdominal ultrasound.

11 days prior to admission, received the results of an ultrasound where two gallbladder stones were found.In the
interim, the abdominal pain, generalized body weakness and yellowing of sclera persisted while the patient rested at
home, and continued to take Tramadol.

8 days prior to admission, the patient still had abdominal pain of 10/10 with the generalized body weakness, and the
yellowing of eyes. She went to a tertiary hospital for the surgical removal of the gallbladder stones, but was told to wait up
to three weeks for the schedule. In the interim patient continued Tramadol intake, and follow-up with the schedule of
surgery.

On the day of admission, the patient decided to consult the UERM hospital.She has abdominal pain of 10/10 with
generalized body weakness,yellowing of eyes,weight loss of 5kg, tea-colored urine, ash-gray and greenish stool but no
nausea, vomiting, fever, and shortness of breath.
 HISTORY

Past Health ● Allergies: Tramadol

Maintenance ● Childhood Diseases: Measles,Chickenpox,Mumps,Rubella
History ● Immunizations: COVID-19 Vaccine (Sinovac)with 1 booster shots (Brand unrecalled)
● Surgeries: None
● Hospitalization: Local Hospital-UTI-Procedures Unrecalled- >10 years ago
● Major Illnesses:
Polycystic ovary syndrome (PCOS) - 2022- Unrecalled Medication
Gastroesophageal reflux disease (GERD)-Unrecalled-Gaviscon (10 mL)
● Accidents:None

Family History

Social History Patient denies use of tobacco, illicit drug use, and coffee. And alcohol intake of one to two times a year.She is sexually
active without routine contraceptive use.

REVIEW OF SYSTEMS

General (-) Fever, (+) fatigue, (-) sweating, (+) weight loss, (-) weakness (-) chills Weight loss
from 68kg (Feb
7, 2024) to 63kg
(Feb 27, 2024)

Skin (-) Changes in color, (-) changes in texture, (+) itching, (-) rashes, (-) changes in hair/nails Tramadol allergy

Eyes (-) Redness, (-) tearing, (-) pain, (+) double vision, (-) discharge, (-) trauma, (+) discoloration, (-) Yellowing of
changes in vision sclera

Ears (-) Hearing loss, (-) otalgia, (-) discharge, (-) tinnitus

Nose, Throat, (-) Abnormal olfaction, (-) hoarseness, (-) dysphagia, (-) odynophagia,, (-) trauma, (-) frequent Brownish blood
Mouth colds/cough, (-) epistaxis, (-) neck mass, (-) dental caries, (-) facial pain, (+) gum bleeding, (-) noted
toothache

Respiratory (-) Cough, (-) difficulty of breathing, (-) wheezing, (-) hemoptysis

Cardiovascular (-) Palpitation, (-) syncope, (-) chest pain, (-) hypertension, (-) orthopnea, (-) dyspnea

Gastrointestinal (-) Dysphagia, (-) nausea, (-) vomiting, (+) loss of appetite, (+) abdominal pain, (-) melena, (-) Stool (Bristol
jaundice, (+) indigestion, (+) heartburn, (-) hematemesis, (-) fatty food intolerance, (+) stool type 6) grayish
frequency/character, (-) hemorrhoids, (-) abdominal distension, (-) hernia and greenish in
color, 2x a week

Abdominal pain
of 10/10

Genitourinary (-) Dysuria, (+) changes in volume, (-) retention, (-) bleeding, (-) stream, (-) polyuria, (-) nocturia, Increased urine
(-) stones, (-) infection, (-) hesitancy, (-) urgency, (+) changes in color, (-) frequency, (-) dribbling output (3-4
cups), dark
 brown color

Breast (-) Nipples, (-) lumps, (-) pain, (-) discharge

Extremities (-) Cyanosis, (-) clubbing, (-) edema, (-) varicosity, (-) ulcer, (-) claudication

Hematologic (-) Excessive bleeding/bruising, (-) anemia, (-) pica

Nervous (-) Headache, (-) tremor, (-) fainting spells, (-) seizures, (-) neurologic deficit, (-) gait disturbance,
(-) dizziness/vertigo, (-) head trauma, (-) sensory perversions

Musculoskeletal (-) Joint stiffness, (-) pain, (-) swelling, (+) muscle weakness Back pain
localized at the
medial region of
the back along
the length of
spine

Endocrine (-) Heat or cold intolerance, (-) thyroid problems, (-) neck surgery/irradiation, (-) DM indicators

Psychiatric (+) Mood swings, (-) behavioral changes, (+) anxiety, (-) depression

TEMPORAL PROFILE

PHYSICAL EXAMINATION

General survey The patient was acutely ill, awake, alert, responsive,not in cardiorespiratory distress, maintains
appropriate dress, grooming, and personal hygiene, coherent, oriented to time, person, and place,
and coordinated motor activity .

The patient’s height is 165 cm, weight is 63 kg, and BMI is 26.2 which is overweight.

Vital Signs The temporal temperature is 36.2 °C, blood pressure on left arm is 110/180 mmHg and 120/80
mmHg in right arm; Pulse rate is 81 bpm; Heart rate is 78 bpm,Respiratory rate is 18/min ; SpO2 is
97% at ventilated room (room air).

Skin and Hair The skin presents jaundice, a smooth and dry moisture, good turgor and symmetrical temperature
on both arms. Upper and lower extremities have transparent nails.Multiple, disseminated,
well-defined erythematous smooth round papules on the whole back .Hair black, smooth, and soft.
And the scalp is clean and dry.
Chest and Lungs No signs of respiratory distress,deformities or asymmetry of the thorax, no tender areas, symmetric
chest expansion, no lag on the lungs, tactile fremitus is symmetrical, both lungs were resonant,
symmetrical and vesicular breath sounds over most of both lungs, no egophony, no bronchophony,
and no whispered pectoriloquy.

Cardiovascular Precordium is flat, there is presence of bilateral pitting edema on both lower extremities, periorbital
region is normal, no swelling, and not shrunken, lips are normal, no pallor, no lesion, no cyanosis,
no clubbing of nails, buccal mucosa and gums are pinkish, conjunctiva is pale, peripheral pulses
are symmetrical and regular , heart sounds are heard at the apex on the left side and S1 is greater
than S2, at the base S2 is greater than S1, no murmurs or extra sounds, capillary refill time is 1
second, pink tone returns immediately to blanched nail beds when pressure is released. Jugular
venous pressure is 7 cm with the head elevated at 30°.

Abdominal Abdomen is flabby with normoactive bowel sounds (11/min),no notes of borborygmi, tympanic on all
abdominal quadrants, tenderness on percussion in the right upper quadrant and positive Murphy’s
sign.There is tenderness noted on light palpation, spleen, bladder, and liver non-tender and
non-palpable, liver size and edge was not measured and palpated due to tenderness in the right
upper quadrant.Findings were also negative for both shifting dullness and fluid wave.