Davao Medical School Foundation, Inc.

Medical Drive, Bajada, Davao City

S.Y. 2019-2020

PATIENT DATABASE
INTERNAL MEDICINE

Submitted to:
Dr. Hansel Magno Jr.
Clinical Instructor

Submitted by:
Calunsag, Analyn M.
NMD-3

August 1, 2019
 COMPREHENSIVE HEALTH HISTORY

Personal Data

Date and time of admission: July 20, 2019, 11:00 am

Date and time of interview: July 31, 2019, 3:30 pm

Name: X
Age/Sex: 43/F
Civil Status: Separated
Address: Davao City
Religion: Roman Catholic
Occupation: Call Center Agent
Nationality: Filipino

Chief Complaint

Abdominal Pain

History of Present Illness

Three days prior to admission, patient had her evening routine where she would take her
dinner after work and eventually have her normal urge to defecate every after meal. Later that
evening, she experienced sudden onset of cramping abdominal pain localizing in the umbilical
region. There was no suprapubic pain, flank pain, regurgitation and dysuria noted. The
abdominal pain subsided and she was able to sleep without any medication taken.

Two days prior to admission, patient was able to go to work but noted abdominal
bloating. In that evening, patient experienced the same cramping abdominal pain with a pain
scale of 10 out of 10 and was constipated. The pain was felt from the umbilical region and
radiated towards the epigastric area with fully distended abdomen however no referred back
pain was noted. There was no fever, nausea, vomiting, dysphagia and diarrhea. Patient did not
take any medication, instead she rushed to the ER of the nearest hospital in Manila. She
underwent series of work ups like abdominal x-ray and was advised for operation. She opted to
forego the operation and chose to have the procedure done at Davao because there’s no one to
take care of her.

One day prior to admission, upon processing her hospital bill, she had recurrent
cramping abdominal pain and vomited profusely. There was failure to pass flatus but
normoactive bowel sounds were noted. She was brought back to the ER and given IV infusion
of tramadol. After the medication, she had another episode of vomiting.

On the day of admission, when the patient was feeling better, she flew in from Manila
and directly went to the hospital. Patient came in with the same complaint of abdominal pain
and was scheduled for operation at 3 pm of the same day, thus prompted her admission.
Past Medical History

She was diagnosed 3 years ago with Diabetes mellitus and is compliant with her
maintenance drugs of Metformin 500 mg and Glimepiride 2 mg. She was also in injectable
insulin. Patient was diagnosed with hypertensive at the age of 42 and was currently taking
Losartan 50 mg as her maintenance.

Surgical History

Patient had appendectomy 9 years ago

Allergies

No food and drug allergies noted.

Gynecologic:

LMP: July 12, 2019, 2 packs on the first day

Patient was diagnosed with Polycystic Ovarian Syndrome and was given OCP
however she already stopped taking for 4 years.

FAMILY HISTORY

Patient’s father is diabetic and hypertensive. Her mother died of breast carcinoma. And
her 2 siblings have asthma.

PERSONAL AND SOCIAL HISTORY

Patient is a non-smoker and non-alcoholic drinker. She just had one cup of rice in day or
sometimes none as part of her diet.

Review of System:

General (-) weight loss, fatigue

Skin No color change, no itchiness (+) hot flush
HEENT Head: No light headedness, no headache
Eyes: No blurring of vision
Ears: No tinnitus
Nose: No discharge or itching, no colds
Throat: No hoarseness of voice, no regurgitation
Neck No lumps
Cardiovascular No chest pain, no palpitations
Peripheral vascular No swelling of feet, no tingling sensation
Urinary No polyuria and pelvic pain
 Musculoskeletal No joint pain
Endocrine + heat intolerance

Physical Examination:

General appearance: Patient is conscious, cooperative and coherent

Vital Signs:

BLOOD PRESSURE: 140/90 mmHg Elevated

TEMPERATURE: 36.6 C Normal

PULSE RATE: 80 bpm Normal

RESPIRATORY RATE: 20 cpm Normal

Anthropometric measurements

WEIGHT: 62 kilograms

HEIGHT: 5 feet and 2 inches

BMI: 25.2 Overweight

Skin

Inspection- skin is brown and dry. No scars and lesions noted. No rashes were noted.
No clubbing of the nails.

Palpation- Skin was warm. 1-3 secs skin turgor and classified as good

HEENT:

Head

Inspection- blonde hair, normal thickness of hair strand, scalp has no lesion and scars.

Palpation – no head deformities, no lumps

Eyes:

Inspection – Symmetric eyebrows, no scar and lesion on both eyebrows. No redness was
noted. No cataract was noted.
Ears:

Inspection - ears are symmetric, normal pinna. No scars and lesion.

Palpation- no pain in the tragus and post-auricular area.

No tenderness during tug test.

Nose:

Inspection - septum is midline, no alar flaring

Palpation: no tenderness in all sinuses

Mouth/Throat:

Inspection – no ulcers in the buccal cavity, Tonsils not inflamed, uvula is in the midline, tongue
is not deviated

Neck:

Inspection: No scars or lesion

Palpation: Trachea is in the midline, Thyroid gland not enlarge

Lymph nodes

Preauricular: (-) tenderness Submandibular: (-) tenderness

Posterior auricular: (-) tenderness Submental: (-) tenderness

Occipital: (-) tenderness Superficial cervical: (-) tenderness

Tonsillar: (-) tenderness Posterior cervical: (-) tenderness

Deep cervical: (-) tenderness Supraclavicular: (-) tenderness

Clavicle: Intact and no fracture

Chest and Thorax

Inspection –no signs of accessory muscles used. No deformities.

Palpation – No tender areas, no crepitus noted, tactile fremitus symmetric, good chest
expansion and symmetric
Percussion- Resonant on both upper lung fields

Auscultation – Normal breath sounds was noted in all fields

Cardiovascular

Inspection - No cyanosis, jugular vein not distended

Palpation- No heaves and no thrills noted. Carotid pulse was brisk

Auscultation – Regular heart sounds, no murmur

Abdomen

Inspection – abdominal contour was globular. Midline incision from roughly 1 cm above the
umbilicus to hypogastric region

Auscultation - Hyperactive bowel sounds.

Percussion – abdomen in four quadrants were tympanic.

Palpation –Tenderness in light and deep palpation in all quadrants.

Kidney punch – no tenderness

Genitalia and Rectum

Not assessed

Musculoskeletal

Inspection: No bipedal edema noted

Palpate: No tenderness in both hand (wrist joint, anatomic snuffbox, MCP, PIP and DIP)

Peripheral Vessels

Inspection: No pallor

Capillary refill: 1-3 secs (within normal)

Neurologic:

Mental status: Cooperative, Answers question coherently, awake and oriented

Cerebellar: Able to performed finger to nose test

Sensory: Intact pain, light touch, vibrations.

Motor: Good muscle bulk, good muscle tone, muscle strength of 5/5

Cranial Nerve Assessment:

CN I – intact

CN II – intact

CN III – pupillary constriction and consensual reflex intact

CN III, IV, VI - Extraocular muscle - intact

CN V – Sensory – intact; motor - intact

CN VII – Motor – intact

CN VIII – cannot localize in Weber test, Rinne’s test AC>BC (normal)

CN IX, X – Motor - intact

CN XI – Motor - intact

CN XII – motor - intact

Deep Tendon Reflexes:

Reflex Right Left

Biceps ++ ++
Triceps ++ ++
Brachioradialis ++ ++
Knee ++ ++
Ankle ++ ++
Salient Features:

Pertinent Positive Pertinent Negative

• 43/F (-) suprapubic pain
• Cramping abdominal pain from umbilical (-) flank pain
region radiating to the epigastric area (-) referred back pain
• Distended abdomen (-) dysuria
• Vomiting (-) Rashes
• Tympanic in all quadrants (-) fever
• Tender upon palpation (-) nausea
• BMI = 25.2 (normal) (-) dysphagia
• Hypertensive (-) diarrhea
• Diabetic (-) non-alcoholic
• Appendectomy (9years ago) (-) non-smoker
• Constipated
• Failure to pass flatus
• Normoactive bowel sound

Impression:

Intestinal Obstruction secondary to post-operative adhesion

Differential Diagnoses:

Diseases Rule In Rule Out

Peptic ulcer disease Abdominal Pain No weight loss

Vomiting No chest pain
Bloating No dyspnea
Non- Smoking
non- Alcohol
No regurgitation
Fully distended abdomen
Acute pancreatitis • Abdominal pain • No referred back pain
• Onset after eating • No fever
• Vomiting • Non-alcoholic
• Non-smoker

Peritonitis • Abdominal pain • No fever

• Distended abdomen • No diarrhea
• Failure to pass flatus • Normal urine output
• Vomiting

Paralytic Ileus • Abdominal Pain • Weight loss

• Vomiting • Normoactive bowel sounds
• Constipation • Crampy abdominal pain
• Failure to pass flatus
Inflammatory Bowel Disease Crampy abdominal pain • No diarrhea
• No fever
• No weight loss
Stump Appendicitis • History of appendectomy Periumbilical pain radiating
• Abdominal pain to the epigastric area
• vomiting No Right lower quadrant
pain

Final Impression:

Intestinal Obstruction secondary to post-operative adhesion