Date of Interview: February 05, 2015Informant: PatientHistory taken by: Causapin, Angelie, G.Percent reliability: 80%

IDENTIFYING DATA: Lina S. Nerizon, 63 y/o, Female, Married, Filipino, Housewife, Iglesia Ni Cristo, born on October 7, 1951, Presently residing at B8 L2 Ecols St., Quezon City, Admitted for the 1st time at FEU-NRMF Medical Center on February 02, 2015

CHIEF COMPLAINT: Abdominal Pain

HISTORY OF PRESENT ILLNESS:

9 days PTA, patient experienced sudden hypogastric pain with radiations to the back producing a belt like distribution, has sharp pricking quality and a 6/10 score in terms of pain scale. No associated signs and symptoms like fever, chest pain, dysuria, nausea and vomiting. No medications taken. No consult done.

6 days PTA, there was persistence of the above signs and symptoms, but pain had progressed from a score of 6/10 to 9/10. Patient took Mefenamic acid 500mg per tablet OD but afforded no relief. Patient was noted to be pale looking. No associated signs and symptoms like fever, chest pain, dysuria, nausea and vomiting. No consult was done.

5 days PTA, still with the persistence of the above signs and symptoms, finally her daughter decided to seek consult East Ave. hospital. Routine laboratory tests were done but results were unknown to the patient except that she had low hemoglobin levels that were not specified. Patient was advised to undergo blood transfusion but the patient did not consent and decided to go home. She was then given the following upon discharge: Omeprazole 40mg/tablet OD, Rebamipide 10mg/tablet OD, and Ferrous sulfate OD.

Few hours PTA, still with the above signs and symptoms, patient opted to go to our institution to seek consult and hence, the admission.

PAST MEDICAL HISTORY: Experienced the common childhood illness: Chickenpox, measles Unrecalled immunizations received 1994: Diagnosed with hypertension. Highest recorded BP: 200/100 and usual BP: 130/90. Maintenance medication is Amlodipine 5mg/tablet OD Unrecalled: Diagnosed with Chronic bronchitis. Given DOXYPHILIN and CLOMOCYL?? OD No history of DM, kidney and liver diseases No known food allergy Has drug allergy to Senecod No history of any accident or trauma No history of blood transfusion No history of any psychiatric illness

FAMILY HISTORY: Parents are both deceased Father: Deceased at an unrecalled age and cause Mother: Deceased at an unrecalled age and cause 2 siblings: Both apparently well Patient is youngest among the eldest among the 3 No known familial history of cancer, DM, kidney diseases, thyroid, lung and renal disease All 8 children are apparently well

PERSONAL AND SOCIAL HISTORY: Patient is an elementary graduate, housewife, married for 42 years. Lives in a well lit, well ventilated two-story house. She is a non-smoker, and non-alcoholic beverage drinker, with no history of illicit drug use. Patients diet usually consists of vegetables and fish. No regular form of exercise. Water supply is from Maynilad and drinks purified water. Garbage collection is twice daily.

OBSTETRIC AND GYNECOLOGIC HISTORY: Menarche at 12y/o Subsequent menses were regular with: unrecalled interval lasting for 3-5days using PASADOR?? G9P8 (8018) All delivered NSD assisted by a manghihilot Ligation: Unrecalled

REVIEW OF SYSTEMS:

Constitutional symptoms: (+) weight loss of 6 kgs, (+) decrease in appetite (-) body weakness, (-) fatigue, (-) fever Skin: (-) itchiness, (-) excessive dryness, (-) change in color Head: (-) headache, (-) dizziness, (-) vertigo Eyes: (-) pain, (+) blurring of vision, (-) double vision, (+) use of eye glasses Ears: (-) earache, (-) deafness, (-) ear discharge Nose and Sinuses: (-) changes in smell, (-) nose bleeding, (-) nasal obstruction, (-) nasal discharge Mouth and Throat: (-) toothache, (-) gum bleeding, (-) sore throat, (-) disturbance in taste Neck: (-) pain, (-) limitation of movement, (-) presence of mass Respiratory: (-) difficulty of breathing, (-) shortness of breath, (-) cough, (-) sputum production Cardiovascular: (-) sub-sternal pain, (-) palpitations, (-) easy fatigability, (-) orthopnea Gastrointestinal: (-) abdominal pain, (-) nausea, (-) vomiting Genitourinary: (-) dysuria, (-) hematuria, (-) incontinence, (-) urinary frequency, (-) urgency; Extremities: (-) edema on Left upper extremities (-) swelling of joints, (-) stiffness Nervous: (-) headache (-) vertigo, (-) syncope Hematologic: (-) bleeding tendency, (-) pallor, (-) easy bruising Endocrine: (-) intolerance to heat and cold, (-) polydipsia, (+) weight change, (-) polyuria, (-) polyphagia

NOTE:

Medications given sa East Ave: Doxiphilin and Clomocyl. Check niyo net ung names. Nalabas lang doxycycline and clomocycline.