FAR EASTERN UNIVERSITY -Dr. Nicanor Reyes Medical Foundation

MEDICAL CENTER

Regalado Ave., Corner Dahlia Street, West Fairview Quezon City 1118

Telephone Number: 427-02-13DEPARTMENT OF INTERNAL MEDICINE

CLINICAL HISTORY

February 2, 2015

Informant: Patient

Reliability: 85%General Data: Nerizon, Lina Silagan, 63 years old, female, married, Filipino, Iglesia ni Cristo, born on October 7, 1951, currently residing at Block 8 Lot 2 Ecols St., Quezon City, admitted for the 1st time at FEU-NRMF Medical Center on February 2, 2015.

Chief Complaint: Abdominal pain History of the present illness:

The history of the present illness started 9 days prior to admission when the patient experienced sudden onset of left upper quadrant abdominal pain radiating to the right flank to the back, described as sharp pricking pain with a pain scale of 6/10. No associated signs and symptoms like fever, chest pain, dysuria, nausea and vomiting. No consultation was done. No medications taken.

6 days prior to admission, still with the above signs and symptoms, but now with a pain scale of 9/10. The patient took Mefenamic acid 500mg per tablet OD but to no avail. No associated signs and symptoms like fever, chest pain, dysuria, nausea and vomiting. No consultation was done.

Until 5 days prior to admission, due to the persistence of the above signs and symptoms, her daughter decided to sought consult at a public hospital. Laboratory tests were done but results were unknown to the patient. She was advised to undergo blood transfusion but the patient decided to go home the same day. She was given a take home medications like Omeprazole 40mg/tablet OD, Rebamipide 10mg/tablet OD, and Ferrous sulfate OD.

Few hours prior to admission, still with the above signs and symptoms, patient opted to go to our institution to seek consult. Patient was then subsequently admitted.

Past Medical History:

Patient was diagnosed Hypertensive 20 years ago. Highest BP was 200/100 with a usual BP of 130/90. Medications taken was Amlodipine 5mg/tablet OD.

No history of Diabetes mellitus, kidney, lung, and liver disease. No history of malignancy.

No known allergies to any food; she has allergy to Senecod.No previous history of accidents, trauma and psychiatric diseases.

Family History:

Father: Died at an unrecalled age and cause.

Mother: Died at an unrecalled age and cause.

Patient is eldest among 2 siblings. All are apparently well according to the patient.No other heredofamilial diseases such as Bronchial Asthma, Diabetes Mellitus, Thyroid, Lung, Liver and Renal Diseases.Personal and social history:

Patient is an elementary graduate, unemployed, married for 42 years in a well lit, well ventilated two-storey house. Patient is a non-smoker, and non-alcoholic beverage drinker, with no history of illicit drug use. Patient is fond of eating vegetables and fish but has no regular form of exercise. Water supply is from Maynilad and drinks purified water. Garbage collection is twice daily.

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

Physical Examination upon Admission:

General Survey: Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress with the following vital signs:

BP: 140/80 mmHg CR: 91 bpm RR: 20 cpm Temperature: 36.50C Skin: fair in color, normal degree of elasticity, mobility and thickness; nail beds are pale, nail plates are smooth, no lesion; nail folds are normal looking.

Head: Hair is black with white, evenly distributed, normocephalic, no mass, no tenderness; temporal arteries are visible but palpable, with strong equal pulsesEyes: Eyebrows are black, thin evenly distributed, no erythema and no lesions noted; palpebral fissures symmetrical; eyelashes are thin, with outward direction of growth, no matting, No exophthalmos, enophthalmos on both eyes. Pale palpebral conjunctivae, anicteric sclera, lens are clear; iris are black with regular contours, pupils are 2-3mm equally reactive to light and accommodation.

Ears: Auricles are symmetrical and non-tender; auditory canals are patent, no discharge.

Nose: Nose is symmetrical, patent vestibules, mucosa is pink, septum midline and intact, turbinates are not congested, no nasal discharge, no tenderness over the frontal and maxillary sinuses

Mouth and Oral Cavity: Lips are pink, moist, buccal mucosa and gums are pinkish moist and smooth. Tongue is at midline. Hard and soft palate is pinkish, no lesions, uvula is at midline. Tonsils not enlarged; pink pharyngeal walls, no exudates

Neck: supple, symmetrical, no neck vein engorgement, no mass, normal muscle development and tone, trachea in midline, no palpable lymph nodes.

Lungs/Chest: skin is brown in color, no visible mass, no abnormally dilated blood vessels. Bony thorax is elliptical and symmetrical, normal muscle development. Symmetrical chest expansion, no retractions, clear breath sounds, no lagging, equal tactile fremitus on all lung fields, no tenderness, no adventitious breath sounds. Heart: Adynamic precordium, normal rate, regular rhythm, normal S1 and S2, no extra heart sounds, point of maximum impulse at 6th ICS left midclavicular line, (-) murmur

Abdomen: Flat, umbilicus is inverted, no superficial blood vessels, no visible mass, hyperactive bowel sounds, soft, no mass, no tenderness. Negative costovertebral tenderness.Extremities: No gross deformities, full and equal pulses on both extremities, (-) edema (-) cyanosis

Neurologic exam:

Cerebrum: Patient is conscious, coherent, oriented to time, place and person with GCS 15 (E4V5M6)

Cerebellum: No nystagmus, no dysmetria, and no dysdiadochokinesia

Cranial nerves

CN I: intact smell

CN II: 2-3mm, both equally reactive to light and accommodation

CN III, IV, & VI: intact six cardinal directions of gaze

CN V: Can clench teeth

CN VII: no facial asymmetry

CN VIII: intact gross bilateral hearing

CN IX and X: Uvula is at midline, (+) gag reflex

CN XI: can shrug shoulders

CN XII: tongue is in the midline

Pathologic reflexes: (-) Babinski

Signs of meningeal irritation: (-) Nuchal rigidity, (-) Brudzinski, (-) KernigsAssessment:

Upper GI BleedingPlan:

Diet: NPO temporarily except RebamipideIVF: D5 NSS x 80cc/hrDiagnostics:

CBC, FBS, PT, PTT, Blood typing, Na, K, Crea, SGPT, SGOT,

Fecalysis, Urinalysis

12 Lead ECG

CXR (PA-view)Therapeutics:

Rebamipide 100mg/tablet 1 tablet TID

Pantoprazole 40mg TIV OD30 minutes before breakfast

Transfuse 3 units PRBC properly typed and crossmatched

Give Diphenhydramine 50mg/ amp TIV 1 amp30 minutes prior to BT

SOP while on BT

Take note of color and size of stools

Refer to Gastro service for co-management and evaluation (for colonoscopy and EGD and anemia secondary)

JIIC Ganir

Co-JIIC De Perio

Lacuin

Taghavi