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Central Philippine University

COLLEGE OF MEDICINE
School Year:
First Semester

ADULT PATIENT HISTORY & PHYSICAL ASSESSEMENT
by:
Name: Lizlin Noemi C. Bajada
DATE AND TIME OF ASSESSMENT
Date of Interview: July 16, 2014
Time of Interview: 1:30 P.M
I.General Data

Name : Mrs. B.S.J
Sex : Female
Age : 36 years old
Birthdate : January 13, 1978
Civil Status : Single
Educational Attainment : College Graduate BS Accountancy
Nationality : Filipino
Blood Type : O+
Occupation : Currently unemployed
Religion : Iglesia ni Cristo
Place of Residence : Arevalo Villa, Iloilo
Source of Data : Patient
Reliability : 95% respectively
Date of Admission : July 3, 2014
Room Number : F15
II. Chief Complaint: Abdominal pain
III. History of Present Illness
Eight days prior to admission, the patient was discharge from previous hospitalization
due to Typhoid fever and urinary tract infection. She was prescribed with antibiotic,
Multivitamin (appeton) then was advice for follow up. However, as few days past, tolerated
abdominal pain, constipation and loss of appetite was noted.
One day prior to admission, patient had persistent diffuse abdominal pain, pain scale of
8/10, but non-radiating with associated dyspnea upon exertion. Patient seek for consultation for
further work up. Thus, opted for admission.
Pertinent Negatives:
-Diarrhea
-Hematemesis
-Fever
-Nausea and vomiting
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IV. PAST MEDICAL HISTORY
Childhood Illnesses: Chickenpox, Measles, No mumps and Scarlet Fever.
Adult Illness:
Medical: The patient was diagnosed with Rheumatoid Arthritis at Iloilo Mission Hospital
on 2004.She was 26 year old then. At the same year June 3 she was again diagnosed with
Hyperthyroidism at Western Visayas Medical Center due to persistent body malaise,
drastic weight loss, palpitations, heat intolerance, difficulty of swallowing, and slightly
enlargement of the neck. Her laboratory test results revealed T3,T4 and TSH level
increase. On June 10, the patient admitted at Iloilo mission hospital and diagnose Urinary
Tract Infection and typhoid fever due to persistent fever with associated, chills, headache,
dyspnea, and palpitations. No history of surgery, psychiatric disorder, allergies.
Immunization are unrecalled.
Obstetric/Gynecological: Menarche- 11 y.o
Menstrual Cycle duration = 2-4 days
Uses 2 pads/day
LMP- 2 mos ago
Nulliparous
V. FAMILY HISTORY
Her mother died at the age 65 due to cardiac arrest, had a history of diabetes mellitus,
while her father, 56, currently healthy, had a history of hypertension and arthritis. Her uncle died
with colon cancer. The patient is the eldest child among the 3 siblings. She has 2 younger
brothers who are currently healthy. On the other hand, there were no familial history of
hyper/hypothyroidism, anemia, liver and kidney diseases, tuberculosis, seizure or mental illness.
All of her siblings are currently healthy

VI. PERSONAL AND SOCIAL HISTORY

Patient is a resident of Arevalo, Villa Iloilo City. She lives together with her 2 siblings.
Their house is located along the road and is made of wood and other light materials with a 4 and
1 bathroom and pour-flash type room. No pets or any animals were noted in their home, a
garbage truck usually collects their garbage every week

Patient daily food intake usually consist of more than 2 cups or rice, chicken and
vegetables, and sometimes fish or pork. She usually takes at least 6 glasses of water a day. She
seldom drinks milk and consume junk foods. The patient does not drink coffee or tea. She is not
a cigarrette smoker but she is an occasional alcoholic beverage drinker. She has no history of
using illicit drugs or any alternative herbal medications. She is active in her religious activities
and she has a very good relationship with her neighbors.




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PHYSICAL EXAMINATION

GENERAL SURVEY:

The patient is lying in bed with one pillow placed beneath the head. She is awake, appears
tired and weak but well groomed (wears a hospital gown) and respond cooperatively. Ill looking,
slender, appears according to stated age. Makes eye contact and responsive to questions asked.
Conscious, coherent, and not in cardiopulmonary distress. Oriented to person, place, time and
situation.

VITAL SIGNS:

Temperature: 36.8 C
Pulse Rate: 88 beats/min
Respiratory Rate: 24 breaths/min
Blood Pressure: 80/60 mmHg

SKIN:
The patient has a brown complexion, smooth and even but appears pale; dry and slightly warm to
touch; with ecchymosis right antecubital fossa, with two inch linear burn scar on right wrist due
to childhood accident, appears well healed, with mole 1 inch on the right lateral heel, appears
bluish black in color similar to patch with irregular border. No hypo or hyper pegmented areas.
Without swelling, redness, bruise, cyanosis or pallor. No lesions noted. Normal skin turgor. Hair
is smooth and evenly distributed. Nails pinkish in color. Fingernails and toenails trimmed.
Edges are smooth and rounded. Capillary refill < 2 seconds. No clubbing of nails.

HEENT:

A. HEAD: Normocephalic and bilaterally symmetrical. Hair is black in color. Hair is evenly
distributed. Scalp is moist and without lesions. No nodules, masses, depressions, or tenderness
noted upon palpation of the scalp and face. No edema or lesions.

B. EYE: Symmetrical and dark brown in color. Eyebrows are symmetrical and evenly
distributed. No redness, edema, inflammation or lesions on the eyelids. Irises are flat and
symmetrical. Corneas are clear, convex, without lesions and with good sensitivity. Conjunctivae
are clear and shiny. No redness or exudates. Pale, dirty yellowish sclera noted. Pupils are equally
round and responsive to light and accommodation. There is presence of direct and consensual
reactions. Well-coordinated movements of the six cardinal directions of gaze.

C. EAR: External structures are bilaterally symmetrical. Auricles are of equal size, normal in
shape and at level with each other. No lesions, drainage, nodules or redness. External auditory
canals with minimal cerumen. Without redness, swelling or lesions. Mastoid area without
tenderness, redness or warmth. No perforations on both sides of the ears. With good ear recoil.

D. NOSE: Same color as the face. No masses, swelling, bleeding, lesions or foreign bodies.
Without flaring and discharge. Nasal septum midline without lesions or bleeding noted. Nasal
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mucosa pale in color, dry, and without swelling. No pain elicited upon palpation of the frontal
and maxillary sinuses.

E. MOUTH and THROAT: Lips are dark pink and dry. No lumps, lesions, ulcers or surface
abnormalities. Tongue is located in the midline, moves freely, dry, and without lesions but with
scanty white patches. Buccal mucosa is pink, moist, smooth, and is free from lesions. Gums are
pale red in color without swelling, inflammation, lesions or bleeding noted. Uvula is midline,
pink in color without swelling or exudates. Tonsils pink and without hypertrophy. With good gag
reflex.


NECK:
Symmetrical and with intact skin. No scars, visible pulsations, masses, swelling, or venous
distention. Able to perform active range of motion without pain. Lymph nodes non-palpable and
non-tender. Trachea is midline. There are no spasms or rigidity noted. Thyroid gland is palpable.
Lobes slightly enlarged, without nodules, tenderness or gritty sensation. No bruits upon
auscultation.

THORAX/LUNGS:
Chest wall is symmetrical with good chest expand. Respiratory rate and pattern is even,
coordinated, and regular with occasional sighs. Chest wall feels smooth, warm and dry upon
palpation. No tenderness, bulging or retraction of the chest and intercostal spaces. Front and back
of thorax with warm skin, normal turgor and moisture. No tenderness or subcutaneous crepitus.
Muscles feel firm and smooth. Diaphragm descend 5-6 cm upon full expiration. Tactile fremitus
with normal vibrations and voice sounds with normal transmission. No adventitious sounds
heard upon auscultation.

CARDIOVASCULAR:
Adynamic precordium. Jugular Venous Pressure is approximately 4 cm above the sternal angle
with of bed elevated to 30 degree. No bounding pulses. No distended neck veins. Point of
Maximal Impulse at 5
th
intercostal space Mid-Clavicular Line. Carotid Pulse, Brachial Pulse and
radial Pulse palpable. No heaves or thrills. No bruits. S1 louder than S2 at the apex. No murmur
was noted

ABDOMEN:
- Inspection: patients abdomen is flat, symmetric, and without masses and exaggerated
pulsations. Umbilicus is depressed with no signs of inflammation. No lesions and discolorations.
- Auscultation: Normal bowel sounds of 24 clicks per minutes. No bruits in all four quadrants.
-Percussion: tympani at the upper left quadrant. Dullness noted over the right upper quadrant.
- Palpation: Superficial - no tenderness and masses. Liver, Spleen, and Kidney not palpable.
-No rebound tenderness.

GENITOURINARY:
Not assessed but patient reported that there were no lesions, discharges and warts. Voided straw-
colored urine.

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MUSCULOSKELETAL:
Mandible is midline. Temporo-mandible joint is with good range of motion; without pain,
tenderness and swelling. Spine is with normal curvature and range of motion. Shoulders, arms
and elbows are symmetrical with normal contour; without nodules, swelling deformities, and
webbing between fingers. With joint deformities in the proximal phalangeal joints. Good range
of motion in the hips and spine. Legs, ankles and feet are without swelling, redness, nodules and
deformities. No unusual pigmentation. With good range of motion. Patient had some limited
movement due to muscle weakness.

NEUROLOGIC:
Mental Status: coherent and cooperative. She is oriented to time, place, person and other people.
With good memory, remote memory and general knowledge. Level of consciousness: Alert with
appropriate behavior and good hygiene. Has clear and spontaneous speech.
Cranial Nerves: I - XII = Intact
Motor System: good muscle bulk and tone
Muscle Strength: 4/5 upper extremities
4/5 lower extremities
Cerebellar : finger-nose intact
Romberg test not elicited
No pronator drift
Sensory : Pinprick, light touch, able to distinguish light touch from pain.
Babinski reflex absent
Reflexes. : 2+ and symmetric with plantar reflexes down-going
BICEPS TRICEPS BRANCH. KNEE
RT 2+ 2+ 2+ 2+
LT 2+ 2+ 2+ 2+
Cranial Nerves
CN 1 - Olfactory. - Sense of smell on each side intact.
CN 2 - Optic. - Visual Activity - able to read newsprint at 12 inches with eyeglasses.
CN 3 - Ocolomotor - Eyes move in conjugate fashion and converge when they
CN 4 - Trochlear - Look at near object; Able to look up and down;
CN 6 - Abducens - Able to look laterally; EOM - intact
CN 5 - Trigemiral - Sensation - with good blinking reflex
Mastication - No difficulty in mastication
CN 7 - Facial Expression - patient is able to smile and frown symmetrically
CN 8 - Vestibulocochlear - Hearing - Able to hear whispered words.
CN 9 - Glossopharyngeal - Swallowing - Able to swallow
CN 10 - Vagus - Gag Reflex - Intact Gag Reflex
CN 11 - Spinal - Neck Motion - Able to rotate the neck, reflexion and Extension, Able to shrug
shoulders.
CN 12 - Hypoglossal - Tongue Protrusion - Able to stick tongue out.



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DIFFERENTIAL DIAGNOSIS:


Differentials Rule In Rule Out
Urinary tract infection Abdominal pain
Fever,
Chills,
Malaise,
Dysuria,
Urinary urgency and
frequency,
A sensation of bladder
fullness or lower abdominal
discomfort,
Suprapubic tenderness

Typhoid Fever Abdominal pain
Fever (39-40 C),
Chills,
Rose spots,
Maculopapules,
Liquid diarrhea
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Working Diagnosis:Typhoid Fever

DIAGNOSIS
Diagnosis of typhoid fever (enteric fever) is primarily clinical.
Importantly, the reported sensitivities of tests for S typhi vary greatly in the literature, even among the
most recent articles and respected journals.
Culture
o The criterion standard for diagnosis of typhoid fever has long been culture isolation of the organism.
Cultures are widely considered 100% specific.

o positive for S typhi several days after ingestion of the bacteria secondary to inflammation of the
intraluminal dendritic cells. Later in the illness, stool culture results are positive because of bacteria
shed through the gallbladder.
o Blood culture: gold standard (2
nd
week)
o Stool culture alone yields a positive ( 3
rd
week)

o Bone marrow aspiration. Not routinely done. Highly suspicious cases or if negative blood or stool
culture. Done during illness. 5 days of prior antibiotic therapy.


MANAGEMENT

-If a patient presents with unexplained symptoms and returning from an typhoid fever (enteric fever)
endemic area or following consumption of food prepared by an individual who is known to carry typhoid,
broad-spectrum empiric antibiotics should be started immediately.
-Treatment should not be delayed for confirmatory tests since prompt treatment drastically reduces the
risk of complications and fatalities.
-Compliant patients with uncomplicated disease may be treated on an outpatient basis.
Malaise,
Constipation,
Weight loss
Hyperthyroid Heat intolerance,
History of Palpitations,
Muscle weakness
Weight loss
Oligormenorrhea
History of tremors,
T4 increase


Hypothyroid

Fullness in the throat,
Weakness in the extremities,
Dry skin,

Cold intolerance,
Weight gain,
Pitting edema of the lower
extremities
Hashimotos Disease

Dry skin,
Menstrual irregularities

Cold intolerance,
Weight gain

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-Must be advised to use strict handwashing techniques and to avoid preparing food for others during the
illness course.
-Hospitalized patients should be placed in contact isolation during the acute phase of the infection.
-Feces and urine must be disposed of safely.
TREATMENT:
Empirical treatment: Ceftriaxone, Azithromycin
Fully Susceptible: Ciprofloxacin (1
st
line), Amoxcillin (2
nd
line), Chloramphenicol
Multi-Drug Resistant: Ciprofloxacin, Ceftriaxone, Azithromycin.