History # 4

Name of the Patient: MM

Informant: Patient
Reliability: Self informed, 90%
Historian: Sevilla, Romelyn S.
Group # 3 Section F

Preceptor: Dr. R. dela Cruz

Date of Interview: January 22, 2014
Date Submitted: January 27, 2014

GENERAL DATA:
MM is a 26 year old male, married, Filipino, Roman Catholic, born on December 11,
1987 in Dr. Jose Fabella Memorial Hospital. He is a student and a pedicab driver. He resides at
Villa Teresa, Marulas, Valenzuela City. MM had his first consultation at Fatima University
Medical Center on January 22, 2014 at around 9:00 am.
CHIEF COMPLAINT: Pain in the left subcostal at the level of the xiphoid process
HISTORY OF PRESENT ILLNESS:
MM stated that a week prior to his consultation, he experienced a sudden pain on his left
subcostal at the level of his xiphoid process which lasted for about 10 minutes. He said that the
pain is twitching and localized. He did not take any medications for this pain but he took a rest
which relieved the pain. MM rated the pain as 5 on a scale of 1 to 10, with 10 being the worst
possible pain. He denies any head trauma, recent illness, fever, tinnitus or other neurologic
symptoms.
PAST MEDICAL HISTORY:
Immunizations: Patient has complete immunizations.
Childhood Illnesses: Patient had mumps, measles and chicken pox.
Adult Illness: Patient had tetanus.
Allergy: Patient has no known allergies.
Psychiatric Illnesses: There were no known psychiatric problems.
Previous Hospitalization: Patient has not been hospitalized.
Previous Medications: Patient has not received any medications.
Previous Surgeries: Patient has not undergone any surgical procedures.
Blood Transfusions: Patient has not experienced any blood transfusion.
FAMILY HISTORY:
Patients father, 43, died because of a bus accident while his mother, 51, is still alive. He
has three siblings. There is a history of hypertension on his fathers family side. No known
history of heredofamilial disease such as cancer and goiter. No known history of familial
diseases such as pulmonary tuberculosis, hepatitis infection and arthritis.
PERSONAL AND SOCIAL HISTORY:
MM is currently taking a vocational course on Automotives and, at the same time,
working as a pedicab driver for 2 years. He had also worked in a computer shop as a keeper for
5 years. He started smoking when he was 16 years old wherein he consumes 5 sticks per day.
He also drinks hard alcoholic beverages 4x a week. MM had not used any prohibited drugs. He

eats three times a day and prefers fish and vegetables as viand. He also takes multivitamins
daily. He sleeps from 10:00 pm to 4:00 am.
MM lives in an apartment together with his wife, child, mother and youngest sibling. The
house is made of cement, with 3 windows, one bedroom and one toilet (manual flushing). Water
used for drinking is mineral water. Garbage is collected every Wednesday and Saturday. He has
a pet dog.
REVIEW OF SYSTEMS:
General:
(-) chills
(-) tremors
(-) dizziness
(-) fever
(-) malaise
(-) weakness
(-) weight loss
(-) fatigue
Integumentary:
(-) dryness
(-) itchiness
(-) jaundice
(-) hematoma
(-) sweating
Head and Neck:
(-) head injury
(-) lymphadenopathy
(-) mass
Eyes:
(-) blurring of vision
(-) diplopia
(+) reading glasses
(-) lacrimation
(-) pain on both nasal sides
(-) photophobia
Ears:
(-) hearing loss
(-) tinnitus
Nose and Sinuses:
(-) disturbance in smell
(-) epistaxis
(-) obstruction
(-) pain
Mouth:
(-) disturbance of taste
(-) sore throat
Respiratory:
(-) back pain
(-) chest pain
(-) colds
(-) dyspnea
(-) wheezes
(-) cough
CVS:
(-) chest pain
(-) dyspnea
(-) easy fatigability
(-) orthopnea
(-) palpitation
(-) syncope
GIT:
(-) abdominal enlargement
(-) anorexia (-) constipation
(-)
diarrhea
(-) dysphagia
(-) flatulence (-) hematemesis
(-)
hematochezia
(-) melena
(-) nausea (-) steatorrhea
(-) vomiting
GUT:
(-) discharge
(-) dysuria
(-) flank/suprapubic pain (-) oliguria
(-) hematuria
(-) incontinence
(-) nocturia
(-) polyuria
(-) passage of stone
(-) urinary incontinence
Musculoskeletal:
(-) atrophy
(-) back pain
(+) joint pain: every morning
(-) muscle pain
(-) swelling
(-) restriction of motion
(-) weakness
(-) bone deformation
Neurological:
(-) dizziness
(+) memory loss: sometimes
(-) syncope

(-) tremors
(-) weakness/paralysis
(-)
hallucinations
(-) seizures
Endocrine:
(-) abnormal growth
(-) easy fatigability
(-)
urinary
frequency
(-) goiter
(-) heat/cold intolerance (-) insomnia
(-) polydipsia
(-) polyphagia
(-) polyuria
Hematological:
(-) easy bruisability
(-) easy fatigability
(-) pallor

GENERAL SURVEY:
MM is a 26 year old man who appears healthy. He is awake and oriented to person, time
and environment. He has a medium built-body with a height of 165.1 cm and a weight of 54.4
kg. He has a brown complexion. When spoken to in a normal voice, he responds quickly and
fluently.
He is a smiley person and is cooperative during the physical examination. He wears tshirt, shorts and slippers. Any odor from him is absent. Overall, he is well-groomed. His posture
while sitting is slouched. He stands erect, sits and lies down without discomfort. He also walks
smoothly with balance. There are no motor abnormalities and gross deformities seen.
VITAL SIGNS:
Palpatory systolic pressure: 120 mmHg.
Blood pressure: 110/70 mmHg left arm, sitting.
Cardiac rate: 71 beats per minute and regular.
Respiratory rate: 16 cycles per minute.
Temperature: 36.7C, axillary.
Pain scale: zero, not in pain.
PHYSICAL EXAMINATION:
Integumentary:
Patients skin is brown in color, smooth and warm by touched. It is mobile and can return
to its normal state easily. There is no pallor, petechiae, ecchymoses, scaling, rashes and edema
seen. However, tattoos are present on his right arm (10 cm) and right forearm (11.5 cm).
Patients hair is black in color, smooth and equally distributed. His nails do not show clubbing.
Capillary refill is less than two seconds.
HEENT:
Cranium
Patients natural hair color is grayish white, abundant, well distributed and smooth, and
has a moist texture. The scalp has no lesion and lice. There are no sutures seen. The cranium
is normocephalic, symmetrical and has no deformities. Temporal arteries are not visible but
palpable with weak pulsation.

Face
The face is symmetrical and has no abnormal facies. Skin is brown in color, smooth and
has no lesions. Face has no involuntary movements.
Eyes
Eyebrows are black in color, thin and well distributed. Eyelashes are black, short, and
are present in both upper and lower eyelids.
Eyelids have no lesions, no edema and are negative for lid lag. Palpebral fissure is
about 4 cm in diameter. There is no ptosis. Eyeballs have no sign of exopthalmos and
enopthalmos. Periorbital areas are not sunken. There is no swelling and hematoma noted.
Conjunctivae are pale in color. There is no edema and lesions noted. Sclera is dirty
looking, white in color and has no lesions noted.
Cornea is transparent, clear and has no
lesions noted. Iris is round and brown in color. Pupils are round, symmetrical and about 4 mm
upon constriction. There is normal accommodation reflex and is reactive to both direct and
consensual light. Lenses are transparent.
The patient was able to read the smallest font in a newspaper print at a distance of
about one foot. There are no gross deformities in the visual fields and no tenderness noted
upon palpation. Fundoscopy is positive for red orange reflex.
Ears
External ears are triangular in shape and symmetrical. There are no deformities, lesion
and tenderness noted over the auricles and mastoid. External auditory canals are patent, and
have no discharges and foreign bodies. Walls are pinkish in color. Tympanic membrane is
pearly white and showed a good cone of light. There are no retraction and perforation seen.
Patient can hear the rubbing of fingers on both ears.
Nose
Nose is symmetrical and blunt. There is no flaring of ala nasi. Vestibule is patent.
Mucosa is pinkish in color with no secretions and bleeding. Nasal septum is straight at the
midline and has no perforation. Upon transillumination, there are no tenderness and clouding of
paranasal sinuses noted.
Mouth and Throat
Lips and buccal mucosa are pinkish in color and moist. There are no lesions and
swelling noted. Tongue is in the midline. It can move without difficulty upon protrusion and
retraction. There is no hypertrophy, atrophy and lesions observed.
The patient has no upper teeth. Gingivas are pinkish and have no bleeding and
hypertrophy. Palate is pinkish and has no lesion. Uvula is in midline. Palate wall has
symmetrical elevation. Tonsils are small and pink. Posterior pharyngeal wall is pinkish and has
no lesion, swelling and exudates.
Neck
Skin is brown in color. The neck is symmetrical and has well developed muscles. There
is no deformity and deviation noted. Trapezius and sternocleidomastoid are well developed and

normotonic. Trachea is in midline. Thyroid gland is not visible and palpable. There is no
submental, preauricular, posterior auricular, occipital, tonsillar, submandibular, superficial
cervical, posterior cervical, deep cervical and supraclavicular adenopathy.

Chest and Lungs:

Inspection
Skin is fair in color. Lesions and subcutaneous blood vessels are absent. Bony thorax is
symmetrical, elliptical in shape and has no deformities. Retraction, bulging, narrowing or
widening of intercostals spaces, and lagging are also absent. Respiratory rate is 16 cpm.
Inspiration is longer than expiration with effortless breathing, and has symmetrical lung
expansion.
Palpation
Chest expansion was symmetrical. Muscle tenderness is absent. There is normal equal
tactile fremitus on both lung fields.
Percussion
Percussion note is resonant over the lung areas.
Auscultation
Breath sounds are vesicular on both lung fields. There are no bronchophony, egophony,
whispered pectoriloquy and adventitious sounds heard.
Cardiovascular:
Inspection
Bulging or depression of the precordium is absent. The apex beat is seen at the 5 th
intercostal space left midclavicular line. There are no visible pulsations on base epigastric and
parasternal areas. Carotid pulsation is visible. There is no neck vein distention. JVP is 9 cm.
Palpation
The apical beat is at the 5th intercostal space left midclavicular line. Palpable pulsations,
thrills, heaves, and lifts are absent.
Auscultation
Heart rate is within the normal range and regular. S1 is loudest at the apex while S2 is
loudest at the base. Physiological splitting is not appreciated. There are no murmurs and gallop.
Radial, brachial, carotid, femoral, popliteal and dorsalis pedis arteries are bilaterally normal, and
has equal rate and normal rhythm. Bruit on the carotid artery is absent.

Abdominal Examination:
Inspection
Abdomen is flat and symmetrical. Waist circumference is 75 cm. Umbilicus is inverted.
Skin is brown in color. Hair is minimal and well distributed. There are no striae, scars, prominent
blood vessels, visible peristalsis and visible masses.
Auscultation
Bowel sound on RLQ is 7 per minute. Abdominal bruits both on epigastric and lumbar
area are absent.
Palpation
Abdomen is soft in consistency. Masses and tenderness on all quadrants on both light
and deep palpation are absent.
Percussion
All four quadrants are tympanitic. Liver span is 7 cm. Fluid wave, shifting dullness, and
direct and rebound tenderness are absent. Patient is negative for Rovsings sign, Psoas sign,
Obturator sign, Costovertebral angle tenderness and Murphys sign.
Musculoskeletal Examination:
Hands
Nail beds are pinkish in color. Nail plate abnormalities, clubbing, swelling of nail folds
and nodes are absent. No swelling is noted on the interphalangeal and metacarpophalangeal
joints. Signs of tenderness or anything that can suggest scaphoid fracture in the anatomical
snuffbox are absent. There is full range of motion on both hands as to flexion, extension,
adduction and abduction of the fingers, and apposition of thumb.
Wrists joint
Swelling, tenderness and crepitus are absent. There is bilateral full range of motion as to
flexion, extension, adduction and abduction of the wrist. Pain or tingling sensation is absent
upon performing Phalens and Tinels signs. Allen test shows that ulnar and radial arteries are
not occluded.
Forearm
Muscle mass is symmetrical on both forearms. Physical deformities, swelling and
tenderness are absent. Styloid process is palpable. There is bilateral full range of motion as to
supination and pronation.
Elbow joint

Medial and lateral epicondyles, and olecranon process are palpable. Deformities,
swelling, tenderness and crepitus are absent on the elbow joint. There is full range of motion on
both sides as to flexion and extension.
Upper arm
Muscle mass is symmetrical on both upper arms. Muscle deformity, swelling and
tenderness are absent.
Shoulder joint
Coracoid process, acromion process and greater tuberosities of humerus are palpable.
Muscle mass is symmetrical on both shoulders. Swelling and tenderness are absent. There is
bilateral full range of motion on both shoulder joints as to flexion, extension, adduction,
abduction, internal and external rotation, and circumference.
Neck/Spine
There is normal prominence of the C7 spinal vertebrae. Curvature of the spine is good.
There is full range of motion of cervical spine as to flexion, extension, rotation, and lateral
bending. Muscle deformity, swelling, tenderness, and crepitus of spinous process and
paravertebral muscle are absent.
Hip joint
Iliac crest, iliac tubercle and greater trochanter are palpable. Deformities, swelling and
tenderness on hip joint are absent. Patricks test, straight leg raising and Trendelenbergs test
show negative results. There is bilateral full range of motion as to flexion, extension, adduction,
abduction, and internal and external rotation.
Knee joint
Medial and lateral epicondyles are palpable. Deformities, swelling, tenderness, cysts on
anterior and posterior of knee joint, and crepitus are absent. There is bilateral full range of
motion as to flexion, extension, internal rotation and external rotation.
Ankle joint
Calcaneus, and lateral and medial malleolus are palpable. Muscle deformities, swelling
and tenderness are absent. There is full range of motion on both ankle joints as to eversion,
inversion, dorsiflexion & plantarflexion.
Foot
Metatarsophalangeal joint, and proximal and distal interphalangeal joints are palpable.
Muscle deformities, swelling and tenderness of both pedal and big toes are also absent. There
is bilateral full range of motion as to flexion and extension.

Neurological Examination:
Cerebral Function
The patient is conscious, coherent, was oriented to person, time and place, no slurring of
speech, was able to follow simple commands, can do simple calculations, was able to recall 3
out of 3 objects, was able to know the former president of the Philippines, was able to answer
the situation given to him with good judgment.
Cerebellar Function
Patient is able to bilaterally execute finger to nose test smoothly. Able to perform rapid
alternating pronation and supination. Able to perform heel to shin test smoothly at both sides.
Dysmetria, dysdiadochokinesia and intentional tremor are absent. Patient can easily execute
tandem walking.
Cranial Nerves
I: Patients olfactory nerve is intact because he can distinguish the smell of coffee on both
nostrils.
II: Patients optic nerve is intact, can read a font size of 10 on a newspaper at a distant of 1 foot.
Visual Acuity is 20/20 able to read the smallest font of the jaegers chart. Visual field is normal,
able to identify fingers at 6 cardinal directions. For fundoscopy, fundus is normal.
II (Optic) & III (Oculomotor) are intact. Both pupils are round and respond to direct and
consensual light stimuli, which constrict to about 3 mm. Ptosis is absent.
III(Oculomotor), IV(Trochlear) & VI(Abducens) nerve are intact. There is intact extraocular
muscle movement. Patient is able to follow the six cardinal gazes.
V Trigeminal nerve is intact. Patient was able to distinguish different kinds of sensation in the
facial area. Muscles of mastication does not show atrophy. There is positive corneal reflex. A
normotonic & symmetrical muscle tension can be observed upon clenching of teeth.
VII Facial Nerve is intact. Patient can identify sweet and bitter taste or able to distinguish
different kinds of taste sensation in the ant. 2/3 of the tongue. Nasolabial folds are symmetrical.
Left and right facial movements are intact. There is also symmetrical muscle tension upon
closing the eyes. Able to demonstrate normal tone and force in the muscle of facial expression.
VIII Acoustic nerve is intact. Both ears can hear & localize the source of the sound produced by
rubbing fingers. Patient was able to repeat words whispered to him and was able to localize the
sound.
IX (Glossopharyngeal) & X (Vagus) nerve is intact. Uvula in the midline. Palate symmetrically
rises upon saying aah. Gag reflex is intact.

XI Spinal Accessory nerve is intact. No fasciculations, tremors or atrophy noted. Patient was
able to shrug his shoulders equally and bow his head with resistance. Able to rotate his head
against resistance. Muscles are normotonic.
XII Hypoglossal nerve is intact. Tongue is in the midline, symmetrical when protruded. Deviation
upon protrusion and retraction are absent. No fasciculations and involuntary movements
observed
Motor Testing
Atrophy, hypertrophy, involuntary movements and fasciculation are absent upon
inspection. Muscle tone is normotonic No spasticity, rigidity or hypotonicity. Muscle strength is
5/5 bilaterally.
Deep Tendon and Pathologic reflexes
Tests for biceps, triceps, knee and ankle reflexes are all normal with a grade 2. Patient is
negative for Babinski, Chaddock reflex and Openheim signs.
Sensory Exam
Intact and equal levels of sensation for pain, crude touch and position sensation on both
upper and lower extremities are observed. Stereognosis and graphesthesia are present and
normal. Rhombergs test is negative.
Meningeal Signs
Patient is negative for Kernigs and Brudzinski sign. Nuchal rigidity is absent.