Date of interview: February 1, 2017 Informant: Patient

History taken by: John Lester V. Butac Percent Reliability: 90%

IDENTIFYING DATA: Amelita Moscardon, 45 years old, female, married, Filipino, housewife, Roman
Catholic, born in Iloilo on February 21, 1971, presently residing at Batasan Hills, Quezon City, admitted
for the second time at FEU-NRMF Medical Center on January 20, 2017.

CHIEF COMPLAINT: abdominal pain

HISTORY OF PRESENT ILLNESS:

The history of present illness started one month prior to admission as epigastric pain characterized
as mild stabbing but does not radiate to other region of the abdomen. The symptom is associated with easy
fatigability and shortness of breath. The sudden shortness of breath was described as a drowning feeling
that awakens her from sleep. Patient is relieved when sleeping in right lateral decubitus position with 1
pillow orthopnea. No consultations made due to the fear to doctor.

One week PTA, patient experienced epigastric pain characterized as severe stabbing pain which
occurs twice a day for two hours duration. It does not radiate to other parts of the abdomen but pain is
aggravated by doing household activities and usually relieved by drinking hot water. There are no
associated symptoms such as fever, headache, nausea and vomiting.

Three days PTA, patient still had epigastric pain but does not radiate to other region of the abdomen.
Pain is associated with dizziness and poor appetite.

One day PTA, patient experienced progressive stabbing pain in the epigastric area described as
feeling of losing consciousness which radiates all over the abdomen. Abdomen is firm and bloated.

Eight hours PTA, patient still with progressive stabbing epigastric pain which radiates to whole
abdomen and back.

One hour prior to PTA, patient still with severe stabbing abdominal pain and self-medicated
Loperamide 2mg but did not relieved any pain. This prompted the patient to seek consult in FEU-NRMF
Medical Center and was subsequently admitted.

PAST HEALTH HISTORY:

-Patient had chicken pox during his childhood.
-had received BCG immunization
-2001, admitted at a public hospital in Manila for about 1 week duration due to miscarriage
-2011, admitted at FEU-NRMF hospital due to miscarriage
-No history of allergies, blood transfusions, accidents, injuries, or psychiatric diseases

FAMILY HISTORY:
Mother: Catalina, 70s, apparently well
Father: Agapito, 80s, apparently well
1st Children: 18 yrs old, apparently well
2nd & 3rd: deceased due to miscarriage
4th children: 14 yrs old, apparently well

- No history of heredo-familial diseases such as cancer, stroke, diabetes, tuberculosis, heart diseases, kidney
diseases, blood disorders and psychiatric illnesses.
PERSONAL AND SOCIAL HISTORY:
The patient is married for 20 years with her husband, 45 yrs old who is apparently well. She is a
housewife but she usually sew clothes. Her sleep pattern is from 10 PM to 3 AM daily. She eats 3 times a
day usually with vegetables and meat. She used to drink coffee, but stop for 2 years ago. She is non-smoker,
non-alcoholic. There is no illicit drug use. No history of STI.

MENSTRUAL AND OBSTETRIC HISTORY:

The patient had her menarche at the age of 13. Subsequent menses were irregular, duration of 3
days, with mild flow using only 1 pad per day. Her LMP was in December. She is gravida 4, parity 2 with
2 instantaneous abortion (2022). All was delivered normal. She didn’t used any birth control methods.

REVIEW OF SYSTEMS:
Constitutional symptoms: (-) Weight loss, (+) generalized body weakness, (+) easy fatigability, (-) fever,
(-) chills, (-) decreased appetite
Skin: (-) itchiness, (-) easy sweating, (+) cyanosis (-) pallor (-) jaundice (-) erythema
Head: (-) headache, (+) dizziness, (-) vertigo
Eyes: (-) pain (-) blurring of vision, (-) double vision, (-) photophobia, (-) excessive lacrimation, (+) use of
eyeglasses
Ears: (-) slight deafness on both ears, (-) ear ache, (-) tinnitus, (-) ear discharge
Nose and Sinuses: (-) changes in smell, (-) nose bleeding, (-) nasal obstruction, (-) nasal discharge, (-) pain
over nasal sinuses
Mouth and Throat: (-) toothache, (-) gum bleeding, (-) disturbance in taste, (-) sore throat, (-) hoarseness
Neck: (-) pain, (-) limitation of movement, (-) mass
Breast: (-) pain, (-) lumps, (-) nipple discharge
Respiratory: (-) pleuritic chest pain, (-) hemoptysis, (+) cough, (-) sputum production, (-) audible wheezing
Cardiovascular: (-) substernal pain, (-) palpitations, (-) orthopnea, (-) syncope
Gastrointestinal: (-) nausea, (-) vomiting, (-) dysphagia, (+) diarrhea, (-) constipation, (-) regurgitation
Genitourinary: (-) dysuria, (-) urinary frequency, (-) urgency, (-) hesitancy, (-) polyuria
Extremities: (+) edema, (-) swelling of joints, (-) stiffness, (-) numbness, (-) limitation of movement
Nervous: (-) headache, (-) syncope, (-) vertigo, (+) loss of consciousness, (-) focal weakness, (-) paralysis,
(-) numbness, (-) paresthesia, (-) speech disorder, (-) memory loss, (+) confusion
Hematologic: (-) bleeding tendency, (-) pallor, (-) easy bruising
Endocrine: (-) intolerance to heat and cold, (-) polydipsia
PHYSICAL EXAMINATION

General Survey
The patient is awake, alert, and response appropriately to verbal stimuli; looks appropriate to stated age,
well-kept and clean, cooperative, rational, friendly and interested in the interview; mood is euthymic and
appropriate affect; no signs of distress.

Vital signs:
BP: 110/80 CR: 61
RR: 18

HEENT

Head: normocephalic, symmetric; thick, black with evenly distributed hair, coarse and oily; temporal
arteries have equal pulsations, smooth consistency of arterial walls and are not tortuous; scalp has no
tenderness, scars, scales, masses nor lice;

Face: oval, symmetrical, normal facie , fair-skinned with hyperpigmented nevi over the left eyelid, left
cheek and lower right chin, no involuntary movements, no masses.

Eyes
Eyebrows: hair are evenly distributed, intact, symmetrically aligned; eyelashes: thick, evenly distributed,
curled outward, no matting; eyelids: intact, no presence of discharge and discoloration, lids close
symmetrically with bilateral blinking; palpebral conjunctiva is pink, smooth and shiny with transparent,
white sclera; eyeballs: normally aligned, intact, no exophthalmos or enopthalmos; lacrimal glands show no
edema or tenderness.

(Opthalmoscopic Examination was not performed due to time constraint)

Cornea is transparent, shiny, smooth; Iris are visible and flat, round, and brown in color; Pupil is black,
equal in size, round with smooth border; Lens is transparent, positive with the red-orange reflex, presence
of retinal vessels and normal optic disc.

Ear: normal in size, symmetrical, no deformity, swelling, lumps, pain, discharge, inflammation and no
tenderness

(Otoscopic exam was not performed due to time constraint)

Ear is patent, pearly white and intact, flat tympanic membrane no discharge, no swelling in the walls of ear
canal,

Nose: symmetrical, no flaring, nose tip not tender

(Nasal cavity and paransal sinuses not assessed due to time constraint)
Nasal cavity is patent and pink in color; Septum is pink in color and at the midline; Turbinates are pink in
color and flat; frontal and maxillary sinus is non-tender, (+) to transillumination test

Mouth: pink, symmetrical, moist, no lesion; buccal mucosa pink and smooth; pink gingiva, no swelling
nor bleeding; teeth is complete, no dental carries, good oral hygiene; roof, floor and palate pinkish, no
lesions; uvula in the midline, tonsils not enlarged, pharynx is pink, no lesions, no exudates

Neck: normal in size, symmetrical, no visible mass, deformity, swelling; normal range of motion; Trachea
is in the midline; Lymph nodes are not palpable; Thyroid gland is not visible nor palpable
Thorax and Lungs:
Thorax: skin is brown, elliptical, symmetric with normal AP diameter; no lesions, dilated blood vessels,
deformities; symmetrical chest expansion. Lungs: normal tactile fremitus; right lung is more resonant than
the left; vesicular breath sounds with occasional wheezing on right and left posterior apices.

Cardiovascular System (not performed due to time constraint):

Jugular vein not visible; carotid arteries are weak and unequal; the location of the precordium is in 5th
ICS at 1-2cm medial to LMCL or 7-9 cm from the midsternal line; size is <2.5cm and the amplitude is
normal; auscultated heart rate has a regular irregular rhythm; soft sound can be heard from both S1 and S2;
no splitting S1/S2 as well as S3 and S4.

Peripheral Vascular System: erythema on the left forearm and hematoma at the right antecubital fossa,
no cyanosis, no dilated blood vessels; no clubbing of the fingers, peripheral pulses for brachial, radial is 1+
weak, irregular rhythm.

Abdomen (not performed due to time constraint): symmetrical, brown in color, shape is flat, umbilicus
is inverted, no macules, papules nor scars; no bulging flanks and localized bulges; no dilated blood vessels,
nor abnormal pulsations; no visible peristalsis, no mass; bowel sounds are normoactive; no bruit heard over
the epigastrium, right and left paraumbilical areas; liver span is normal; no masses or splenomegaly

Extremities (not performed due to time constraint): peripheral pulses in the femoral, popliteal, anterior
tibial, dorsalis pedis, brachial, and radial areas are normal; no cyanosis, clubbing, or edema are noted.

Neurological (not performed due to time constraint): cranial nerves II-XII, motor and sensory of the
upper and lower extremities, gait and cerebellar function are all normal; reflexes are symmetrical bilaterally
in both extremities.