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I. GENERAL DATA
Reliability: 85%
5 years prior to admission the patient persistent right lower quadrant pain that is relieved by rest.
4 years prior to admission the patient noticed a presence of the small inguinal mass in her right lower
quadrant of the abdomen with a size ranging from 10 -15 mm that is accompanied by pain whenever the
patient cough’s
A day prior to admission the patient no longer tolerated the pain which prompted her to go to the
Region 1 Medical Center
Integumentary: (-) Rashes (-) Lumps (-) Itching (-) Dryness (-) Change in nails
HEENT: (-) Trauma (-) Tenderness (-) Pain (-) Lacrimation (-) Redness (-) Photalgia (-) Hearing problem (-)
Discharge (-) Dryness (-) Bleeding (-) Sneezing (-) Discharges (-) Bleeding gums (-) Mouth sores
RESPIRATORY: (-) Hemoptysis (-) Grunting (-) Wheezing (-) Stridor (-) Pain (+) cough
CARDIOVASCULAR: (-) Palpitation (-) Angina (-) Edema (-) Orthopnea (-) PND
GIT: (-) LBM (-) Hemorrhoids (-) Vomiting (-) Melena (-) Hernia (-) Hematochezia (-) Hematemesis
MUSCULOSKELETAL: (-) flaccid (-) Stiffness (-) joint swelling (-) Trauma (-) Backache
V. FAMILY HISTORY
Both Parents are deceased, husband is also a Farmer, has 4 children (2 Males/2 Females) with 12
grandchildren.
The patient is living with his husband together with their 12 grandchildren. Family is living near the rice
fields, with a stream across. Source of drinking water is mineral water delivered to their home..
Vital Signs
Temperature: 36.8 °C
Respiratory Rate: 15
HEAD:
Head is symmetric, with good contour, no lumps nor lesions. Non tender sinuses upon palpation
EYES:
Good alignment, anicteric sclera, 3mm pupil size, tender orbital area right side
EARS:
Aligned no deformities, no discharge, positive cone of light on both ears, tender right auricular area
NOSE:
Symmetric, patent no septal deviation. Patent bilateral nares and negative discharge. No mass nor
lesions seen
MOUTH:
NECK:
CHEST:
Symmetric chest expansion, no chest tenderness, no wheezing heard, normal breath sounds.
ABDOMEN:
Symmetric flat, Veins not prominent, negative striae, and negative pulsations seen, normal bowel
sounds, post-surgical incision seen on right lower quadrant and midline (hypogastric region)
HEART:
Normal rate and rhythm, apex 5th ics, no murmur nor thrills, no muffled heart sounds
X-Ray:
Gas dilated loops of bowels predominantly of the small type are seen in the abdomen
obstruction.
PA view
Levin tube is seen with its tip collected at the gastric cavity
Changes