Class

No.
(font
26;
bold)

NAME: EBRON, MARLON DEAN B.

nd

2 year Section A2
Preceptor: Doctor Nepomuceno

Report No. 6

Date of Meeting: (09/18/14)

Date of Admission: 09/08/14
Date of Interview: 09/12/14

SOURCE AND RELIABILITY:

The daughters of the patient, the two daughters only have a fair reliability only the other daughter has a
good reliability
PATIENT PROFILE:
Patient, C.E., is a 74 year old male, Filipino, Roman Catholic, and was born on December 30, 1938 at
Masbate. The patient is widowed and lives with his 3 daughters at Sta. Mesa, Manila. Their house is a
two storey house made of concrete.
He is a retired machine operator. He started working at 39 years old, and retired in 2001. His bills are
going to be shouldered by his philhealth and his pension.
The patient only stays home, and living a sedentary lifestyle, his usual day is waking up in 5:30am then
read the newspaper and at 6:30am he eats his breakfast, usually pandesal or any rice meals, 9-11 am he
usually walks or bikes around outside, around 11am-12nn is his usual lunch time his food is commonly
consists of rice and pork or fish as a viand. Around 12nn 3pm he usually just watch television or just
sleep. His evening sleep is being disturbed at times due to the pain hes feeling at his abdomen.
Patient has current maintenance drugs. June 2014, he was prescribed with Tamsulosin for his diagnosed
BPH. August 2014 he was prescribed with eperisone(myonal) a muscle relaxant, Rosuvastatin and
motilium.
CHIEF COMPLAINT:
Chronic abdominal pain of 6 months duration
HISTORY OF PRESENT ILLNESS:
The abdominal pain started over the epigastric area and the pain is aggravated upon palpation and
whenever the patient changes his position while lying in bed. The pain also usually occurs after eating
also thus, resulting to his loss of appetite.Patient also feels abdominal distention and feeling of being full
most of the time.
3 months PTA, is the onset of his abdominal pains and has an intermittent regularity. Mostly the pain
occurs in the afternoon or evening, with a pain scale of 6/10. The patient also had a feeling of dribbling
and forceful urination and took antibiotics for 4 weeks. Also at that time the patient was diagnosed with
Benign Prostatic Hypertrophy.

2 months PTA, another onset of abdominal pain with a pain scale of 6/10 as stated by the patient and
only self-medicated with kremil-s.
1 month PTA, Patient sought to consultation and went at the OPD, and motilium was prescribed, at this
time there are no episodes of epigastric pain.
1 week PTA, Patient stated that he has a feeling that his abdomen is moving, then the patient now has
loss his appetite due to the pain, the severity was increased to 7/10 pain scale rating and the patient
stated decrease in amount of stool upon defecation.
6 days PTA, abdominal pain persisted in the morning and still took motilium as intervention. Same thing
happened on the next day.
4 days PTA, The pain still persisted but this time with a pain scale rating 0f 8/10 and he then went to the
emergency room he had 2 pain relievers and was given buscopan intravenously.
3 days PTA the patient was released in the ER at around 5am and went home, around 9 am the
abdominal pain recurred again so they went back to the OPD where blood and urine test was done,
results of the urinalysis showed elevation in the WBC which is a sign of UTI and was given Ciprofloxacin.
After the OPD on their way home the patient then felt DOB, and had him rest only.
2 days PTA, patient felt an excruciating pain with pain scale of 10/10 as stated by the patient, they went
back to UERM and was ordered for KUB and results showed positive in gall bladder stones. Pain still
persistent on the next day that time the whole abdomen hurts.
On the day of admission, the patient can no longer hold the pain, he is already holding back and
manifests DOB.
The patient has positive abdominal distention, (+) constipation, (+) abdominal pain, (+) gall stones upon
KUB, (+) abdominal pain upon palpation change in position and movement in the abdomen, (+) Dribbling
of urine, (+) urinary continence. (+) BPH, (+) UTI. But the patient did not show, diarrhea, did not show
mass in the abdomen. Patient was also taking antibiotics when diagnosed with UTI thus could lead to
affect normal flora in the GIT but theres no diarrhea.
PAST MEDICAL/SURGICAL/HEALTH MAINTENANCE HISTORY:
The patient is complete of immunizations, he already had previous medical consultation, as a teenager
1992 he had an episode of abdominal pain and doctor said that it was caused by his cigarette smoking,
he was advised to stop. June 2014nhe was diagnosed with BPH and was given Tamsulosin for
maintenance. May 2014 he had a severe headache with pain scale rating of 9/10 and was ordered to
have CT scan and MRI, no abnormalities were found.

FAMILY HISTORY:
His father died of cancer, and his mother died at 94 years old due to old age.

Father Died
Of Cancer
Mother Died of
old Age
Patient
1st

sister- died

When giving birth

2nd sister
3rd brotherdied due
Stab wounds
4TH Brother
5th sister Dead
unknown age
Brother 86 years
Old
Died at birth
Sister 68 years
old

REVIEW OF SYSTEMS:

GENERAL

DESCRIPTION
FEVER_(-)_ FATIGUE_(-)_ SWEATING_(-)_
WEIGHT LOSS_(-)_ WEAKNESS_(-)_

SKIN

Loss of appetite but there

was no prominent weight
loss

COLOR_N_ TEXTURE_ N _ ITCHING_(-)_ RASHES_(-)_

CHANGES IN HAIR/NAILS_(-)_

EYES

VISUAL IMPAIRMENT_(-)_ REDNESS_(-)_ TEARING_(-)_

PAIN_(-)_ DOUBLE VISION_(-)_ DISCHARGE_(-)_ TRAUMA_(-)_

EARS

HEARING_ N _ PAIN_(-)_ DISCHARGE_(-)_ TINNITUS_(-)_

NOSE THROAT MOUTH

OLFACTION_ N_ HOARSENESS_(-)_ SORE THROAT_(-)_ TRAUMA_(-)_
FREQUENT COLDS/CONGESTION_(-)_ NOSE BLEEDING_(-)_
NECK MASS_(-)_ DENTAL CARIES_(-)_ MIDFACIAL PAIN_(-)_
SINUS DISORDER_(-)_ GUM BLEEDING_(-)_ TOOTHACHE_(-)_
RESPIRATORY
COUGH_(-)_ DIFFICULTY OF BREATHING_(+)_
WHEEZING_(-)_
TB/TB EXPOSURE_(-)_ HEMOPTYSIS_(-)_
CARDIOVASCULAR
PALPITATION_(-)_ SYNCOPE_(-)_ CHEST PAIN_(-)_
EDEMA_(-)_ HYPERTENSION_(+)_ ORTHOPNEA_(-)_ DYSPNEA_(-)_
GASTROINTESTINAL

Difficulty of breathing was

noted
due
to
the
unbearable pain the patient
was feeling
Heart rhythm is normal

DYSPHAGIA_(-)_ NAUSEA_(-)_ VOMITING_(-)_LOSS OF APPETITE_(+)_

ABDOMINAL PAIN_(+)_ MELENA_(-)_ ULCER PAIN_(-)_
JAUNDICE_(-)_ BLEEDING_(-)_ INDIGESTION_(-)_ HEART BURN_(-)_
HEMATEMESIS_(-)_ FATTY FOOD INTOLERANCE_(-)_
STOOL FREQUENCY_(+)_ CHARACTER (Soft watery stool)
HEMORRHOIDS_(-)_
ABDOMINAL DISTENTION_(+)_ HERNIA_(-)

URINARY
PAIN_(-)_ VOLUME_(decreased)_ RETENTION_(+)_ BLEEDING_(-)_
STREAM_(-)_
STONES_(-)_ INFECTION_(+)_ HESITANCY_(-)_ URGENCY_(-)_
CHANGE IN COLOR_(-)_ FREQUENCY_(decreased)_ DRIBBLING_(+)_
POLYURIA_(-)_ NOCTURIA_(-)_

GENITOREPRODUCTIVE
MENARCHE_(-)_ POST MENOPAUSAL_(-)_
EXTREMITIES

Loss of appetite was shown

due to the pain in the
abdomen upon intake of
food
Abdominal pain was noted
as
recurrent
and
aggravated by movement
and change in position
while lying down. Patients
pain scale upon admission
was 10/10 and was
unbearable
Abdominal distention was
noted upon palpation
Constipation was noted as
decrease in amount of stool
upon defecation
Gall bladder stones was
noted as the KUB was done
to the patient
He was diagnosed with UTI
as a result of his urinalysis.
Patient
has
URINARY
RETENTION, decrease in
frequency and DRIBBLING
OF URINE which is due to
his BPH

CYANOSIS_(-)_ CLUBBING_(-)_ EDEMA_(-)_

VARICOSITY_(-)_ ULCERS_(-)_

HEMATOPOIETIC SYSTEM
EXCESSIVE BLEEDING/BRUISING_(-)_ ANEMIA_(-)_ PICA_(-)_
NERVOUS SYSTEM
HEADACHE_(+)_ TREMOR_(-)_ FAINTING SPELLS_(-)_ SEIZURES_(-)_
DIZZINESS/VERTIGO_(-)_ HEAD TRAUMA_(-)_
SENSORY PERVERSIONS_(-)_

Patient had an unbearable

headache where CT scan
and MRI was done, results
showed
were
unremarkable and was
relieved with pain relievers

MUSCULOSKELETAL
JOINT STIFFNESS__(-) PAIN_(-)_ SWELLING_(-)_
MUSCLE WEAKNESS_(-)_

ENDOCRINE SYSTEM
HEAT/COLD INTOLERANCE_(-)_ THYROID PROBLEMS_(-)_
NECK SURGERY/IRRADIATION_(-)_
DM INDICATORS_(-)_
PSYCHIATRIC
MOOD SWINGS_(-)_ BEHAVIORAL CHANGES_(-)_
ANXIETY_(-)_ DEPRESSION_(-)_

TEMPORAL PROFILE:

Abdominal Pain

Headache

GENERAL SURVEY:
The patient is chronically ill but alert, awake,coherent and cooperative, lying on the bed. Responds softly.
He is well groomed and appropriately dressed for the weather. He is showing slight respiratory distress ,
and shows no anxiety or depression. He shows appropriate affect during the interview and observes eye
contact also. Mood is observed as euthymic.

VITAL SIGNS:
BP: 150/70
HR: 98BPM
RR: 20 breaths/min
Temp: 37.5 degree celsius

PHYSICAL EXAMINATION:
SKIN:. No jaundice. No cyanosis. No abnormal lesions noted. Good skin turgor.
HEAD: No deformities. No lesions.
EYES: Anicteric Sclera. Pink palpebral conjunctiva. Pupils are equal, reactive to light and accomodation
EARS: No discharge, tenderness, or lesions
NOSE: No tenderness, lesions, discharge or obstruction.
MOUTH: Pink buccal mucosa. No ulcers. Tongue at midline.
NECK: No lesions or masses. Trachea at midline. No enlarged cervical lymph nodes. No bruit. No jugular
vein distention.
CHEST: No lesions, deformities, or masses. No retractions. Symmetrical expansion of the chest. No
adventitious breath sounds on all lung fields. Regular rhythm. No murmurs. No thrills. Apex beat and PMI
at 5th ICS left MCL.
ABDOMEN: No lesions or masses. Distended. No bowel sounds heard on auscultation. Tympany on
percussion on all regions. Tenderness on all regions, especially right hypochondriac and epigastric
EXTREMITIES: No clubbing. Capillary refill less than 2 secs.