Internal Medicine

GENERAL DATA
• General Data : E.C ,51 yrs old,female,married, Catholic,Antipolo
• Birthday:Aug. 28,1966
• Date and Time of Exaination: 2/2/18 - 1;30pm
• Confined at QMMC Ward on Jan. 27,2018
CHIEF COMPLAINT
• CC: “ Diffuse abdominal pain”
HISTORY OF PRESENT ILLNESS
• 3 days PTA , patient had a sudden episode of a diffuse crampy
abdominal pain,VAS 10/10 ,with associated symptoms of
undocumented intermittent fever ,nausea, nonprojectile vomiting of
bilous vomitus amounting to 2 cups per episode and two times
nonbloody diarrhea.

• pain radiation on shoulder

• Patient self-medicated with unrecalled dosage of Kremil S ,no consult
was done
HISTORY OF PRESENT ILLNESS
• 1 day PTA ,with progressive symptoms ,hencepatient consulted a local
clinic.Patient was then advised to be admitted and had take home
medication of unrecalled dosage of Buscopan , with no relief. Hence
patient consulted QMMC.
HISTORY OF PRESENT ILLNESS
PAST MEDICAL HISTORY

• (-) Hypertension, (-) Kidney Disease, (-) Diabetes, (-)Tuberculosis, (-)

Asthma,(-) Allergy, (-) Arthritis (-) Cancer
• (+) QMMC, diagnosed with Gallstone- Waived Surgery
• (-) Accidents
• (-) Surgery, Blood Transfusion
• (-) allergies
FAMILY HISTORY

• (-) Gout ;(-) Hypertension ;(-) Heart Disease; (-) Diabetes; (-) Kidney
Disease; ; (-) Cancer
PERSONAL AND SOCIAL HISTORY

• (-) Smoker
• (-) Alcohol
• (-) illicit drug use
• (-) sexual activity
• (-)tattoos and body piercing
PERSONAL AND SOCIAL HISTORY
• (-) Exercise

• Living Arrangement: 4 in house

• OB history : G5P5 (5005)
REVIEW OF SYSTEMS
• General : (+) weightloss ( ???? ) ; (+) chills , (+) sWEATS

• Skin : (-) rashes ; (-) itching ; (-) bruIsing ; (+) PRURITUS

• HEENT : (+) headache ; (-) syncope; (-) blurring of vision on both eyes
; (-) loss of vision ; (-) eye discharge ; (-) ear pain ; (-) deafness ; (-)
epistaxis; (-) soreness of throat; (-) hoarseness ; (-) dyysphagia , (-)
odynophagia
REVIEW OF SYSTEMS
• Respiratory : (-) wheezing

• Cardiovascular: (-) palpitation ; (-) cyanosis; (-) edema ; (-) cold

extremities

• Gastrointestinal: (-) loss of appettite ;(-) dysphagia ;(-) change in

bowel habits ;(-) change in stool

• Genitourinary : (-) dysuria; (-) changes in color of urine; (-) urinary

retention ; (-) urinary incotinence; (-) dysuria , (-) hematuria ,(-)
pyuria,(-) incontinence, (-) pain or colic
REVIEW OF SYSTEMS
• Musculoskeletal: (-) muscular weakness; (-) atrophy ; (-) night cramps

• Endocrine : (-) heat and cold intolerance; (-) polyphagia; (-)

polydipsia; (-) polyuria
PHYSICAL EXAMINATION
• Examined on Feb .2 , 2018 (patient’s 6th day of admission)

• General Survey : awake ,conscious, coherent

• Vital Signs : BP = 90/70; HR = 99/min ; RR= 25/min; Temp= 36.4

PHYSICAL EXAMINATION

• HEENT: hair average texture ; (-) pale conjuctivae; anicteric sclerae;

(+) pale mucosa
hearing is good to whispered voice; nasal mucosa is pink,septum
midline; no tenderness on frontal and maxillary sinuses; oral
mucosa is pink and pharynx with no exudates; (-) mass on
anterior neck ; (-) cervical lymph
- (-) jaundice
PHYSICAL EXAMINATION
• Lungs : unremarkable

• Cardiac: no heaves; no thrills; Apex beat and Point of Maximal

Impulse (PMI) at the 5th ICS; noted S1 and S2; no adventitious
heart sounds, regular rate and rhythm;
PHYSICAL EXAMINATION

• Abdomen: globular ,non-distended; no lesions and hematoma;

hypoactive bowel sounds ,(-) tenderness on all quadrants ,(-) Murphy
;(-) fluid wave, (-) shifting dullness , (-) Kidney punch
DDX
• 1. Chole - more likely sabi ni doc

• DDX
• ACUTE PANCREATITIS
• AGE
• Thyroid problem

• Accd sa chart : acute renal failure with anterior neck mass ????
SALIENT FEATURES
Primary Working Impression
DIFFERENTIAL DIAGNOSIS
MOST LIKELY LESS LIKELY
MOST LIKELY LESS LIKELY
MOST LIKELY LESS LIKELY
DIAGNOSTIC PLAN
THERAPEUTIC PLAN
THANK YOU VERY MUCH 