Date of Interview: September 19, 2019

Time of Interview: 9AM

I. GENERAL DATA

V.A. 67 y/o female farmer from Urdaneta City, Pangasinan

Source of information: patient

Reliability: 85%

II. CHIEF COMPLAINT: “bukol sa tyan” (luslos)

III. HISTORY OF PRESENT ILLNESS

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

IV. Review of Systems

General: (-) Chills (-) Sweats (-) poor oral intake

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

GUT: (-) polyuria (-) Hematuria (-) Anuria (-) Oliguria

ENDOCRINE: (-) night sweats (-) Excessive sweating (-) polydipsia

MUSCULOSKELETAL: (-) flaccid (-) Stiffness (-) joint swelling (-) Trauma (-) Backache

NEUROPSYCHIATRIC: (-) seizures

V. FAMILY HISTORY

Both Parents are deceased, husband is also a Farmer, has 4 children (2 Males/2 Females) with 12
grandchildren.

No History of Hypertension, Diabetes, Tuberculosis & Cancer in the Family

VI. SOCIOECONOMIC HISTORY

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..

VII. PHYSICAL EXAM

Vital Signs

Blood Pressure: 120/80

Temperature: 36.8 °C

Cardiac Rate: 85 bpm

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:

Pink lips and oral mucosa, abraded enamel on upper incisors

NECK:

No lumps nor lesions, no tenderness no palpable lymph nodes, no bruit

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:

Plain Upright (AP upright & Supine views)

Gas dilated loops of bowels predominantly of the small type are seen in the abdomen

without significant air-fluid level. Findings are suggestive of small bowel

obstruction.

No significant air fluid level

No definitive pneumoperitonium seen

The renal areas and psoas outlines are obscured

Flank stripes are delineable

No definite pathologic intra-abdominal calcification is noted

Marginal Spurring is noted in the lumbar spine suggestive of degenerative changes

PA view

Levin tube is seen with its tip collected at the gastric cavity

No definitive lung infiltrate is seen

Heart is magnified. Aorta is atherosclerotic

Diaphragm and both costophrenic sulci are unremarkable

Visualized bones are demineralized

Marginal spurring is noted in the thoracolumbar spine is suggestive of degenerative

Changes

IMPRESSION: Indirect Inguinal Hernia Right incarcerated