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Y CASE
REPORT
SUBMITTED BY,
CHANDRAN SRINIVASAN
ROLL NO : 19
BATCH: IMD 14
SECTION: C
ROLL NO:- 19
SEX: MALE
CITIZENSHIP-I INDIAN
CURRENT ADDRESS: MARFORI, DAVAO
Name- T.J.M
Sex-Male
Religion- Catholic
Nationality- Filipino
Occupation-Student
Informant-Mother
Relibility- 90%
Chief Complaint:-
3 days prior to admission the patient present with right lower quadrant abdominal pain withthe pain
scale of 7/10, associated with 2 episodes of vomiting which was watery.The patient also had
persistent fever , the temperature wasn’t documented.The patient took paracetomol and acyclovir
no consult was done.Due to the persistent symptoms, it prompted the patient to consult a doctor.
Past medical history:- No history of previous traumaNo history of previous hospitalizationNo history
of previous medical illnesses.No previous surgical history noted.
Family history:- The patient has 7 members in the family including his parents and siblings.No family
history of hypertension, DM, asthma or any mental illness.
Immunization:-
The patient has a complete history of immunization taken from the barangay.Last year he took an
anti-meseals shot from the school .
Diet- the patient consumes 2 cups of rice with vegetables or chicken as well as eatsstreet food and
drinks milk and soft drink. The patient doesn’t smoke nor consumes
alcohol . The patient isn't allergic to food nor medicinesThe patient has no travel history.
Environmental history:-The patient stay in a clean house but the surrounding around isn't that
hygienic,there are mosquitoes around the house . The school which he goes to is clean
andhygienic.They dont have any pets in the house.
Eye: pain(-),redness(-),itching(-)
Ear: deafness(-),tinnitus(-),discharge(-)
Nose:epistaxis(-),discharge(-),sinusitis(-)
Cardiac : pain(-),edema(-),palpitations(-)
Vascular: phlebitis(-),claudication(-)
PHYSICAL EXAMINATION:-
HEART RATE: 85
HEIGHT:150cm
WEIGHT: 40 kg
CONSCIOUS, FEBRILE.
CARDIOVASCULAR:
ABDOMEN:-
SPECIAL TESTS:- ROVSING’s SIGN: +veTENDERNESS OF RLQ IF PALPATE LLQ. PSOAS SIGN:
+veTENDERNESS ON EXTENSION OF THE RIGHT LEG
Differential Diagnosis:-
Acute Appendicitis
Rebound tenderness
PANCREATITIS
RULE IN RULEOUT
CHOLECYSTITIS:-
RULE IN RULEOUT
Fever No nausea
CASE 2:-
GENERAL DATA
– NAME: EV
– AGE:30YEARS
– SEX: FEMALE
– RELIGION: CATHOLIC
– NATIONALITY: FILIPINO
– OCCUPATION:HOUSEWIFE
– INFORMANT: PATIENT
– RELIABILITY: 95%
CHIEF COMPLAINT
ABDOMINAL PAIN
– THE PATIENT WAS DIAGNOSED AS CHOLECYSTITIS LAST YEAR .SHE HAD A PROVOCAL
AT THAT TIME.SHE GOT RELIEVED AT THAT TIME.
OB-GYNE HISTORY:
– MENARCHE: 14 YEARS
– DURATION: 4 DAYS
– SYMPTOMS: NO DYSMENORRHEA
IMMUNIZATION :
FAMILY HISTORY
THE PATIENT HAS FAMILY HISTORY OF DIABETES MELITUS ON HER MATERNAL SIDE.NO
KNOWN PATERNAL ILLNESS. NO OTHER FAMILY HISTORY OF HYPERTENSION, TB, HEART
DISEASE, ANEMIA, OR ANY MENTAL ILLNESS.
PERSONAL AND SOCIAL HISTORY
THE PATIENT LIVES WITH HER FAMILY. THE PATIENT IS NON SMOKER, NON
ALCOHOLIC AND NO OTHER ILLICIT DRUG USAGE.NO ALLERGIES TO ANY FOOD ,
MEDICATION, PET ,DRUGS.
TRAVEL HISTORY:
ENVIRONMENTAL HISTORY
REVIEW OF SYSTEMS
GENERAL SURVEY: (-)WEIGHT CHANGE, (-)INSOMNIA, (-)FATIGUE, (+)LOSS OF
APPETITE(LATE)
NOSE: (-)POSTNASAL DRIP; (-) RHINORRHEA ; (-) DISCHARGE, (-)SINUSITIS, (-) NASAL
CONGESTION
PHYSICAL EXAMINATION
VITAL SIGNS:
TEMPERATURE: 36.1°C
HEIGHT: 150cm
WEIGHT: 49 kg
BMI: 23
SKIN: COLD, PALE AND SOFT TO TOUCH, WITHOUT ANY DISCOLORATION OR LESIONS,
CAPILLARY REFILLING TIME TWO SECONDS
CHEST EXAMINATION:
BREAST EXAMINATION:
NOT PERFORMED.
CARDIOVASCULAR SYSTEM:
ABDOMINAL EXAMINATION:
PERCUSSION:NOT PERFORMED
SALIENT FEATURES:
• GC 38 YEARSOLD FEMALE.
• ABDOMINAL (RUQ)PAIN
• WEAKNESS
• FATIGUE
• LOSS OF APPETITE
• TENDERNESS ON PALPATION
• AGE: 30 YEARS
• SEX: MALE
• NATIONALITY: FILIPINO
• INFORMANT: PATIENT
• RELIABILITY:92%
CHIEF COMPLAINT
TWO MONTHS PRIOR TO ADMISSION PATIENT MET WITH A VEHICULAR ACCIDENT AND GOT
INJURIES IN THE LOWER PART OF THE LEFT LEG.ONE DAY PRIOR TO ADMISSION THE
PATIENT WAS SCHEDULED FOR SKIN GRAFTING SURGERY.SO THE PATIENTSEEKED
CONSULTATION AND GOT ADMITTED.
FAMILY HISTORY:
REVIEW OF SYSTEMS
(-)THYROID PROBLEMS
PHYSICAL EXAMINATION:-
VITAL SIGNS:
TEMPERATURE: 36.5 °C
HEIGHT: 170cm
WEIGHT: 60 KG
RESPIRATORY SYSTEM:
INSPECTION:CHEST EXPANSION SYMMETRIC ON BOTH SIDES.
PERCUSSION: NORMAL RESONANT SOUNDS WERE HERD OVER THE LUNG FIELDS.
CARDIOVASCULAR SYSTEM:
ABDOMINAL EXAMINATION:
IMPRESSION
SKIN GRAFTING
DIFFERENTIAL DIAGNOSIS:
MANAGEMENT:
A SOFT SILICONS WOUND CONTACT DRESSING IS BEEN USED THAT IT CAN BE CHANGED
OFTEN AND PATIENT EXPERIENCE LITTLE PAIN . IT IS ALSO PROVIDES STRUCTURAL SUPPORT
FOR THE GRAFT.
CASE 4
GENERAL DATA
Name:-BR
Age:-57
Sex:-MALE
Occupation:-GOVT. EMPLOY
Religion:-PROTESTANT
Marital status:-MARRIED
Nationality:-FILIPINO
Informant:-PATIENT
Reliability:-95%
5 days Prior to consult patient had anal pain. Pain lasts for almost 20min. Patient describe the character of pain
as hitting pain. The pain increases if the px sits for a long time or had a long bike ride. Patientt consulted a local
doctor and was medicated with tinitol and suppositories which give him relief
No surgical history.
No accidents or trauma.
No psychiatric history.
Environmental history:-
FAMILY HISTORY:
The patients grandmother had hypertension. No known paternal and maternal illness.
REVIEW OF SYSTEM:
(-)WEAKNESS;(-)FATIGUE;(+)ANOREXIA
(-)Thyroid problems
GASTROINTESTINAL: (-) Nausea, (-) Vomiting, (-)Heart burn ; (-) Bloody stool;
Bp:- 150/90)
H.R:- 74bpm
P.R:- 66bpm
Temp. :- 36°c
Ht. :- 5'7
Wt. :- 81kg
GENERAL: PATIENT IS AWAKE ,ALERT , ORIENTED AND CONSCIOUS ,FEBRILE ,NOT IN RESPIRATORY
DISTRESS,AMBULATORY.
EYES: SYMMETRICALLY ALIGNED EYES AND EYEBROWS.UPPER EYELIDS COVER THE PORTION OF THE IRIS. PINK
PALPEBRAL CONJUNCTIVA. PUPILS ARE EQUAL ROUND AND REACTIVE TO LIGHT .NO DISCHARGE NO PTOSIS.
Mouth- - No ulcers noted; No whitish or reddish lesion noted; Absence of bleeding gums; No deviation of the
tongue, Uvula in the midline; Rising of the soft Palate noted with the use of tongue depressor, no swelling of
tonsils noted.
AUSCULTATION:NO ADVENTITIOUS SOUND HEARD LIKE CRACKLES, WEEZES OR Vesicular sounds heard on
auscultation.
CARDIOVASCULAR:
INSPECTION: adynamic precordium, no lesions, no scars, no deformities. , PMI at 5th intercostal space, mid-
clavicular line left side at the apex.
ABDOMEN:
PERCUSSION: tympanic
DIAGNOSIS: Hemorrhoids
DIFFERENTIAL DIAGNOSIS:
Anal Fissure
Bloody stools
ULCERATIVE COLITIS:-
Reliability: 85%
CHIEF COMPLAINT:
2 weeks PTA patient had lower stomach pain and it has been getting worse. Patient
described the pain as sharp and constant pain on both sides of the lower abdomen. No
alleviating or aggravating factors and no radiations informed. A few days PTA patient
patient experienced nausea and chills. Patient had slight vaginal bleeding Patient came in to
the hospital due to unbearable pain in the lower abdomen.
OB/GYNE History :
The patient had her menarche when she was 13 years old. It lasts 5 to 7 days and
it is regular and she has cramps.
Family History :
The patient has a family history of Hypertension diabetes and bad arthritis.
Patient was born in the city and is Afro-American. Patient is 17 y.o. And is a
student.patient is allergic to dogs and cats and is asthmatic. Patient does not consume
alcohol. No history or drug abuse or substance abuse noted. Patient has 1 sexual partner
and uses condoms as contraceptive.
REVIEW OF SYSTEM:
General: (-) weight loss, (-) malaise, (-) fatigue, (-) anorexia, (-) insomnia
Head: (-) headache, (-) dizziness, (-) disequilibrium Eyes: (-) Lacrimation , (-) blurring of
vision, (-) itchiness, (-) pain
Ears: (-) pain, (-) tinnitus, (-) hearing loss, (-) hearing difficulty
Mouth & Throat: (-) gum bleeding, (-) mouth sores, (-) sore throat, (-) hoarseness Neck: (-)
pain, (-) lumps, (-) mass, (-) cervical lymphadenopathy
Breast: (-) pain, (-) lumps, (-) discharge Respiratory: (-) orthopnea, (-) nocturnal cough, (-)
hemoptysis, (-) cough
Urinary: (-) frequency, (-) dysuria , (-) nocturia , (-) hematuria , (-) flank pain, (-) incontinence
Genitalia: (-) discharge (+) cramps Peripheral Vascular: (-) phlebitis, (-) varicose
Musculoskeletal: (-) joint swelling, (-) joint pain, (-) cramps, (-) limited range of motion, (-)
gout
Neurologic: (-) fainting, (-) seizures, (-) motor and sensory loss, (-) difficulty remembering
PHYSICAL EXAMINATION:
The patient is lying in bed, conscious and alert, she is able to respond cooperatively to
questions during the course of the interview.
VITAL SIGNS:-
Temperature 100.3F
Weight :-61 kg
Height:- 5’3
Skin: Skin is pale and uniform in color. There are no rashes, scars and discoloration.There
was no presence of clubbing or cyanosis. She had warm and moist skin with senile skin
turgor. Nails have good capillary refill time.
Eyes: Anicteric sclera, pale conjunctiva, pupils equally reactive to light and accommodation.
Lungs:
Cardiovascular:
Inspection: Apex beat at fifth intercostal space, left midclavicular line. Adynamic
precordium
Palpation: PMI felt at fifth intercostal space, left midclavicular line. No heaves or thrills
Abdomen:
Inspection: Globular, no masses and scars. No dilated veins and palpitations of abdominal
aorta, ascites was not noted.
Percussion: Tympanic
Genitourinary: cervix is symmetric and open, it appears inflamed and there is small amount
of blood and mucous at the cervical OS. There is adnexal tenderness.
Extremities: Symmetrical, strong pulse, no atrophy, capillary refill time of less than 2
seconds. With ulceration at left foot below the 4th toe, measuring about 0.5 inches. With
thickening of skin at right plantar area.
Salient Features:
Age : 17yrs FEMALE
Lower abdominal pain
Blood in urine
Cramps on period
Mucopus in cervix
Differential Diagnosis:
1. Appendicitis
2.PID:-
3.Diverticulitis :-
Discussion:- Pelvic inflammatory disease is an infection of the uterus and cervix untreated
PID might cause scar tissue and collections of infected fluid ( abscesses) to develop in your
Fallopian tubes and damage your reproductive organs. Due to the use of condoms the
patient’s introitus must have had a change in the ph. Causing inflammation and constant
coitus must have caused inflammation a diagnostic test for gonorrhea was done and
confirmed. Patient has pelvic inflammatory disease with a gonococcal infection.
Final Diagnosis: Pelvic inflammatory disease secondary to gonococcal
infection
CASE 6 - VR :-
Name: T.J.
Reliability: 85%
Chief Complaint:
5 hours priors to admission the patient had a right lower quadrant pain and said it was
constant. The patient characterized the pain as burning. The pain was aggravated on
straightening up and alleviated on bending forward. No radiations noted and only
associated symptom was nausea and it was only when the pain was unbearable.
Family History:
Patient is a 7 male and is 18y.o. and has had sexual partners and uses condoms. Patient
has 2 older brothers. Patient doesn’t smoke nor consume alcoholic beverages. Patient
consumes coffee and has a regular diet.
Review of Systems
General: (-) weight loss, (-) malaise, (-) fatigue, (-) anorexia, (-) insomnia
Mouth and Throat: (-) gum bleeding, (-) mouth sores, (-) sore throat, (-) hoarseness Neck:
(-) pain, (-) lumps, (-) mass, (-) cervical lymphadenopathy
Respiratory: (-) orthopnea, (-) nocturnal cough, (-) hemoptysis, (-) cough
Gastrointestinal: (-) vomiting, (-) dysphagia, (-) jaundice, (-) hematemesis, (-)
abdominaldistention, (-) reflux, (-) colicky pain, (-) diarrhea, (-) bleeding, (-) hemorrhoids, (-)
constipation
Urinary: (-) frequency, (-) dysuria, (-) nocturia, (-) hematuria, (-) flank pain, (-) incontinence
Musculoskeletal: (-) joint swelling, (-) joint pain, (-) cramps, (-) limited range of motion, (-)
gout
Neurologic: (-) fainting, (-) seizures, (-) motor and sensory loss, (-) difficulty remembering&
Hematologic: (-) abnormal bleeding, (-) easy bruising Endocrine: (-) heat intolerance, (-) cold
intolerance, (-) excessive sweating
Physical Examination:
The patient is lying in bed, conscious and alert, she is able to respond
cooperatively to questions during the course of the interview.
Weight :-63kg
Height :- 5’7
Skin: Skin is pale and uniform in color. There are no rashes, scars and discoloration.There
was no presence of clubbing or cyanosis. She had warm and moist skin with senile skin
turgor. Nails have good capillary refill time.
Eyes: Anicteric sclera, pale conjunctiva, pupils equally reactive to light and accommodation.
Cardiovascular:
Inspection: Apex beat at fifth intercostal space, left midclavicular line. Adynamic
precordium
Palpation: PMI felt at fifth intercostal space, left midclavicular line. No heaves or thrills
Abdomen:
Inspectiom: Globular, no masses and scars. No dilated veins and palpitations of abdominal
aorta, ascites was not noted.
Percussion: Tympanitic
Salient Features:
Age : 18y.o., RLQ abdominal pain * Burning pain and constant *Psoas sign positive
Differential Diagnosis:
1. Cholecystitis.
3. Acute appendicitis.
MANAGEMENT: APPENDECTOMY.
REFLECTION PAPER:
In Surgery Modular School And Clinical Rotation,
First I Went To Clnical Rotation In Spmc Under Dr.Samantha Cunanan. I Learned How To
Take History And Physical Examination.
Vr Under Dr. Josil Cruz., In Vr I Gained Knowledge About Requesting Lab Test Which Are
Necessary & Came To Know How To Manage With Appropirate Treatment And Proper
Management. This Will Definitely Help Me Out In My Clerkship And Also For My Future.