RAMOS, CRISS RAYMOND P.

MED II-B
CLASS NUMBER 37
GENERAL DATA:
July 2, 2010
This is the case of patient X, a 44 year-old female, Filipino and is a resident of Lower
Brookside, Baguio City, Philippines. The patient is a Roman Catholic. The patient is
separated from his husband. She is currently working as a sales lady at Center Mall.
She has 5 living children, 4 of which dont live with her already. The patient was
born on ________ and was born in Lingayen, Pangasinan. She was previously
confined for the delivery of her 5th child. The informant is the patient herself and has
80% reliability.
CHIEF COMPLAINT: Insomnia
HISTORY OF PRESENT ILLNESS:
2 months PTC, the patient started to have difficulty sleeping. Her usual sleeping
time is 9:00 pm and when she tries to sleep beyond that time, shell be in a lot of
trouble trying to sleep. The patient has verbalized that she has been consuming
energen prior to sleeping. She feels cold at night so she wanted to drink something
warm. Since she does not want to drink coffee she opted to have energen.
Whenever she is not able to have a substantial amount of sleep, she experiences
head ache. She feels this pain along the nape area, characterized as dull and is not
radiating to any other part of the body. She has rated the pain as 5/10. She said that
she takes relief by drinking water. She takes in vitamin C and Ferrous Sulfate. She
also associates her difficulty to sleep with her constant thinking. A lot of things
bother her mind. She feels weak whenever she isnt able to sleep but generally
would not affect in her ADLs.
PAST PERSONAL MEDICAL HISTORY:
The Patient was born via NSD, with no known allergies, and she had received
vaccines when she was young but failed to remember them. She had UTI about 5
months ago. She sought consult at the Baguio General Hospital and details of it
cant be recalled. She was confined at a hospital (cant remember) for her 5 th
delivery. The first 4 children were born via Normal Spontaneous Vaginal Delivery at
their home supervised by a midwife. She has history of injury and that was when
she was a child. She acquired bruises on the left arm and on the forehead. She
occasionally drinks alcohol, doesnt drink coffee and tea and doesnt smoke.
OB-GYNE HISTORY

The patient had her menarche at the age of 17 with a 2-day duration. Her menstrual
flow was said to be moderate and has an OB scoring of G6P5 (5-0-1-5). Her first 4
children were all delivered via Normal Spontaneous Vaginal Delivery. LMP was
second week of June 2010.
SOCIAL AND ENVIRONMENTAL HISTORY:
The patient is living in a rented room shared by her son and niece. They have a
common toilet for all occupants; they segregate their garbage and are collected by
a garbage truck. Their direct source of drinking water is through water delivery.
There are no pets inside the house. The patient finished college and earned a
secretariat degree. She ran her own business before and is now working as a sales
lady at Baguio Center Mall. The patient does not take any drugs, alcohol or smoke
tobacco. Her diet is usually composed of vegetables and avoids meat. She is fond of
eating wheat bread instead of the usual Filipino heavy meal. She seldom completes
the required 8 hour sleep since she experiences insomnia.
FAMILY HISTORY:
The patients father died of complications of hypertension at the age of 68; her
mother died of complications of diabetes at the age of 58. Their family has a history
of hypertension and diabetes. The Patient has _ siblings and all are alive and well.
All her children are all doing fine in their own endeavors.

REVIEW OF SYSTEMS:
1. General: ( ) fatigue, ( ) weight gain, ( ) fever, ( ) chills, ( ), night sweats, ( )
dizziness
2. Skin: ( ) rash, ( ) itching, ( ) moles, ( ) sores, ( ) hives, ( ) pigmentation
3. Head and Neck: ( ) headache, ( ) trauma, ( ) pain, ( ) stiffness, ( ) swelling
a. Eyes: ( ) pain, ( ) diploplia, ( ) scotoma, ( ) visual dysfunction, ( )
dryness, ( ) redness, ( ) tearing, ( ) use of corrective lenses
b. Ears: ( ) difficulty hearing/deafness, ( ) tinnitus, ( ) pain, ( ) discharges, (
) vertigo/dizziness
c. Nose: ( ) epistaxis, ( ) dryness, ( ) pain, ( ) discharge, ( ) obstruction,
( ) smell dysfunction, ( ) sneezing
d. Mouth: ( ) soreness, ( ) pain, ( ) ulcers, ( ) hoarseness, ( ) dryness, ( )
gum and dental problems
4. Breast: ( ) discharge, ( ) lump/mass, ( ) pain, ( ) bleeding, ( ) infection
5. Respiratory: ( ) cough, ( ) dyspnea/shortness of breath, ( ) sputum, ( )
hemoptysis, ( ) cyanosis, ( ) wheezing/asthma, ( ) occupational exposure,
( ) tuberculosis/PTB exposure, ( ) past PPD, ( ) previous chest x-ray.
6. Cardiac: ( ) chest pain/discomfort, ( ) orthopnea, ( ) dyspnea, ( )
paroxysmal nocturnal dyspnea, ( ) palpitation, ( ) undue fatigue, ( ) edema,
( ) cyanosis, ( ) syncope, ( ) hypertension, ( ) past heart diseases, ( )
exercise limit
7. Vascular: ( ) intermittent claudication, ( ) leg cramps, ( ) ulcers, ( ) varicose
veins
8. Gastrointestinal: ( ) anorexia, ( ) nausea/retching, ( ) vomiting, ( )
dysphagia, ( ) hematemesis, ( ) indigestion, ( ) melena, ( ) hematochezia, (
) heart burn, ( ) abdominal pain, ( ) abdominal distention, ( ) jaundice, ( )
diarrhea, ( ) constipation, ( ) change in bowel movement habits, ( ) hernia, (
) haemorrhoids, ( ) use of laxative
9. Renal and Urinary: ( ) dysuria, ( ) hematuria, ( ) incontinence, ( ) nocturia, (
) urinary frequency, ( ) dribbling, ( ) kidney stones
10.Gynaecological: (+) menarche (age) 17 y/o, (+) cycle regular, (+) duration of
menstruation 2 days, ( ) abnormal bleeding, ( ) vaginal discharge, ( )
itching, ( ) dysmenorrhea/pelvic pain, ( ) dyspareunia, ( ) contraceptive use,
( ) history of venereal diseases, (+) number of pregnancies 6, (+) number
and type of deliveries: 5 and all are delivered via NSVD, ( + ) abortions:
Miscarriage of the 6th child, ( ) birth control method, ( ) menopause (age)

11.Male Genitalia: ( ) pain, ( ) swelling, ( ) urethral discharge, ( ) hernias, ( )

testicular pain, ( ) masses, ( ) history of venereal disease, ( ) erectile
dysfunction/potency, ( ) sexual habits, ( ) ulcers
12.Musculoskeletal: ( ) muscle pain, ( ) joint pains, ( ) cramps, ( ) weakness,
( ) stiffness, ( ) history of trauma, ( ) swelling, ( ) limitation of motion, (+)
backache
13.Haematological: ( ) anemia, ( ) excessive bleeding, ( ) easy bruising, ( )
past transfusions
14.Endocrine and metabolic: ( ) heat/cold tolerance, ( ) weight change, ( )
thyroid problem, ( ) excessive sweating, ( ) polydipsia, ( ) polyphagia, ( )
hair change
15.Nervous System: (+) headaches, ( ) syncope, ( ) seizure, ( ) weakness, ( )
head trauma, ( ) stroke, ( ) sleep disorder, ( ) coordination problem, ( )
sensory disturbance, ( ) motor problem, ( ) tremors, ( ) memory
16.Psychiatric/Emotional: ( ) anxiety, ( ) depression, ( ) loss of control/violence,
( ) nervousness, ( ) memory change, ( ) suicide attempts, ( ) substance
abuse