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Physician Chief Complaint(s) History of Present Illness The patient presents with pain on suprapubic area and radiating pain on both flanks. He described the pain as severe with an intensity of 9/10. Two weeks prior to admission, patient experienced frequent urination in small volumes. He self medicate it with water and the pain was relieved and apparently well. 3 hours PTA he experienced low-grade fever and chills along with nausea, shortness of breath, chest pain and bright red blood in the urine and dysuria hence was rushed to the Davao Medical Center by 911. At 11:00 P.M. the patient decided to be transferred to DMSF hospital. Past History Patient had mumps at 9 years old and chicken pox at age of 12. Adult Illnesses : Medical. Last 2001, patient was diagnosed with tuberculosis of the lungs. He underwent 6 months of drug therapy. He also stated that he has high blood pressure as high as 160/120 and was diagnosed last year. He is not taking any maintenance for his hypertension. Surgical. None Psychiatric. None Health Maintenance. Immunizations. Patient is not able to recall his immunizations. Family History On his paternal side, grandfather died at age of 65 due to stroke. His father has hypertension and his mother has cardiovascular disease. Both parents are still alive. Personal and Social History Born and raised in Koronadal, South Cotabato. Graduated college, married at age 28.Worked as a structural designer for 2 years. His family moved to Canbantian, Davao City last year. They have 2 children and he is also an active church member. Exercise . He plays basketball regularly. Diet . He prefers to eat vegetables and high – carbohydrate foods. Habits . Patient is a non-smoker. He is an occasional drinker. : : : : : : : : : : : Ronel Sigampong Deca Homes Cabantian, Davao City 31 years old Male Married Protestant Self- employed College Graduate – Civil Engineering January 4, 2010; 11:00 P.M. – DMSF Hospital Dr. Edgar Allan Piatos Pain in urination with blood in the urine
REVIEW OF SYSTEMS General Skin HEENT : Has gained weight : No skin rashes but there is presence of macules on the face. : Head: Normocephalic and hairs are evenly distributed. Eyes: Vision is good with visual acuity of 20/20 on both eyes Ears : Hearing is good. No tinnitus Nose: No discharges noted and sinuses were not inflamed Throat: No bleeding gums were seen : No lumps, pain and swollen glands : No lumps, discharges and nipple retractions : Positive for TB 8 years ago : High blood pressure or with hypertension Appetite is good. Bowel movement about once daily : Presence of blood in the urine and dysuria. : No history of leg pain : No history of depression or psychiatric treatment : Memory is good. Fainting was observed.
Neck Breast Respiratory Cardiovascular GI : Urinary Peripheral Vascular Psychiatric Neurologic
Physical Examination Mr. Sigampong is a medium built man who responds quickly to questions. He is in pain and anxious on the medications given. His hair is fixed and neat. He is more comfortable in sitting position. Vital signs BP : 130/100 mmHg HR : 98 beats / min RR : 21 Temp. : 36.5 C Skin : Fair – skinned and palms are cold. Nails without cyanosis and clubbing Head : Hair – of average texture; Scalp – no lesions and normocephalic Eyes : Visual acuity of 20/20 on both eyes Visual fields full by confrontation Conjunctiva pink; sclerae are white Ears : Waxes are seen and no discharges Nose : No mucosal discharges and sinus tenderness Throat : Tongue in midline position, no sores and swelling of gums Neck : Trachea is midline. No palpable masses Lymph nodes : No palpable lymph nodes. Thorax : No skin retractions. No palpable masses. Both lungs are resonant and no wheezing is observed. Cardio : No irregular bulging. It is dynamic without heaves and thrills. No murmurs are observed. Breast : No skin retractions, breast is symmetrical, no nipple discharges. No masses and lymph nodes were palpated. Abdomen : No surgical scars were seen and abdomen is flat. No irregular bowel sounds were heard. Radiating pain towards the right flank during palpation and percussion. Spleen and liver are not palpable. Extremities : No varicosities, edema and it is warm to touch. Calves are non Tender Diagnosis : Paitent has Urinary Tract Infection
Defined Patient Data Base
Presented to Edgar Allan A. Piatos, M.D.
Prepared by Sha Hezra Muhamad Maridee Sebumpan