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History of Present Illness

One day prior to confinement on the night of Thursday, the patient felt pain on her left lower quadrant

and decided to take 1 tablet of 10mg Buscopan to relieve the pain. She states that the pain subside that

night and recur on Friday morning. Despite the pain, the patient states that she could still do her normal

daily routine. She narrates that she was still able to pick her son up to school and clean her house

around noon the day of her confinement. Afternoon that day the patient felt a severe pain on her left

lower quadrant that radiates to her left upper quadrant and lastly to her right lower quadrant, she

stated that that’s when she again take 1 tablet of 10mg Buscopan. However, later that night the patient

can no longer bear the pain that’s coming from her right lower quadrant and was rushed to Ospital ng

Sampaloc and undergone an emergency Appendectomy for the initial diagnosis of Acute Appendicitis.

Physical Assessment

General The patient was conscious, coherent and cooperative. She was oriented to person,

Survey place and time. She is properly groomed and there is no noted body odor. Facial

grimace noted due to pain of surgical site. The patient’s weight is 63kg and height is

162.56cm.

V/S:

BP: 110/70 mmHg Temp: 36.4 C PR: 101 bpm RR: 20 cpm

Integumentary The skin of the patient is not dry, good skin turgor noted. No presence of primary

lesions nor edema. Patient have a dressing on her right lower quadrant subsequent

to appendectomy and a scar on her right lumbar area because of her past surgery

(Cholecystetomy).
Hair is brown, thick and dry; no presence of lesions on scalp nor signs of lice

manifestation/dandruff. Patient’s nails are dirty, long and have smooth texture, with a

blanch test of < 3 seconds.

HEENT The facial features and movements are symmetrical. Patient’s head is normocephalic

and is proportionate with her body. No tenderness noted upon palpation. No

involuntary muscle movements. Pupils equally round reactive to light and

accommodation. Both eyes coordinated, move in unison with parallel alignment.

No tenderness in the ears upon palpation however patient verbalized tinnitus on her

right ear. The nares of the patient are patent. There are no swelling, bleeding, and no

lesions are noted. No discharge observed. There is no tenderness during palpation of

the frontal, ethmoidal, sphenoidal and maxillary sinuses.

Lips are moist and color pink with no lesions. Gums is color pink, moist and has a

firm texture. Patient has a cavity on her lateral incisor. No retraction, swelling and

bleeding observed. No halitosis. No dentures.

The patient is able to move her hear in full range of motion without complain of pain

and discomfort. No lesions observed. No masses palpated. Submandibular lymph

nodes are palpabale. The patient’s thyroid gland is not enlarged and not tender upon

palpation.

Thorax The patient’s collar bone is equal on left side to the right side. The patient has a

regular and normal breathing pattern; quiet effortless and regular respirations. No

presence of lesions or tenderness during palpation. Normal breath sound is heard

upon auscultation.
Extremities The patient’s radial and brachial pulses were regular. A slight difficulty of movement

is noted due to her surgical incision. No hand tremors noted. No edema observed.

Genitourinary Patient reports no pain in urinating or defecating. No presence of constipation nor

diarrhea.

Laboratory Results:

OSPITAL NG SAMPALOC
LABORATORY DEPARTMENT
URINALYSIS

NAME: BDV DEPT. ER DATE: August 17, 2018

AGE: 39 years old SEX: Female

Macroscopic Macroscopic
Pus Cell 1-2
Color Yellow
Red Cell 5-8
Transparency Slightly Turbid
Epithelial Cell Moderate

Mucus Thread
Chemical
Amorphous Urates Moderate
pH
Phosphates Moderate
Specific Gravity
Crystals
Protein
Cast
Glucose
Bacteria FEW
Pregnancy Test NEGATIVE
Others