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General data

Name of patient: M.S

Age: 27

Sex: Female

Address: Camasi, Peñablanca, Cagayan

Marital status: Married

Religion: Roman Catholic

Occupation: None

Date of admission: May 10, 2018

Chief complaint:

Epigastric pain, vomitting

History of Present Illness:

 In 2012 around 10a.m., the patient was brought to Peoples Emergency Hospital complaining of
epigastric pain. According to her, she was taking a rest after doing the household choirs when
she suddenly felt extreme pain on her abdomen. Medication was given and instructed to take
only when in pain.

 May 9, 2018 , around 10 p.m., as the patient was sleeping in their bedroom with her husband,
she suddenly felt extreme pain on her abdomen located at epigastric region that caused her to
woke up and unable to sleep anymore until the following day. According to her, she only ate
tomato and egg , and drunk a cup of coffee (around 500 mL) as her dinner before going to sleep.
The patient did not seek any consultation.

 May 10, 2018, while she was laying on her bed and complaining about the pain , the patient
vomited for 4 times (6am, 8am, 12pm, 2pm). She characterized the vomitus as yellowish in color
only with almost 1 litter of volume per vomit. Because of this, the patient decided to visit CVMC
for consultation and was admitted around 3pm.
History of Past Illness:

 In the year 2016, the patient had epigastric pain. She went to the hospital in Quezon and was
diagnosed with Urinary Tract Infection. Medications were given that will cover for 1 week and
her condition stabilized.

Personal and social history:

Ms. M.S is a 27 year old housewife who lives in Camasi, Peñablanca, Cagayan. She is
married and don’t have children. She drinks 4 cups of coffee a day in which each cup contains
500 mL of it. She has a liking for salty foods , especially junk foods.

Family History:

Her father has hypertension.

Review of System:

 Integumentary: No pruritus
 CNS: No seizure, no LOC, no nape pain, no blurring of vision
 CVS: No peripheral edema
 CRS: No hemoptysis
 GIT: (+)abdominal pain, no diarrhea, no nausea, no vomiting
 Musculoskeletal: No arthralagia, no myalgia, no easy fatigability
 Hematologic: No easy brusising
 Endocrine: No heat/ cold intolerance
 HR: 82 bpm
 RR: 30
 BP: 110/80

Initial impresion:
 Peptic Ulcer , Gastritis