C/C:

My patient, Madam Halena, a 45 y/o married lady currently living in Rawang was
admitted to HSB with the chief complain of right abdominal pain for the past 2 weeks.

HOPI:
Madam Halena was previously well until 2 weeks ago, she experienced some
abdominal discomfort over the right side. At that period of time, she was still able to
tolerate it and did not seek treatment. However, 1 week ago, the discomfort gradually
progressed to become pain which was pulling in nature, radiating to the loin area and
associated with nausea each time after meal. She felt feverish, lethargy and loss of appetite
as well. The pain was intermittent, exacerbated by deep breathing and relieved by
paracetamol, but 4 days ago, the pain was not relieved by paracetamol anymore. She rated
the pain as 3/10 at the start of the episode and worsening to 10/10 since 4 days ago. She
was feeling giddy with cold peripheries and unable to work, so her family send her to ED
HSB for further investigation and management.
Otherwise, no vomiting, constipation, diarrhea, loss of weight, UTI symptoms such as
dysuria and hematuria, SOB and chest pain.

PMH:
5 years ago – gastritis
History of LSCS in 2004 in Hosp Selayang due to breech presentation
History of renal colic secondary to UTI in 2010
History of laparoscopic appendicectomy in Hosp Seremban in 2015
24 years ago – accident during working in factory, loss of left 2nd and 4th finger
No DM, HTN, hyperlipidemia.

Gynae History:
LMP: 20th June 2019
Regular menses
No menorrhagia / dysmenorrhea

Family History:
10 Siblings ranging from 50 – 28 years old
She is the 3rd. Eldest past away due to IHD
Father passed away at 49 years old during year 1996 due to liver and heart disease
Mom passed away 2 years ago at 58 years old due to CAD

Social History:
Madam Halena is a coconut seller who works from 8am to 5pm daily except weekend.
She was married and have 5 children ranging from 15 to 21 years old, all are healthy
She does not smoke, drink alcohol or take recreational drug.