CAGAYAN STATE UNIVERSITY

COLLEGE OF MEDICINE

SURGERY WARD
Case No. 1

CSU MD-3C GROUP 1

Date of Interview: September 12, 2018
Time of History: 1:20 PM
Date of Admission: September 10, 2018
Time of Admission : 9:30 PM

GENERAL DATA:

Name: Raquel Marcos

Age/Sex: 20/female
Birthday: June 14, 1990
Address: Sta. Ana, Cagayan
Birthplace : Sta. Ana, Cagayan
Nationality: Filipino
Religion: Jehovah’s Witness
Informant: patient herself
Reliability : 100%

CHIEF COMPLAINT:

 Radiating right upper quadrant and epigastric pain

HISTORY OF PRESENT ILLNESS:

6 months PTA, she was hospitalized at St. Anthony Hospital because of abdominal pain and
was diagnosed with gastritis. 4 months PTA, she was again hospitalized at St. Anthony Hospital
because of abdominal pain and was diagnosed with gastroenteritis. 3 months PTA, the patient was
diagnosed with gallstones and was prescribed hyoscine, metronidazole and ranitidine. She was
feeling well the following months and haven’t experienced abdominal pain ever since.
3 days PTA, the patient experienced right upper quadrant abdominal pain upon waking
up from her afternoon sleep to prepare for her night shift at her job. She had resorted to go to St.
Anthony Hospital in Sta. Ana and tramadol had been administered to her which made her
comfortable during her work. The following day, 2 days PTA, she experienced the same pain again
and went to the same hospital for her medications, she was given Ketorolac, and continued to work.
On the day of the admission at around 2 pm, she went again to the same hospital for her
medications. She was temporarily relieved of the pain but at around 7pm, the pain was not
bearable already that they opted to go to CVMC.
PAST MEDICAL HISTORY:

 RM had complete immunizations.

 No known allergies. No known childhood illnesses
 She had been hospitalized twice at St. Anthony Hospital because of abdominal pain
last March and May and was diagnosed of Gastritis and gastroenteritis, respectively.
 She had been diagnosed to have gallstones last June
 The prescribed medicines that were given to her were ranitidine, metronidazole,
tramadol, ketorolac, hyoscine, and many other that she can’t remember

FAMILY HISTORY:

 Her father is alive and well while his mother has heart disease.
 Her cousin had died from leukemia.
 Other members of her family had no known illnesses.

PERSONAL AND SOCIAL HISTORY

 RM is married for three years. She has a daughter, 2 years of age, who is alive and
well.
 Her highest educational attainment is undergraduate.
 Her occupation is an online casino dealer which required her to be on the night shift,
which is 6PM-6AM, ever since the month started. This didn’t hinder her to take in meals
thrice a day. She drinks 2-3 cups of coffee per day to keep her awake on her job. She
was only able to have a sound sleep for 3 hours in a day.
 Their source of drinking water is a deep well.
 She is a non-smoker. She occasionally drinks once or twice a month.
 She lives with her mother, father, husband, child and a niece in their home. They live in
a neighborhood that is quite crowded.
 They have animals at home like dogs and cats.
REVIEW OF SYSTEMS:
CONSTITUTIONAL:
SKIN:
HEAD:
EYES:
EARS:
NOSE AND SINUSES:
MOUTH AND THROAT:
NECK:
RESPIRATORY:
GASTROINTESTINAL:
RENAL:

PHYSICAL EXAMINATION:

General Survey:

Vitals Signs:

Temperature:
Respiratory rate:
Pulse rate:
Blood pressure:

Skin:

Head, Eyes, Ears, Nose, Throat (HEENT)

Head:
Eyes:
Ears:
Nose:
Throat:

Neck:
Chest and Lungs:

Cardiovascular:

Abdomen:

Extremities and Musculoskeletal:

Neurologic system:

Clinical Impression: Benign Febrile Convulsions