SURGER

Y CASE
REPORT

SUBMITTED BY,
CHANDRAN SRINIVASAN

IMD -14 SEC- C

ROLL NO : 19

SUBMITTED TO: DR.NEILA BATUCAN.

CONTENT:
 CURRICULUM VITAE
 CASES DURING CLINICAL ROTATION
 CASE 1
 CASE 2
 CASE 3
 CASE 4

 CASES GIVEN IN VIRTUAL LAB SESSION

 CASE 1
 CASE 2
 REFLECTION PAPER
CURRICULUM VITAE
NAME: CHANDRAN SRINIVASAN.

BATCH: IMD 14

SECTION: C

ROLL NO:- 19

CURRENT YEAR: 3RD YEAR.

CLINICAL ROTATION: DR.SAMANTHA CUNANAN

VIRTUAL LAB: DR. JOSIL CRUZ

SEX: MALE

D.O.B: 16 DEC 1995

P.O.B- ERODE,TAMIL NADU, INDIA

CITIZENSHIP-I INDIAN
CURRENT ADDRESS: MARFORI, DAVAO

CASES DURING CLINICAL ROTATION

CASE 1
General Data

Name- T.J.M

Age-13 yrs old

Sex-Male

Religion- Catholic

Nationality- Filipino

Occupation-Student

Civil status- Child

Informant-Mother

Relibility- 90%

D.O.B-15th sept 2005

Date of admission – 8th july 2019

Chief Complaint:-

Abdominal pain on the right lower quadrant.

HISTORY OF PRESENT ILLNESS:-

3 days prior to admission the patient present with right lower quadrant abdominal pain withthe pain
scale of 7/10, associated with 2 episodes of vomiting which was watery.The patient also had
persistent fever , the temperature wasn’t documented.The patient took paracetomol and acyclovir
no consult was done.Due to the persistent symptoms, it prompted the patient to consult a doctor.

Past medical history:- No history of previous traumaNo history of previous hospitalizationNo history
of previous medical illnesses.No previous surgical history noted.

Family history:- The patient has 7 members in the family including his parents and siblings.No family
history of hypertension, DM, asthma or any mental illness.
Immunization:-

The patient has a complete history of immunization taken from the barangay.Last year he took an
anti-meseals shot from the school .

Personal/social history:-The patient is 13 yrs old student studying in grade 7.

Diet- the patient consumes 2 cups of rice with vegetables or chicken as well as eatsstreet food and
drinks milk and soft drink. The patient doesn’t smoke nor consumes

alcohol . The patient isn't allergic to food nor medicinesThe patient has no travel history.

Environmental history:-The patient stay in a clean house but the surrounding around isn't that
hygienic,there are mosquitoes around the house . The school which he goes to is clean
andhygienic.They dont have any pets in the house.

REVIEW OF SYSTEMS: general : no weight loss , fever (+), sweats(-)

Endocrine: diabetes(-),thyroid(-),neck surgery(-)

Eye: pain(-),redness(-),itching(-)

Ear: deafness(-),tinnitus(-),discharge(-)

Nose:epistaxis(-),discharge(-),sinusitis(-)

Mouth: bleeding gums(-),dental scars(-),fissures(-)

Throat : tonsillitis(-),Soreness(-)Neck: stiffness(-) ,limited motion(-)

Gastrointestinal: nausea(+),vomiting(+),abdominal pain(+),heartburn(-)

Pulmonary: dyspnea(-),cough(-),pain(-),shortness of breath;-)

Cardiac : pain(-),edema(-),palpitations(-)

Vascular: phlebitis(-),claudication(-)

Genito urinary : dysuria(-),flank pain(-),urgency(-),pain(-)

PHYSICAL EXAMINATION:-

VITAL SIGNS:TEMPERATURE: 38.8 °C

BLOOD PRESSURE: 120/80

RESPIRATORY RATE: 15 BREATH CYCLE PER MIN

HEART RATE: 85
HEIGHT:150cm

WEIGHT: 40 kg

GENERAL: PATIENT IS AWAKE ,ALERT , ORIENTED AND

CONSCIOUS, FEBRILE.

SKIN : WARM, NO SCARS, NO LESIONS,NO DISCOLORATION

HEAD: NORMOCEPHALIC, NO ALOPECIA, NO LESIONS, NO

SCARS ON THE SCALP.

EYES: SYMMETRICALLY ALIGNED EYES AND EYEBROWS.

PUPILS ARE EQUAL.

EAR: NO LUMPS,NO DEFORMITY, NO DISCHARGE

CHEST :INSPECTION: NO DEFORMITIES, NO RETRACTION,NORMAL CHEST EXPANSION.PALPATION:

NO MASSES,NO TENDERNESS, NORMAL

TACTILE FREMITUS.PERCUSSION: RESONANT ON BOTH LUNG.AUSCULTATION: NO ADVENTITIOUS

SOUND HEARDLIKE CRACKLES, WEEZES OR RONCHI

CARDIOVASCULAR:

INSPECTION: ADYNAMIC PRECORDIUM,NOLESIONS, NO SCARS,NO DEFORMITIES, PMI AT 5th

INTERCOSTAL SPACE.

PALPATION: NO HEAVES, NO THRILLS.

AUSCULTATION: HEART RATE IS 124 BPM

WITH REGULARLY REGULAR RHYTHM.

ABDOMEN:-

INSPECTION: FLAT ABDOMEN, NO RASHES, NO CAPUT MEDUSAE, NO SCARS, NO LESIONS, NO

MASSES

.AUSCULTATION: NORMOACTIVE BOWEL SOUNDS,NO BRUITS.

PERCUSSION: TYMPANIC TO DULLNESS.

PALPATION: REBOUND TENDERNESS IN RIGHT ILIAC REGION.

EXTREMITIES: NO EDEMA, NO CYANOSIS,NO ULCERATION.

MUSCULOSKELETAL: NO POSTURE, NO SPINE CURVATURE, NO DEFORMITIES

SPECIAL TESTS:- ROVSING’s SIGN: +veTENDERNESS OF RLQ IF PALPATE LLQ. PSOAS SIGN:
+veTENDERNESS ON EXTENSION OF THE RIGHT LEG

OBTURATOR SIGN: +veTENDERNESS ON INTERNAL ROTATION OF FLEX THIGH.

Differential Diagnosis:-

Acute Appendicitis

RULE IN RULE OUT

Severe Abdominal pain in right lower quadrant

Vomitting & nausea & fever Cannot be ruled out

Rebound tenderness

PANCREATITIS

RULE IN RULEOUT

Severe Abdominal pain Pain not radiate anywhere

Rendume tenderness No rapid pulse

Vomitting No weight loss

CHOLECYSTITIS:-

RULE IN RULEOUT

Tenderness in abdomen Pain not spread to ithe region

Fever No nausea

Vomitting No in upper abdomen

DISCUSSION:-Taking the history and findings of the physical examination into

consideration and after factoring in all the differentials, we determine ‘acute appendicitis
as our final diagnosis.Acute appendicitis is an acute inflammation of the vermiform
appendix due to infection or other idiopathic cause which may lead to complications such
as perforation or peritonitis thereby indicating appendectomy on emergent basis.CT scan
will confirm the diagnosis of appendicitis and also rule out diverticulitis. Lack of severe
nausea and vomiting along with jaundice like symptoms rule out cholecystitis or disorders
of biliary tree. No history of weight loss, lack of referred back pain and absent epigastric
pain rule out pancreatitis.

MANAGEMENT:- Acute appendicitis are managed by Appendectomy(open or laproscopic).

CASE 2:-
GENERAL DATA
– NAME: EV

– AGE:30YEARS

– SEX: FEMALE

– MARITAL STATUS: MARRIED

– RELIGION: CATHOLIC

– NATIONALITY: FILIPINO

– ADDRESS:BAGO ,DAVAO CITY

– OCCUPATION:HOUSEWIFE

– INFORMANT: PATIENT

– RELIABILITY: 95%

– DATE OF ADMISSION:27 JUNE, 2019

CHIEF COMPLAINT

ABDOMINAL PAIN

HISTORY OF PRESENT ILLNESS

 TWO DAYS PRIOR TO ADMISSION , THE PATIENT HAD SHARP INTERMITTENT RIGHT UPPER
QUADRANT ABDOMINAL PAIN WITH THE PAINSCALE OF 7/10 , WHICH IS ASSOCIATED WIH
NAUSE AND VOMITING.THE PATIENT HAD VOMMITTING AFTER HER MEALS , WHICH IS HALF
BOWEL AMOUNT AND CONSISTED THE FOOD.PATIENT FELT RELIEF BY DRINKING WATER.
.SHE DIDN’T TAKE ANY MEDICATION. AS THE ABDOMINAL PAIN AND THE SYMPTOMS
PERISTED THE PATIENT PROMPT TO ADMISSION.

PAST MEDICAL HISTORY

– NO CHRONIC ILLNESS OR CO MORBIDITIES LIKE ASTHMA, HIGH BLOOD PRESSURE,

TUBERCULOSIS, CVD, STROKE, PEPTIC ULCER DISEASE NOTED.

– NO HISTORY OF PREVIOUS HOSPITALIZATION.

– NO PREVIOUS HISTORY OF TRAUMA OR ACCIDENTS NOTED.

– NO HISTORY OF PREVIOUS SURGERY NOTED.

– THE PATIENT WAS DIAGNOSED AS CHOLECYSTITIS LAST YEAR .SHE HAD A PROVOCAL
AT THAT TIME.SHE GOT RELIEVED AT THAT TIME.

OB-GYNE HISTORY:

– MENARCHE: 14 YEARS

– INTERVAL: REGULAR( EVERY 28 DAYS)

– DURATION: 4 DAYS

– AMOUNT: 4 PADS PER DAY,

– SYMPTOMS: NO DYSMENORRHEA

– LAST MENSTRUAL PERIOD: JUNE 2, 2019

IMMUNIZATION :

– COMPLETE CHILDHOOD VACCINATION.

FAMILY HISTORY

THE PATIENT HAS FAMILY HISTORY OF DIABETES MELITUS ON HER MATERNAL SIDE.NO
KNOWN PATERNAL ILLNESS. NO OTHER FAMILY HISTORY OF HYPERTENSION, TB, HEART
DISEASE, ANEMIA, OR ANY MENTAL ILLNESS.
PERSONAL AND SOCIAL HISTORY

THE PATIENT LIVES WITH HER FAMILY. THE PATIENT IS NON SMOKER, NON
ALCOHOLIC AND NO OTHER ILLICIT DRUG USAGE.NO ALLERGIES TO ANY FOOD ,
MEDICATION, PET ,DRUGS.

TRAVEL HISTORY:

– THE PATIENT HAD NO TRAVEL HISTORY OF TRAVEL

ENVIRONMENTAL HISTORY

• SHE LIVES IN A HYGIENIC ENVIRONMENT AND GOOD SANITIZATION NOTED.

• NO PETS IN HER HOUSE.

• NO RECENT HISTORY OF MOSQUITOES AROUND THE HOUSE MENTIONED

REVIEW OF SYSTEMS
GENERAL SURVEY: (-)WEIGHT CHANGE, (-)INSOMNIA, (-)FATIGUE, (+)LOSS OF
APPETITE(LATE)

EYE: (-) REDNESS, (-) PAIN, (-)VISUAL DYSFUNCTION , (-)LACRIMATION

EAR: (-)DISCHARGE ;(-) TINNITUS

NOSE: (-)POSTNASAL DRIP; (-) RHINORRHEA ; (-) DISCHARGE, (-)SINUSITIS, (-) NASAL
CONGESTION

MOUTH: (-)DENTAL CARIES ,(-)BLEEDING GUM,(-) FISSURE

THROAT:(-) TONSILLITIS, (-)SORENESS

NECK: (-) STIFFNESS,(-)LIMITED MOTION

GASTROINTESTINAL: (+) NAUSEA, +)VOMITING ,(-)HEART BURN, (-) BLOODY STOOL,

(-)DYSPHAGIA ,(-)CONSTIPATION,(-) DIARRHEA

PULMONARY SYSTEM: (-)ASTHMA,(-) HEMOPTYSIS, (-)CHEST PAIN

CARDIAC: (-) CHEST PAIN/DISCOMFORT, (-)PALPITATIONS, (-) EDEMA , (-)NOCTURNAL

DYSPNEA

GENITOURINARY (-) POLYURIA ; (-)HAEMATURIA , (-)FLANK PAIN,(-)DYSURIA

 MUSCULOSKELETAL:(-)JOINT STIFFNE,(-)SWELLING, (-)CRAMPS

PHYSICAL EXAMINATION

GENERAL DATA: PATIENT ISALERT, AWAKE,AFEBRILE,FATIGUE, AMBULATORY

VITAL SIGNS:

TEMPERATURE: 36.1°C

BLOOD PRESSURE: 120/80 mm HG

HEART RATE: 72Bpm

RESPIRATORY RATE: 14 breaths/min

HEIGHT: 150cm

WEIGHT: 49 kg

BMI: 23

SKIN: COLD, PALE AND SOFT TO TOUCH, WITHOUT ANY DISCOLORATION OR LESIONS,
CAPILLARY REFILLING TIME TWO SECONDS

HEAD: ATRAUMATIC SKULL, NORMOCEPHALIC ,NO SCARS ON THE SCALP.

EYES: SYMMETRICALLY ALIGNED EYES AND EYEBROWS.UPPER EYELIDS COVER THE

PORTION OF THE IRIS. PALE PALPEBRAL CONJUNCTIVA. PUPILS ARE EQUAL ,ROUND AND
REACTIVE TO LIGHT .NO DISCHARGE NO PTOSIS.

EAR: NO DISCHARGES OR LESIONS, NO TENDERNESS

NOSE: SYMMETRIC, NO INFLAMED TURBINATES,, SEPTUM IS IN MIDLINE.

MOUTH/THROAT:- NO DENTAL CAVITIES NOTED. NO BLEEDING OF GUMS OR THROAT

SORENESS, UVULA IN MIDLINE NO TONSILLITIS WAS NOTED.

NECK:- SYMMETRICAL, NO MASSES OR SCARS, NO ENLARGEMENT OF PAROTID GLANDS, NO

LYMPH NODE ENLARGEMENT .

CHEST EXAMINATION:

INSPECTION:CHEST EXPANSION SYMMETRIC ON BOTH SIDES.

PALPATION:NO TENDERNESS OR MASSES ON LIGHT OR DEEP PALPATION NOTED.

PERCUSSION:NORMAL RESONANT SOUNDS WERE HEARD OVER THE LUNG FIELDS

 AUSCULTATION:VESICULAR BREATH SOUNDS NOTED ALL OVER THE CHESTNO CRACKLES,
NO WHEEZES OR ANY ADVENTITIOUS SOUNDS NOTED. 

BREAST EXAMINATION:

NOT PERFORMED.

CARDIOVASCULAR SYSTEM:

INSPECTION: ADYNAMIC PRECORDIUM, NO PALPITATIONNOTED, NO LESIONS, NO SCARS,

NO DEFORMITIES. , PMI AT 5TH INTERCOSTAL SPACE.

PALPATION: NON-TENDER, NO HEAVES AND THRILLS NOTED.

AUSCULTATION: REGULAR RATE AND RHYTHM, NO MURMURS WERE NOTED.

ABDOMINAL EXAMINATION:

INSPECTION: FLAT ABDOMEN , NO RASHES, NO CAPUT MEDUSAE NOTED.

AUSCULTATION: BOWEL SOUNDS ARE TOO LOW AND MUFFLED.

PERCUSSION:NOT PERFORMED

PALPATION: TENDERNESS NOTED. NO ORGANOMEGALY

EXTREMITIES: NO EDEMA, NO CYANOSIS NO VARICOSTIES, NO BONY SWELLING

SPECIAL TECHNIQUES: MURPHYS SIGN (+)

SALIENT FEATURES:

• GC 38 YEARSOLD FEMALE.

• ABDOMINAL (RUQ)PAIN

• VOMITING EVERY TIME AFTER EATING( SALIVA IN THE VOMIT).

• WEAKNESS

• FATIGUE

• LOSS OF APPETITE

• TENDERNESS ON PALPATION

• MUFFLED BOWEL SOUNDS

FINAL IMPRESION: CHOLECYSTITIS.

CASE 3
• NAME: J.N

• AGE: 30 YEARS

• SEX: MALE

• MARITAL STATUS: SINGLE

• RELIGION: ROMAN CATHOLIC

• NATIONALITY: FILIPINO

. ADDRESS: TORIL, DAVAO CITY

• OCCUPATION: 10TH GRADE

• INFORMANT: PATIENT

• RELIABILITY:92%

• DATE OF ADMISSION: 29 JUNE , 2019

• DATE OF INTERVIEW: 2 JULY, 2019

CHIEF COMPLAINT

INJURIES IN LEFT LOWER LEG

HISTORY OF PRESENT ILNESS:-

TWO MONTHS PRIOR TO ADMISSION PATIENT MET WITH A VEHICULAR ACCIDENT AND GOT
INJURIES IN THE LOWER PART OF THE LEFT LEG.ONE DAY PRIOR TO ADMISSION THE
PATIENT WAS SCHEDULED FOR SKIN GRAFTING SURGERY.SO THE PATIENTSEEKED
CONSULTATION AND GOT ADMITTED.

PAST MEDICAL HISTORY:-

• NO CHRONIC ILLNESS OR CO MORBIDITIES LIKE HIGH BLOOD PRESSURE, DIABETES,

TUBERCULOSIS, ASTHMA, CVD, STROKE NOTED.NO HISTORY OF PREVIOUS
SURGERIESNO HISTORY OF ANY MAINTENANCE MEDICATIONS TAKEN.

• PSYCHIATRIC HISTORY:NO PREVIOUS MENTAL ILLNESS, HOSPITALIZATION OR

TREATMENT FOR MENTAL ILLNESSES NOTED,
IMMUNIZATION :

• COMPLETE CHILDHOOD VACCINATION DONE.

FAMILY HISTORY:

YOUNG BROTHER -(+) ASTHMA , GRANDFATHER -(+) ARTHRITIS.NO OTHER

CHRONIC ILLNESS IN HIS FAMILY

PERSONAL AND SOCIAL HISTORY

• PATIENT LIVES WITH HIS FATHER AND MOTHER.

• PATIENT IS A NON-SMOKER.NO ILLICIT DRUG USAGE.NO HISTORY OF ALLERGIES TO

ANY FOOD, MEDICATIONS, PET DANDERS OR DRUGS

• NO RECENT TRAVEL HISTORY.

REVIEW OF SYSTEMS

GENERAL SURVEY: (-)WEIGHT CHANGE;(-)INSOMNIA;(-)WEAKNESS;(-)FATIGUE

SKIN: (-)RASHES;(-)LUMPS;(-)ITCHINESS;(-)CHANGES IN HAIR OR NAILS

ENDOCRINE: (-) HEAT COLD INTOLERANCE ,(-)DIABETIC INDICATORS, (-)NECK SURGERY,

(-)THYROID PROBLEMS

EYE: (-) REDNESS, (-) PAIN, (-)VISUAL DYSFUNCTION,(-)LACRIMATION

EAR: (-)DISCHARGE ;(-) TINNITUS

NOSE: (-)POSTNASAL DRIP; (-) RHINORRHEA ; (-) DISCHARGE,(-)SINUSITIS, (-) NASAL

CONGESTION

MOUTH:(-)DENTAL CARIES ,(-)BLEEDING GUM,(-) FISSURE

THROAT: (-) TONSILLITIS, (-)SORENESS

NECK: (-) STIFFNESS,(-)LIMITED MOTION

GASTROINTESTINAL: (-) NAUSEA, (-)VOMITING, (-)HEART BURN ; (-) BLOODY STOOL

(-)DYSPHAGIA ; (-) FOOD INTOLERANCE ; (-)CONSTIPATION ; (-) DIARRHEA

PULMONARY SYSTEM: (-)ASTHMA, (-) HEMOPTYSIS,(-)CHEST PAIN

CARDIAC: (-) CHEST PAIN/DISCOMFORT ,(-)PALPITATIONS, (-) EDEMA , (-)NOCTURNAL

DYSPNEA
PERIPHERAL VASCULAR : (-)PHLEBITIS, (-) VARICOSITIES, (-) CLAUDICATION

GENITOURINARY: (-) POLYURIA ; (-)HAEMATURIA ,(-)FLANK PAIN,(-)DYSURIA

NEUROLOGICAL SYSTEM: (-) HEADACHE, (-)SEIZURE, (-) HEAD TRAUMA

HEMATOPOIETIC : (-) ABNORMAL BLEEDING, (-) ANEMIA ,(-)PAST TRANSFUSION

MUSCULOSKELETAL:(-)JOINT STIFFNESS, (-)SWELLING, (-)CRAMPS

PSYCHIATRIC : (-) HOSPITALIZATION ; (-) PREVIOUS PSYCHIATRIC PROBLEM.

NEUROLOGIC: (-)VERTIGO, (-)DIZZINESS, (-)HEADACHE

PHYSICAL EXAMINATION:-

GENERAL DATA: PATIENT IS ALERT,AWAKE,FATIGUE,AMBULATORY AND NOT IN ANY

RESPIRATORY DISTRESS.

VITAL SIGNS:

TEMPERATURE: 36.5 °C

BLOOD PRESSURE: 120/80 MMHG

HEART RATE: 78BPM

RESPIRATORY RATE: 16bpm

HEIGHT: 170cm

WEIGHT: 60 KG

SKIN:WARM AND DRY WITHOUT DISCOLORATION, NO RASHES.

HEAD: ATRAUMATIC SKULLNORMOCEPHALIC, NO ALOPECIA ,NO SCARS , NO LESIONS

EYES: NO BLURRING OF VISION , NO DISCHARGE ,PUPIL SIZE ( SYMMETRY)

EAR: NO DISCHARGES OR LESIONS, NO TENDERNESS

NOSE: SYMMETRIC, PALE NASAL MUCOSA, SEPTUM IS IN MIDLINE.

THROAT: NO ENLARGEMENT OF TONSILS, NO CAVITIES . NO MASS OR NECK PAIN.{LYMPH

ADENOPATHY)

RESPIRATORY SYSTEM:
INSPECTION:CHEST EXPANSION SYMMETRIC ON BOTH SIDES.

PALPATION: NO TENDERNESS OR MASSES OR LUMPS NOTED.

PERCUSSION: NORMAL RESONANT SOUNDS WERE HERD OVER THE LUNG FIELDS.

AUSCULTATION: NO CRACKLES, NO WHEEZES

 CARDIOVASCULAR SYSTEM:

INSPECTION: ADYNAMIC PRECORDIUM, NO VISIBLE PULSATIONS.

PALPATION: NO - TENDERNESS, HEAVES AND THRILLS

AUSCULTATION: NORMAL CARDIAC RATE, NO MURMUR WERE NOTED.

ABDOMINAL EXAMINATION:

INSPECTION: NO MASSES, NO LEISIONS AND NO SCARS ARE PRESENT

AUSCULTATION: NORMOACTIVE BOWEL SOUNDS.

PERCUSSION: THROUGHOUT THE ABDOMEN TYMPHANTIC SOUND TO DULLNESS

PALPATION: NO MASSES OR NO TENDERNESS FELT DURING BOTH LIGHT AND DEEP

PALPATION.

EXTREMITIES:NO EDEMA , NO CYANOSIS, NO VARICOSITIES, NO BONY SWELLING

MUSCULOSKELETAL: NO ATROPHY OF MUCLES, NO TENDERNESS

SALIENT FEATURES: J.N 30 YEARS OLD MALE& AFEBRILE & INJURIES

IMPRESSION

SKIN GRAFTING

DIFFERENTIAL DIAGNOSIS:

THERE IS NO DIFFERENTIAL DIAGNOSIS FOR SKIN GRAFTING.

MANAGEMENT:
A SOFT SILICONS WOUND CONTACT DRESSING IS BEEN USED THAT IT CAN BE CHANGED
OFTEN AND PATIENT EXPERIENCE LITTLE PAIN . IT IS ALSO PROVIDES STRUCTURAL SUPPORT
FOR THE GRAFT.
CASE 4
GENERAL DATA

Name:-BR

Age:-57

Sex:-MALE

Address:-MATI DAVAO ORIENTAL

Occupation:-GOVT. EMPLOY

Religion:-PROTESTANT

Marital status:-MARRIED

Nationality:-FILIPINO

Informant:-PATIENT

D.O.A- 11 July 2019

Date of interview- 15 July 2019

Reliability:-95%

Chief Complaint: Blood in stools

HISTORY OF PRESENT ILLNESS:

5 days Prior to consult patient had anal pain. Pain lasts for almost 20min. Patient describe the character of pain
as hitting pain. The pain increases if the px sits for a long time or had a long bike ride. Patientt consulted a local
doctor and was medicated with tinitol and suppositories which give him relief

PAST MEDICAL HISTORY:

No history of previous hospitalization.

No surgical history.

No accidents or trauma.

No psychiatric history.

Medication- Losartan and metformin.

Immunization- patient had completed all the required immunization.

PERSONAL AND SOCIAL HISTORY:

 Patient lives with his wife and brother. Patient was a chronic smoker. Started smoking at the age of 18yrs.
1pack per year. Started drinking from high school days, drinks at least 3-4 bottles of beer daily.No illicit drug
usage.

No allergies to any food, medication, pet dander or drugs.

He has a healthy diet.

No recent travel history.

Environmental history:-

He lives in a good hygenic environment, good sanitization. No pet contact.

FAMILY HISTORY:

The patients grandmother had hypertension. No known paternal and maternal illness.

REVIEW OF SYSTEM:

GENERAL SURVEY: (-)WEIGHT CHANGE;(-)Fever;(-)INSOMNIA;

(-)WEAKNESS;(-)FATIGUE;(+)ANOREXIA

ENDOCRINE: (-) Heat cold intolerance ,(-)Diabetic indicators, (-)Neck surgery,

(-)Thyroid problems

Eye: (-) Redness, (-) Pain, (-)Visual dysfunction,(-)Lacrimation

EAR: (-)DISCHARGE ;(-) Tinnitus

NOSE: (-)Postnasal drip; (-) Rhinorrhea ; (-) Discharge,(-)Sinusitis

MOUTHL-)Dental caries ,(-) Bleeding gum,(-) Fissure

THROAT: (-) Tonsillitis, (-) Soreness

NECK: (-) Stiffness,(-)limited motion

GASTROINTESTINAL: (-) Nausea, (-) Vomiting, (-)Heart burn ; (-) Bloody stool;

(-) Dysphagia ; (-) Food intolerance ; (-) Constipation ; (-) Diarrhea ;

PULMONARY SYSTEM: (-) Cough , (-) Sputum production, (-)Asthma,

(-)Breathlessness , (-) Shortness of breath

CARDIAC: (-) Chest pain , (-) Edema , (-)Nocturnal dyspnea

VASCULAR : (-)Phlebitis, (-) Varicosities, (-) Claudication

GENITOURINARY: (-) Polyuria ; (-)Haematuria ,(-)Flank pain, (+) Painful urination

Skin: (-)Rash,(-)Itching,(-) Pigmentation

NEUROLOGICAL SYSTEM: (-) Headache, (-)Seizure, (-) Head trauma

HEMATOPOIETIC : (-) Abnormal bleeding, (-) Anemia ,(-)Adenopathy

MUSCULOSKELETAL: (-)JoinT stiffness , (-)Swelling, (-)cramps, (-)body pain

Psychiatric : (-) Hospitalization ; (-) Previous problem.

PHYSCIAL EXAMINATION: Vital signs:-

Bp:- 150/90)

H.R:- 74bpm

P.R:- 66bpm

Temp. :- 36°c

Ht. :- 5'7

Wt. :- 81kg

GENERAL: PATIENT IS AWAKE ,ALERT , ORIENTED AND CONSCIOUS ,FEBRILE ,NOT IN RESPIRATORY
DISTRESS,AMBULATORY.

SKIN : WARM AND DRY WITHOUT DISCOLORATION , No RASHES PRESENT.

HEAD: NORMOCEPHALIC, No alopecia, No lesion ,NO SCARS ON THE SCALP.

EYES: SYMMETRICALLY ALIGNED EYES AND EYEBROWS.UPPER EYELIDS COVER THE PORTION OF THE IRIS. PINK
PALPEBRAL CONJUNCTIVA. PUPILS ARE EQUAL ROUND AND REACTIVE TO LIGHT .NO DISCHARGE NO PTOSIS.

EAR:- No lumps, skin lesion, deformity,discharge.

Mouth- - No ulcers noted; No whitish or reddish lesion noted; Absence of bleeding gums; No deviation of the
tongue, Uvula in the midline; Rising of the soft Palate noted with the use of tongue depressor, no swelling of
tonsils noted.

NECK: -Symetrical, No masses,scars,

Palpation- No Enlargement of Parotid or Sub mandibular gland, No lymph node

enlargement; No enlargement of the thyroid noted

CHEST: NSPECTION:No deformities, No retraction; Equal chest expansion

PALPATION: No masses noted;

PERCUSSION: resonant on both lung fields.

AUSCULTATION:NO ADVENTITIOUS SOUND HEARD LIKE CRACKLES, WEEZES OR Vesicular sounds heard on
auscultation.

CARDIOVASCULAR:

INSPECTION: adynamic precordium, no lesions, no scars, no deformities. , PMI at 5th intercostal space, mid-
clavicular line left side at the apex.

PALPATION: no heaves, no thrills

AUSCULTATION: HEART RATE IS 74 BPM WITH REGULARLY REGULAR RHYTHM HEARD. AT THE BASE S2 IS
LOUNDER THAN S1. NO S2 SLPIT HEARD.

ABDOMEN:

INSPECTION: FLAT ABDOMEN, NO RASHES, NO CAPUT MEDUSAE, no scars, no lesions, no masses.

AUSCULTATION: normoactive bowel sounds, no bruits.

PERCUSSION: tympanic

Palpation- No abdominal tenderness on all quadrants, no rebound tenderness

EXTREMITIES- No edema, No cyanosis, No varicosities,No ulceration

MUSCULOSKELETAL:- No spine curvature,No deformities,No crepitus ,No atrophy

DIAGNOSIS: Hemorrhoids

DIFFERENTIAL DIAGNOSIS:

Anal Fissure

Rule in Rule out

Severe long lasting pain after defecation

Bloody stools

Rectal pain Tear in the anoderm

ULCERATIVE COLITIS:-

Rule in Rule out

Bloody stool Abdominal pain

Tenesmus Abrupt onset Fever

MANAGEMENT:- HIGH FIBER DIET, HEMORRHOIDECTOMY

VIRTUAL LAB CASE
CASE 5
Name: .J.K.

Age: 17 year old

Reliability: 85%

CHIEF COMPLAINT:

Lower abdominal pain

HISTORY OF PRESENT ILLNESS :

2 weeks PTA patient had lower stomach pain and it has been getting worse. Patient
described the pain as sharp and constant pain on both sides of the lower abdomen. No
alleviating or aggravating factors and no radiations informed. A few days PTA patient
patient experienced nausea and chills. Patient had slight vaginal bleeding Patient came in to
the hospital due to unbearable pain in the lower abdomen.

PAST MEDICAL HISTORY:

Surgical. No history of Surgical Procedures Hospitalizations and Maintenance

Medications. Patient has controlled asthma,

OB/GYNE History :

The patient had her menarche when she was 13 years old. It lasts 5 to 7 days and
it is regular and she has cramps.

Family History :

The patient has a family history of Hypertension diabetes and bad arthritis.

Personal and Social History :

Patient was born in the city and is Afro-American. Patient is 17 y.o. And is a
student.patient is allergic to dogs and cats and is asthmatic. Patient does not consume
alcohol. No history or drug abuse or substance abuse noted. Patient has 1 sexual partner
and uses condoms as contraceptive.

REVIEW OF SYSTEM:

General: (-) weight loss, (-) malaise, (-) fatigue, (-) anorexia, (-) insomnia

Skin: (-) rashes, (-) pruritus

Head: (-) headache, (-) dizziness, (-) disequilibrium Eyes: (-) Lacrimation , (-) blurring of
vision, (-) itchiness, (-) pain

Ears: (-) pain, (-) tinnitus, (-) hearing loss, (-) hearing difficulty

Nose:(-) sinuses, (-) abnormal bleeding

Mouth & Throat: (-) gum bleeding, (-) mouth sores, (-) sore throat, (-) hoarseness Neck: (-)
pain, (-) lumps, (-) mass, (-) cervical lymphadenopathy

Breast: (-) pain, (-) lumps, (-) discharge Respiratory: (-) orthopnea, (-) nocturnal cough, (-)
hemoptysis, (-) cough

Cardiovascular: (-) chest pain, (-) palpitations, (-) syncope

 Gastrointestinal: (-) vomiting, (-) dysphagia, (-) jaundice, (-) hematemesis, (-) abdominal
distention, (-) reflux , (-) colicky pain, (-) diarrhea, (-) bleeding, (-) hemorrhoids, (-)
constipation

Urinary: (-) frequency, (-) dysuria , (-) nocturia , (-) hematuria , (-) flank pain, (-) incontinence

Genitalia: (-) discharge (+) cramps Peripheral Vascular: (-) phlebitis, (-) varicose

Musculoskeletal: (-) joint swelling, (-) joint pain, (-) cramps, (-) limited range of motion, (-)
gout

Neurologic: (-) fainting, (-) seizures, (-) motor and sensory loss, (-) difficulty remembering

PHYSICAL EXAMINATION:

The patient is lying in bed, conscious and alert, she is able to respond cooperatively to
questions during the course of the interview.

VITAL SIGNS:-

Temperature 100.3F

Heart rate 100 bpm

Respiratory rate:- 18 bpm

Blood pressure:- 100/60 mmHg

Weight :-61 kg

Height:- 5’3

Skin: Skin is pale and uniform in color. There are no rashes, scars and discoloration.There
was no presence of clubbing or cyanosis. She had warm and moist skin with senile skin
turgor. Nails have good capillary refill time.

Head: Hair is symmetrically distributed. Scalp without lesions, normocephalic, no masses.

Eyes: Anicteric sclera, pale conjunctiva, pupils equally reactive to light and accommodation.

Ears: Symmetrical, no masses, no discharges.

Nose: Septum at midline, no sinus tenderness, no alar flaring, no discharge. Mouth/Throat:

Pink oral mucosa, pink gums, tongue at midline, no mucosal bleeding, no tonsillar
enlargement.

Neck: Trachea at midline. No lesions, lymphadenopathies or tenderness.

Lymph nodes: No parotid enlargement, tonsillar and posterior cervical nodes. No axillary or
epitrochlear nodes.

Lungs:

Inspection: Normal anteroposterior diameter, symmetrical, equal chest expansion, no

retractions.

Palpation: Decreased tactile fremitus at lung bases, no tender areas or masses

Percussion: Dullness at both lower lung fields

Auscultation: Decreased breath sounds on both lower lung fields

Cardiovascular:

Inspection: Apex beat at fifth intercostal space, left midclavicular line. Adynamic
precordium

Palpation: PMI felt at fifth intercostal space, left midclavicular line. No heaves or thrills

Ausculation: Regular rhythm, no murmurs

Abdomen:

Inspection: Globular, no masses and scars. No dilated veins and palpitations of abdominal
aorta, ascites was not noted.

Auscultation: Normoactive bowel sounds

Percussion: Tympanic

Palpation: deep palpation voluntary guarding

Genitourinary: cervix is symmetric and open, it appears inflamed and there is small amount
of blood and mucous at the cervical OS. There is adnexal tenderness.

Extremities: Symmetrical, strong pulse, no atrophy, capillary refill time of less than 2
seconds. With ulceration at left foot below the 4th toe, measuring about 0.5 inches. With
thickening of skin at right plantar area.

Salient Features:
Age : 17yrs FEMALE
Lower abdominal pain 

Blood in urine 

Cramps on period

Mucopus in cervix

No urinary frequency No incontinence no suprapubic pain No urinary urgency No ascites

Impression: Pelvic inflammatory disease.

Differential Diagnosis:
1. Appendicitis

*Rule in:- Lower abdominal pain &Cramps in periods

*Rule out:- Hematuria & Muco-pus in urine &No fever

2.PID:-

Rule in:- Lower abdominal pain Crampy pain

Rule out:- Most Probable Diagnosis Cannot Be Ruled Out

3.Diverticulitis :-

Rule in:- Lower abdominal pain Nausea Abdominal tenderness

Rule out:- Hematuria Muco-pus Inflamed cervix

4.Inflammatory bowel disease:-

Rule in:- Lower abdominal pain &Nausea

Rule out:- No Diarrhoea &Fever &No Blood in the stool.

DIAGNOSIS:- PELVIC INFLAMMATORY DISEASE

Discussion:- Pelvic inflammatory disease is an infection of the uterus and cervix untreated
PID might cause scar tissue and collections of infected fluid ( abscesses) to develop in your
Fallopian tubes and damage your reproductive organs. Due to the use of condoms the
patient’s introitus must have had a change in the ph. Causing inflammation and constant
coitus must have caused inflammation a diagnostic test for gonorrhea was done and
confirmed. Patient has pelvic inflammatory disease with a gonococcal infection.
Final Diagnosis: Pelvic inflammatory disease secondary to gonococcal
infection

CASE 6 - VR :-
Name: T.J.

Age: 18 year old Male

Reliability: 85%

Chief Complaint:

Recurrent abdominal pain

History of Present Illness:

5 hours priors to admission the patient had a right lower quadrant pain and said it was
constant. The patient characterized the pain as burning. The pain was aggravated on
straightening up and alleviated on bending forward. No radiations noted and only
associated symptom was nausea and it was only when the pain was unbearable.

Past Medical History:

Surgical. Had a nasal septal repair Hospitalizations and Maintenance Medications.

Keflex and Tylenol for the recovery of the septal repair.

Family History:

No family history of stroke hypertension and diabetes.

Personal and Social History :

Patient is a 7 male and is 18y.o. and has had sexual partners and uses condoms. Patient
has 2 older brothers. Patient doesn’t smoke nor consume alcoholic beverages. Patient
consumes coffee and has a regular diet.

Review of Systems
General: (-) weight loss, (-) malaise, (-) fatigue, (-) anorexia, (-) insomnia

Skin: (-) rashes, (-) pruritus

Head: (-) headache, (-) dizziness,

 Eyes: (-) lacrimation, (-) blurring of vision, (-) itchiness, (-) pain Ears: (-) pain, (-) tinnitus, (-)
hearing loss, (-) hearing difficulty

Nose:(-)sinuses, (-) abnormal bleeding (+) nasal scar

Mouth and Throat: (-) gum bleeding, (-) mouth sores, (-) sore throat, (-) hoarseness Neck:
(-) pain, (-) lumps, (-) mass, (-) cervical lymphadenopathy

Respiratory: (-) orthopnea, (-) nocturnal cough, (-) hemoptysis, (-) cough

Cardiovascular: (-) chest pain, (-) palpitations, (-) syncope

Gastrointestinal: (-) vomiting, (-) dysphagia, (-) jaundice, (-) hematemesis, (-)
abdominaldistention, (-) reflux, (-) colicky pain, (-) diarrhea, (-) bleeding, (-) hemorrhoids, (-)
constipation

Urinary: (-) frequency, (-) dysuria, (-) nocturia, (-) hematuria, (-) flank pain, (-) incontinence

Genital: (-) discharge (-) cramps

Musculoskeletal: (-) joint swelling, (-) joint pain, (-) cramps, (-) limited range of motion, (-)
gout

Neurologic: (-) fainting, (-) seizures, (-) motor and sensory loss, (-) difficulty remembering&

Hematologic: (-) abnormal bleeding, (-) easy bruising Endocrine: (-) heat intolerance, (-) cold
intolerance, (-) excessive sweating

Physical Examination:
The patient is lying in bed, conscious and alert, she is able to respond
cooperatively to questions during the course of the interview.

VITAL SIGNS RESULT

Temperature :-37C

Heart rate :-72 bpm

Respiratory rate:- 14cpm

Blood pressure :-120/70 mmHg

Weight :-63kg

Height :- 5’7
Skin: Skin is pale and uniform in color. There are no rashes, scars and discoloration.There
was no presence of clubbing or cyanosis. She had warm and moist skin with senile skin
turgor. Nails have good capillary refill time.

Head: Hair is symmetrically distributed. Scalp without lesions, normocephalic, no masses.

Eyes: Anicteric sclera, pale conjunctiva, pupils equally reactive to light and accommodation.

Ears: Symmetrical, no masses, no discharges.

Nose: Septum at midline, no sinus tenderness, no alar flaring, no discharge. Mouth/Throat:

Pink oral mucosa, pink gums, tongue at midline, no mucosal bleeding, no tonsillar
enlargement.

Neck: Trachea at midline. No lesions, lymphadenopathies or tenderness.

Thorax and Lungs:

Inspection: Normal anteroposterior diameter, symmetrical, equal chest expansion, no

retractions.

Palpation: Decreased tactile fremitus at lung bases, no tender areas or masses

Percussion: Dullness at both lower lung fields

Auscultation: Decreased breath sounds on both lower lung fields

Cardiovascular:

Inspection: Apex beat at fifth intercostal space, left midclavicular line. Adynamic
precordium

Palpation: PMI felt at fifth intercostal space, left midclavicular line. No heaves or thrills

Auscultation: Regular rhythm, no murmurs

Abdomen:

Inspectiom: Globular, no masses and scars. No dilated veins and palpitations of abdominal
aorta, ascites was not noted.

Auscultation: Normoactive bowel sounds

Percussion: Tympanitic

Palpation: tenderness to light palpation and severe pain on deep palpation

 Extremities: Symmetrical, strong pulse, no atrophy, capillary refill time of less than 2
seconds. With ulceration at left foot below the 4th toe, measuring about 0.5 inches. .

Salient Features:
Age : 18y.o., RLQ abdominal pain * Burning pain and constant *Psoas sign positive

No urinary frequency * No incontinence * No suprapubic pain * No urinary urgency

Impression: ACUTE APPENDICITIS

Differential Diagnosis:
1. Cholecystitis.

2. Small bowel obstruction

3. Acute appendicitis.

DEFINITIVE DIAGNOSIS:- ACUTE APPENDICITIS.

LABARATORY:- 1. X-RAY 2. MRI SCAN 3. URINALYSIS

MANAGEMENT: APPENDECTOMY.
REFLECTION PAPER:
In Surgery Modular School And Clinical Rotation,

First I Went To Clnical Rotation In Spmc Under Dr.Samantha Cunanan. I Learned How To
Take History And Physical Examination.

Vr Under Dr. Josil Cruz., In Vr I Gained Knowledge About Requesting Lab Test Which Are
Necessary & Came To Know How To Manage With Appropirate Treatment And Proper
Management. This Will Definitely Help Me Out In My Clerkship And Also For My Future.