LYCEUM NORTHWESTERN UNIVERSITY

MEDICAL WARDWORK
GENERA DATA Patient E.O, 52 year old Filipino Male, resides at Dagupan, Pangasinan
admitted for the first time in R1MC, October 1,2021
Patient Reliability – 90%
CHIEF COMPLAINT - Jaundice
HISTORY OF PRESENT ILLNESS 6 months prior to admission, patient noted enlarging
abdomen with noted weight loss of approximately 5kg in 3 months. No noted changes in BM,
nausea, vomiting, jaundice. No consult done, no medications taken.
Until 3 days prior to admission, he was noted to have jaundice, with associated RUQ pain. No
fever, consulted to a private MD where hepatitis profile and abdominal ultrasound done.
Few hours PTA, due to progression of symptoms, patient was then brought to nearest hospital
and hence, was eventually admitted.
PAST MEDICAL HISTORY Patient doesn’t have any allergies and has an unknown history of
immunization and no history of cancer, TB, DM, Asthma but presence of Hypertension.
FAMILY HISTORY Patient's brother had Asthma and Hypertension.
PERSONAL AND SOCIAL HISTORY Patient is a college graduate. Their source of drinking is
portable water. Patient is heavy alcoholic beverage drinker and previous smoker with 10 pack
years
REVIEW OF SYSTEMS
Constitutional: (-) unintentional weight loss, (-) easy fatigability, (-) chills Skin: (+) itchiness,
(-)Rash
Head: (-) dizziness; (-) vertigo, (-) Light headedness
Eyes: (-) pain, (-) blurring of vision, (-) double vision, (-) lacrimation (-) photophobia, (-)
preferential gaze Ears: (-) earache, (-) deafness, (-) tinnitus, (-) ear discharge
Nose and Sinuses: (-) change in smell,(-) nose bleeding,(-) nasal obstruction,(-) nasal discharge
Mouth and Throat: (-) toothache,(-) gum bleeding,(-) disturbances in taste,(-) sore throat
Neck: (-) limitation of movement, (-) presence of mass
Respiratory System: (-) dyspnea, (-) hemoptysis, (-) wheezing, (-) history of asthma (-) shortness
of breath, (-) difficulty of breathing
Cardiovascular System: (-) chest pain,(-) palpitation,(-) edema,(-) cyanosis,(-) syncope
Gastrointestinal System: SEE HPI
Genitourinary System: (-) dysuria, (-) urinary frequency, (-) urgency, (-) bladder distention, (-)
hesitancy, (-) polyuria, (-) hematuria, (-) incontinence, (-) genital pruritus, (-) urethral discharge
Extremities: (-) edema,(-) swelling of joints,(-) stiffness,(-) numbness, (-)limitation of movement
Nervous System: (-) vertigo, (-) syncope, (-) loss of consciousness, (-) numbness, (-) paresthesia
Hematopoietic System: (-) easy bruising, (-) history of transfusion reaction Endocrine System:
(-) intolerance to heat and cold, (-) excessive weight gain or loss, (-) polyuria, (-) polydipsia
PHYSICAL EXAMINATION
General Survey: Patient is awake, conscious and coherent, not in cardiopulmonary distress
Vital signs: BP: 140/70 mmHg RR – 22 cpm PR-87 beats/ min Temp: 37 °C
Skin: (+)Jaundice No pallor, no cyanosis.
HEENT: Pink palpebral conjunctiva, icteric sclera
Chest/Lungs: Symmetrical chest expansion, no retractions, no lagging, no visible mass, with
vesicular breath sounds on all lung fields, no wheezes, and no crackles.
Heart: Decreased breath sounds, right base , No murmur
Abdomen: Distended soft abdomen with abdominal girth 105 cm,(-) caput medusa (-) spider
angiomata, Normoactive bowel sounds.
Musculoskeletal: Grade 3 bipedal edema
Neuro Exam: GCS 15. No focal neurologic deficits

ADMITTING DIAGNOSIS:
BASIS:
DIFFERENTIAL DIAGNOSIS:
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MANAGEMENT: