HPI
2 days prior to consultation, the patient had a lower abdominal pain specifically at the umbilicus area.
The patient described the pain as aching and burning pain rating the pain as 5/10. The patient
mentioned that she took ibuprofen for abdominal pain which did not provide relief of pain. No
consultation was done.
1 day prior to consultation, still with persistent abdominal pain took buscopan did not provide relief of
pain. The patient has also loss of appetite. The pain radiated from the umbilicus to the lower right side
of the abdomen with a pain scale of 7/10. This prompted the patient for consult.
RM: Good evening ma’am. Ako po si RM Joseph S. Domingo, 3rd year med student of DMSF at im here po
to take care of your needs. Pero po pwede po ba malaman anong pangalan mo?
Gianne: (state your name)
RM: edad?
Gianne: (age nimo)
RM: address?
Gianne: (address nimo hahahhaha)
RM: civil status?
Gianne: (civil status hahaha)
RM: religion?
Gianne: (ur religion)
RM: Occupation?
Gianne: (tindera po)
RM: ano po blood type nyo po?
Gianne: (mentions your blood type)
RM: Ano pong pinunta nyo dito?
Gianne: masakit po ang tiyan ko.
History of present illness:
RM: (onset) – kelan po ba nag-umpisa ang sakit ng tiyan?
Gianne: Nung isang araw po.
RM (location): pwede nyo po ba ituro kung saan po banda ang sakit ng tyan?
Gianne: (points at the navel) sa may pusod ko po banda
RM (duration): Sa duration po ng sakit ng tyan, matagal po ba syabago mawala?
Gianne: sumasakit po sya kung pagnakahiga po ako sa left side.
RM(character of pain): pwede po padescribe ng sakit ng tyan?
Gianne: parang burning po sya
RM(aggravating): may instances ba na lalong sumasakit ang tyan mo?
Gianne: sumasakit po sya kung nakahiga po ako sa left side.
RM (alleviating): may ininom po ba kayo na gamot para po sa sakit ng tiyan? Kung meron po, ano po?
Gianne: uminom po ako ng alaxan para sa sakit ng tyan.
RM: ano po ginawa nyo para po mawala yung sakit ng tyan?
Gianne: I tried warm compress po pero hindi sya mawala.
RM (associated symptoms): Aside po sa sakit ng tyan, may iba pa bang symptom?
Gianne: wala po akong ganang kumain
RM (radiation): Yung sakit po ba ng tyan, sa may pusod lang po b abanda? Or may sakit din po sa other
parts ng tyan?
Gianne: sa may right side po banda ang sakit
RM (timing): Pwede nyo po bai describe kung kelan po sya sumasakit yung tyan?
Gianne: pagnakahiga po ako sa left side po
RM (severity) on the scale of 1-10, how will you rate your pain?
Gianne: 7/10
Past Medical History
RM: may sakit po ba kayo nung bata kayo? Like measles, chickenpox?
Gianne: chickenpox po
RM: maalala nyo pa ba yung previous nyo na hospitalization? Maalala nyo po ba ang diagnosis? May
complication po ba?
Gianne: (ikaw na answer hahha)
RM: may surgical history po ba?
Gianne: wala po
RM: maselan po ito na tanong mam, may history po ba kayo o ang pamilya nyo ng psychiatric na sakit
(example po wala sa pag-iisip?)
Gianne: wala po
RM: kumpleto po ba immunization nyo?
Gianne: Opo. Mention mo yung covid vaccination and tell when
RM: May allergies po ba kayo?
Gianne: (wala po)
RM (Family history): May sakit po ba ang pamilya nyo sa mother side po? Sa father side? Ano po yon?
Gianne: Both father at mother ko po ay __________.
RM (Personal and social history) – do you drink alcohol? Do you smoke? What do you do in your free
time? Coffee? Kamusta po kayo sa pamilya nyo?
Gianne: okay lang naman po kami. Supportive po sila sa work ko. Di po ako umiinom at naninigarilyo.
RM (environmental history): Yung bahay nyo po ba made of?
Gianne: concrete po.
RM: water source nyo po?
Gianne: gensan water district
Physical examination:
Vitals Signs:
RM: May thermometer po ba kayo jan sa bahay nyo?
Gianne: (action lang na naglagay ng thermometer kung wala) – 37.7 C po doc
RM: may pulse oximeter po ba kayo?
Focused PE
Abdominal examination:
Inspection: no redness and inflammation seen in the abdomen
Auscultation: decreased bowel sounds
Palpation: pain at the umbilicus and the right lower quadrant
Percussion:
Maneuver:
Rovsing sign:
With the patient in the supine position, palpate the lower left abdominal area and release.
Positive rovsing sign if felt in the lower right abdomen.
