History #1 Preceptor: Dr.

Bartolome
Patient: NR Date of Interview: September 4, 2017
Informant: Patient and Brother Date of Submission: September __, 2017
Reliability: 100%
Historian: SEE, Glaiza Kathrina P.
Group 19 III - B

I. General Data
Nelson Villaviray, 49 y/o, Male, Separated with 6 children, Filipino, Roman Catholic, born September 23, 1976
in Manila, unemployed and is currently residing at 199 Kalambayan St. City. Patient is admitted for the 15th
time at Quezon City General Hospital on August 28, 2017.
II. Chief Complaint: LOC
III. History of Present Illness
13 days prior to admission,
After fire accident
drinking spree
Intake of water mixed with gin 2 bottles/day

10 days prior to admission,

(+) Radiating abdominal pain of 5/10
aggravated by physical exertion
Omeprazole 20mg 2x/day - NO relief
Intake of water mixed with gin

9 days prior to admission,

Persistent SSx
(+) yellowish loose watery stool, approximately 7-8x/day with an estimate of 120mL per
defeacation.
assoc with h/a
5 days prior to admission,
pain increase 7/10
noticed urine is very yellow
Omeprazole 20mg 2x/day - NO relief
Cant sleep because of pain
2 days prior to admission,
Patient told his brother that he feels better and that he wants to go to his sisters house
✓ went out of the house naked = disoriented
On day of admission:
Pt. was brought to his sister’s house
(anyone knows what he was doing before passing out)
passed out, hence rushed to ER.

Hours prior to admission,

 (+) LOC accompanied by lock jaw, rolling of the eyes, stiff extremities, unable to speak
(-) convulsions, (-) fever
came to the ER at 11pm and was admitted the next day (7am)

***IN THE QCGH HOSPITAL

• Aug 28 @ ICU
✓ in bed with restraints
✓ stayed for 4 days
• September 1
✓ Transfer to Male ward
✓ potassium correction - oral
IV. Past Medical History

V. Family History
Father: Diseased (52y/o, Cancer of blood)
Mother: Diseased (54y/o, TB)
2 Brothers and Sister: (+) R. Arthritis
VI. Personal-Social History
Highschool Graduate, Negros
Single with a live-in partner
✓ 2 years
✓ sex once a week (estimate)
Box Manufacturing Factory worker
✓ operator, works in an enclosed space
✓ 7am-7pm (Sunday to Saturday)
✓ walks from and to word (10 mins each)
NOT smoke (no smokers at home), NOT consume alcohol, NOT take illicit drugs
NO coffee, Soda 250mL/day, Water 2L/day
Food preference depends the food in the cafeteria at work
✓ eats breakfast, lunch and dinner there
✓ where all workers eat
House (2ppl: Patient and liven partner)
✓ rented, apartment
✓ made up of light materials (wood)
✓ 1 room, 1 floor, 1 window
✓ toilet: “de buhos” type
✓ Water supply: NAWASA & Mineral
✓ Garbage collection: Daily
✓ near a subdivision: congested area
✓ rodents: cockroach, rats
VII. Review of Systems:
 A. General:
(-) fever, (-) chills, (-) malaise, (-) fatigability, (-) weight loss unspecified
B. Integumentary:
(-) pruritus, (-) texture change, (+) lesion / scars: refer to integumentary system
C. Head and Neck:
(-) headache, (-) dizziness, (-) head injuries, (-) syncope, (-) blurring of vision, (-) diplopia, (-) photophobia,
(-) eye pain, (-) hearing loss, (-) ear pain, (-) discharge, (-) tinnitus, (-) vertigo, (-) nasal obstruction, (-)
epistaxis (-) hoarseness, (-) sore throat, (-) taste disturbance
D. Respiratory:
(-) dyspnea, (-) chest pain, (-) cough, (-) back pain (-) SOB
E. Cardiovascular:
(-) palpitation, (-) dyspnea, (-) orthopnea, (-) easy fatigability, (-) SOB
F. Gastrointestinal:
(-) loss of appetite (-) anorexia, (-) dysphagia, (-) nausea, (-) vomiting, (-) diarrhea, ( ) constipation, (+)
abdominal pain: generalized at the epigastric until the hypogastric area upon palpation, (-) flatulence, (-)
abdominal enlargement, (-) steatorrhea, (-) melena, (-) hematemesis, (-) hematochezia
G. Genitourinary:
(-) dysuria, (-) suprapubic pain, (-) frequency, (-) dribbling, (-) incontinence, (-)hematuria, (-)polyuria, (-)
oilguria, (-) discharge
H. Musculo-skeletal:
(-) muscle pain, (-) joint pain, (-) swelling, (-) bone deformity, (-) weakness, (-) atrophy, (-) restriction of
motion (-) weakness
I. Neurolopsychiatric:
(-) syncope, (-) seizure, (-) weakness/ paralysis, (-) headache, (-) tremors, (-) loss of memory, (-) dizziness,
(-) delirium, (-) hallucinations
J. Endocrine:
(-) weight change, (-) goiter, (-) heat/cold intolerance, (-) polyuria, (-) polyphagia, (-) polydipsia, (-)
polyphagia, (-) abdominal growth
K. Hematologic:
(-) easy bruisability, (-) easy fatigability, (-) pallor

————————————-———- PHYSICA L EXAMIN ATION —————————-——————-

I. General Survey
The patient is alert and conscios. Appears to be calm and cooperative with clear but soft speech. Oriented to
person, place and time, with hyposthenic body built. Patient is ambulatory and posture is midline. Not in
cardiopulmonary distress. Vital signs taken and noted:
BP: 100/70 mmHg, right arm while sitting
PR: 77 bpm
RR: 21 cpm
Temp.: 37.2 ℃
II. Integumentary
Patients hair is black and curly evenly distributed on the scalp. Skin is brown, dry and warm with fine hair
distributed along the extremities. Multiple lesions( scabs) noted on the right and left knee as well as on the
right dorsum of the foot. (+) Slow skin turgor. Capillary refill of more than 2secs. No pallor, no clubbing, no
swelling and no jaundice noted.
III. HEENT
(+) sunken eyes, prominent cheekbones and jaws
(+) dry lips
IV. Cardiovascular

V. Chest and Lungs

VI. Abdomen
generalized pain as verbalized by the patient at the epigastric and umbilical region upon light palpation (5/10)
abdomen 36.5 inches
(+) caput medusae
protuberant abdomen with everted umbilicus
bowel sounds: loud, 21
(-) bruit (renal arteries)
VII. Spine and Extremeties

————————————————-D I S C U S S I O N ————————————————-

I. Salient Features
• sunken eyes
• dry lips
• slow skin turgor
• slow capillary refill
• dry skin
• diarrhea ~7-8/day
• ascites: abdominal girth 36.5 inches
• caput medusae
• liver span: Parasternal (6cm), Midclavicular (8cm)
• abdominal pain at the epigastric and umbilical area (5/10)
II. Differential Diagnosis
Electrolyte Imbalance secondary to dehydration
(+) liver cirrhosis
III. Clinical Impression:
IV. Laboratory Examination
V. Treatment and Prevention