Pamantasan ng Lungsod ng Maynila

University of the City of Manila

General Luna cor. Muralla Streets, Intramuros, Manila, Philippines 1002

PLM College of Medicine

SIMULATED WARD WORK

WRITTEN REPORT

Submitted By:
Group 2

Forbes, McJeh Rohi F. 2021-70049

Genilla, Mary Rose C. 2020-70133
Guinto, Francesca Elize S. 2020-70046
Isaguirre, Emilyn Faith J. 2021-70057
Malicdem, Allysa Camille M. 2021-70075
Masangya, Justin Carlo V. 2021-70064
Mendoza, Sophia Patrixia C. 2020-70160
Park, Apple Rosette B. 2021-70083
Patricio, Venice Camille B. 2021-70097
Payson, Rodrigo Joseph S. 2021-70118
Platero, Hannah Gayle R. 2020-70084
Date of History Taking: May 08, 2023
Time of History: 8:45 am
Setting: Hospital (OMMC)
Informant: Patient
%Reliability: 90%

I. General Data
M. M. is a 48-year-old, male, waiter currently residing in 120 Loreto St., Sampaloc,
Manila. He was born on April 03, 1975 at the University of Santo Tomas Hospital. He is Filipino,
single, and is of Roman Catholic faith. He has a height of 5 foot 6 inches and a weight of 65
kilograms with a computed body mass index of 23.1, which is of normal body weight based on
WHO Asian BMI categories standard. He was admitted to Ospital ng Maynila Medical Center in
the evening of May 07, 2023, accompanied by his co-worker. It is his first-time consulting at
OMMC.

II. Chief Complaint

“Nanghina ‘yong kaliwang parte ng katawan ko” - weakness of the left side of the body

III. History of Present Illness

The patient’s condition started 1 day prior to consultation when he experienced severe
headache while at work. When he was about to lift and serve an order, the patient had a
sudden, constant headache graded 9-10/10, described as “pinipiga… parang mabigat,” and
localized to the right posterolateral aspect of the head. This was followed by nausea, dizziness,
and weakness of the left arm and leg. There were no reported visual disturbances, facial
weakness or slurring of speech at the time of the incident. The left-sided weakness caused the
patient to lose consciousness and collapse on the floor. The patient was found unconscious on
the kitchen floor by a coworker. The patient has no recollection of hitting his head during the fall
and no wound or lump on the head is currently noted.

The patient reported no similar experience of such headache, and numbness or

weakness of the extremities in the past; this was the first time the patient experienced such. The
patient was unable to take any medication during the incident due to the sudden onset of
symptoms and loss of consciousness. No medication was taken within the day of the incident
apart from his maintenance medication (see Past Medical History).

Unable to wake the patient, his coworker decided to bring him to the hospital. The length
of time from the loss of consciousness until arrival to the hospital was not determined nor
documented. The patient woke up admitted to the hospital.

During the time of the interview, the patient reported a mild headache and weakness of
the left side of the body mainly the upper and lower extremities. He was able to talk without
slurring of speech, and no facial weakness or visual disturbances reported.

IV. Past Medical History

A. Allergic and Immunologic History

Patient is allergic to dust, smoke, and seafood (shrimps). Last allergic
attack recorded was during his childhood, year uncertain.

Patient received two doses of COVID-19 vaccine (Sinovac-CoronaVac)

and one booster dose (Pfizer-BioNTech; BNT162b2), Hepatitis B vaccine, Flu
vaccine was given in 2022.

B. Diagnosed Illnesses since Childhood

Patient has no history of the following childhood diseases such as
mumps, measles, chickenpox, diphtheria, and polio. There was also no history of
primary complex or tuberculosis.

Patient was diagnosed with hypertension and has a blood pressure range
of 140/90 mmhg to 150/100 mmhg. He was prescribed Amlodipine 5mg and is
compliant to medication.

C. Health Maintenance and Screening

Participates in company APE and reported unremarkable results for chest
X-Ray, CBC, urinalysis, and fecalysis. Patient has poor compliance to blood
pressure monitoring and does so only occasionally
 D. Surgical Procedures

No history of any surgical procedure or blood transfusion.

E. Previous Hospitalizations

No previous hospitalization.

F. Previous Accident and Trauma

No history of accidents or trauma.

G. Sexual History

Patient has a history of sexual contact that started when he was 17 years
old, with the most recent sexual contact occurring last December 2022. Patient
only had one sexual partner. No history of sexually transmitted diseases nor
sexual dysfunction. The patient has not done any form of test for sexually
transmitted diseases and does not engage in casual sex. No form of
contraception is used by the patient and says he only practices withdrawal
methods.

V. Family History

All of the patient’s grandparents on both his paternal and maternal side are not anymore
alive. Both his grandparents on his father’s side died at the age of 78 due to old age. His
grandfather had hypertension but the age of diagnosis and medications taken are
unknown. On his mother’s side, both of his grandparents died in their 70s. His
grandfather died in his sleep while his grandmother died from heart attack and was
known to have hypertension. The age of diagnosis and medications taken by his
grandmother are unknown. Both of his parents are alive at 70 years old. His mother has
hypertension and is taking Losartan 100mg once a day. He has no siblings.
 PATERNAL SIDE MATERNAL SIDE

Cancer No history No history

Hypertension Grandfather Mother

Grandmother

Diabetes No history No history

Lung Disease No history No history

Heart disease No history No history

Stroke No history No history

 Kidney disease No history No history

Arthritis No history No history

Blood disorder No history No history

VI. Personal and Social History

The patient is a waiter with an 8-hour shift schedule in a restaurant in Quirino, Manila.
His work schedule is usually 6 days a week with one-day off. He stated that the possibility of
slipping and falling off of things, serves as a possible hazard to health. His highest educational
attainment is a vocational course in food and beverage in TESDA.

The patient gets along well with his family and friends. He rarely goes out which depends
on his work schedule and only meets with his friends once a week. The patient also reported no
signs of fatigue or loss of motivation in the past 2 weeks.

Patient has been smoking for 10 years, with 1 to 2 sticks per day and has a smoke
pack-year of 1. He also reports frequent exposure to secondhand smoke in the workplace. The
patient rarely consumes alcohol (1 to 2 times per month), and only drinks two to three bottles of
beer or five to ten shots of hard liquor. The patient reported no history of taking illegal drugs.

The patient’s diet consists of three meals a day and eats depending on what is served.
He drinks any type of beverage. Patient is also taking multivitamins everyday. The patient also
exercises by doing weights for 30 minutes to an hour once a week during his day off. Patient
also sleeps seven to eight hours a day. He experiences stress due to work and relaxes through
exercising.

Patient is currently residing with his parents in a well-ventilated two-story house with
three bedrooms, and one comfort room. The house has adequate electric utilities and clean
water supply. Water for consumption is delivered from the water refilling station, and
neighborhood trash collection is scheduled regularly.
VII. Review of Systems
A. General or Constitutional Symptoms
There was no weight loss or weight gain noted. No unusual change in
the appetite. There have been no changes in sleep pattern.

B. Skin, Hair, Nails

There were no reports of itching, redness, or skin dryness. There have
been no notable changes in skin color, hair volume, or nail growth.

C. Head
Refer to History of Present Illness (HPI)

D. Eye
There were no reports of double vision, eye pain, or eye redness. There is
no blurring or blindness.

E. Ears
There were no reports of unusual discharges, earaches, tinnitus,
tenderness, or deafness.

F. Nose
There were no reports of loss of smell, epistaxis, unusual obstruction, or
discharge.

G. Mouth, Throat, Pharynx

There were no reports of bleeding of the gums, mouth sores, disturbance
of taste, or any pain in the mouth including the tongue and teeth. No dysphagia,
odynophagia, hoarseness of voice, and sore throat noted.

H. Neck
There were no reports of enlarged or swollen lymph nodes, or suppurative
lesions, stiffness, and limitation of motion.

I. Breasts
 There were no reports of swelling, lumps, skin dimpling, and mastalgia.
No discharges and change in the color of the areola noted.

J. Respiratory System
There were no reports of dyspnea and shortness of breath. No cough,
wheezing, sputum production or hemoptysis noted. The patient also did not
report any back pain or chest wall deformities.

K. Cardiovascular System and Peripheral Vascular System

The patient did not report any orthopnea, and paroxysmal nocturnal
dyspnea. No chest pain nor pain or swelling in the legs, varicose veins, leg
cramps and discoloration noted. The patient reported that he was diagnosed
with hypertension (see Past Medical History).

L. Gastrointestinal System
The patient has no trouble swallowing, heartburn, and vomiting. The
patient has a normal bowel description. There were no reports of diarrhea,
constipation, hemorrhoids, abdominal pain in any parts, excessive belching,
passing of gas, and jaundice.

M. Genitourinary System
The patient has normal urination. There were no complaints of nocturia
and dysuria. He has a normal color of urine. There was no reported incontinence.

N. Musculoskeletal System
Refer to History of Present Illness (HPI)

O. Hematologic
The patient did not report any abnormal bleeding and clotting, bruising,
pallor, and lymphadenopathy.

P. Neurologic
Refer to History of Present Illness (HPI)
Q. Psychiatric
The patient denied any experience of anxiety, increased feeling of
agitation, incidences of hallucinations, delusion and paranoia, tendencies of
violent behavior and suicidal ideations, nor any experiences of any abrupt mood
changes. No reports of any manifestation of depression that affects the patient’s
daily life and regular activities.

R. Endocrine System
The patient did not report any experience of heat or cold intolerance,
polydipsia or polyphagia, or any changes in body configuration such as sudden
weight loss or changes in facial or body hair, changes in size of hands and feet,
and voice modulation.