IM WARD

ORAL
PRESENTATION
THURSDAY GROUP
CRON, DELA CRUZ, DELOS REYES, DU, EVARDO, EWICK, FULO, GALVEZ, GELLADO, GONZALES

DR. FORTUNO
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 GENERAL
DATA
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 GENERAL DATA

G.E, a 47-year-old female, born on January 19, 1975 in Baybay, Leyte,

single, Filipino, Roman Catholic, presently residing at Imus, Cavite,

and works in Corporate Communications was admitted for the first

time at Fatima University Medical Center (FUMC) last December 9,

2021.
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Gellado, Ma. Carla Gelline

 01

CHIEF
COMPLAINT
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 CHIEF COMPLAINT

Epigastric pain
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 HISTORY
OF
PRESENT
ILLNESS
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 HISTORY OF PRESENT
ILLNESS
8 weeks PTA, the patient experienced epigastric pain with a PS of 2-3/10 for about 30 minutes to 1
hour which occurs 2-3 times a day with episodes of acid regurgitation. No other associated symptoms
and no medications were taken.
2 weeks PTA, the patient still experienced epigastric pain which worsens when lying down after
meals. The pain was relieved by drinking water and self-medicated with Aluminum Hydroxide +
Magnesium Hydroxide + Simethicone(Kremil S) 30 mg taken once a day.

3 days PTA, the patient experienced epigastric pain of 5/10 for about 30 minutes to 1 hour which
worsens after heavy and fatty meals with episodes of acid regurgitation and eructation. The patient
self-medicated with Aluminum Hydroxide + Magnesium Hydroxide + Simethicone(Kremil S) 30 mg
taken twice a day which did not relieved the pain.

Few Hours PTA, the patient experienced increasing epigastric pain of 8-9/10 with longer duration of
about 1 hour to 3 hours. She continued her medication but still has no improvement.
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Due to the persistence of the epigastric pain, the patient prompted to seek for admission. .
Gonzales, Majesty D.
 PAST
MEDICAL
HISTORY
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 PAST MEDICAL HISTORY
The patient claimed to have complete childhood immunization. She also claimed to have
Mumps at 9 years old and Chickenpox at 13 years old.

She also claimed to be completely vaccinated against COVID-19. She was diagnosed
hypertensive in 2019 at 45 years old and is taking Losartan 50mg, once a day for which
she claimed to be compliant. She also takes Vitamin C, B complex, E and D, once a day.
She denies history of other adult illnesses such as diabetes, stroke, CAD, kidney disease,
gastrointestinal disease, tuberculosis, gout, cancer, psychiatric problems, and asthma.

She denies history of surgery, accidents, injuries, disabilities and blood transfusion. No
known allergies to food and medication.

She denies history of same symptoms with other household members.

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Cron, Cherrie Anne

 MENSTRUA
L&
OBSTETRIC
S HISTORY
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 MENSTRUAL HISTORY
The patient menarche at 13 years old, regular menstruation with 4-5 days
duration, normal flow for the first 3 days consuming 4-5 pads, with moderate
flow for the following 4th-5th day of menstruation consuming 2-3 pads per day.
Patient confirms of having premenstrual symptoms like cravings to food, having
less energy and pimple breakout but denies dysmenorrhea. Subsequent
menses come every 28-30 days. Last Menstrual Period was December 1, 2021,
PMP was November 1, 2021. No history of heavy menstrual bleeding.
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Dela Cruz, Jose Carlos

 OBSTETRIC AND GYNECOLOGIC
HISTORY
The patient has G4P4 (4004) all are delivered normally without complications.
No history of Vulvovaginitis, cervicitis and pelvic inflammatory disease
(PID).Patient denies having any gynecologic diseases like ovarian cyst, h-mole or
pelvic malignancy. No history of gynecologic procedure like dilatation and
curettage. There is discharge and foul smell noted at her younger age. No pain
and discomfort noted. No exposure or history of sexually trasmitted disease.
Patient denies use of any form of contraception or any birth control and no
hormonal replacement noted.
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Dela Cruz, Jose Carlos

 FAMILY
HISTORY
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 FAMILY HISTORY
The father of the patient , 74 years old, was diagnosed with
hypertension when he was 64 years old, and is taking his
maintenance medicine, Losartan 50mg OD, compliant and has no
history of other diseases. The mother of the patient died at the age
of 59 due to myocardial infarction. Her sister is apparently well
and healthy as mentioned by the patient and denies other
heredofamilial diseases like asthma, arthritis, gout, cancer,DM,
kidney disease,GI diseases, tuberculosis and psychiatric problems.
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DELOS REYES, ANN R.

 PERSONAL
& SOCIAL
HISTORY
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 PERSONAL AND SOCIAL
HISTORY
Patient is a college graduate and is working in a Corporate Communication for
10 years. She has 4 children which she declares of good health. The patient is a
non-smoker and drinks red wine 4 times a year, consuming 2 glasses per
session. The patient eats 3 times a day. She is fond of eating instant, fried, and
spicy foods. She is also fond of drinking coffee, 5-6 cups per day. Her physical
activities include cycling and running. She sleeps for an average of 8-10 hours
every night. The patient denies the use of prohibited drugs or any substance
abuse.
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 PERSONAL AND SOCIAL
HISTORY
The patient lives in their own house in Cavite for 20 years with her family.
They also have a dog as their pet. The house is clean and well-ventilated.
The source of their drinking water is from a water station and for the
utilities they use tap water. She claims that their neighborhood is neat
and the surroundings are clean. Garbage disposal happens every twice a
week.
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EWICK, Hanna C.
 REVIEW OF
SYSTEMS
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 REVIEW OF SYSTEMS
GENERAL: (-) Fever, (-) Chills, (-) change in weight, (-) malaise

INTEGUMENTARY: (-) Itchiness, (-) dryness, (-) rash, (-) skin discoloration

HEENT: (-) Headache, (-) dizziness, (-) diplopia, (-) blurring of vision, (-) eye pain, (-) ear
discharge, (-) ear pain, (-) hearing loss, (-) tinnitus, (-) toothache, (-) odynophagia, (-) sore throat,
(+) hoarseness, (-) ageusia (-) neck lump, (-) neck pain, (-) stiff neck, (-) nasal obstruction, (-) nasal
discharge, (-) anosmia

RESPIRATORY: (-) cough, (-) wheezing, (-) sputum production, (-) hemoptysis, (-) dyspnea

CARDIOVASCULAR: (-) palpitations, (-) easy fatigability, (+) orthopnea

GASTROINTESTINAL: (-) loss of appetite, (-) dysphagia, (-) diarrhea, (-) constipation, (-) nausea
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and vomiting, (-) hematemesis, (-) hematochezia

Fulo, Nathaniel D.
 REVIEW OF SYSTEMS
GENITO-URINARY: (-) Changes in urine color, (-) dysuria, (-) nocturia, (-) oliguria, (-) hematuria,
(-) flank pain

MUSCULOSKELETAL: (-) Joint pain, (-) numbness, (-) myalgia, (-) swelling of joints, (-) back pain,
(-) muscle stiffness, (-) muscle weakness

HEMATOLOGIC: (-) Easy bruisability, (-) gum bleeding

ENDOCRINE: (-) Heat/cold intolerance, (-) polyphagia. (-) polydipsia, (-) polyuria

NEURO-PSYCHIATRIC: (-) Mood changes/mood swings, (-) behavioural changes, (-) personality
changes, (-) memory loss, (+) sleep disturbance - started a week ago, happened 2 to 3 times due to
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increasing epigastric discomfort (-) pins and needles sensation

GALVEZ, Maria Diane Richelle C.

 PHYSICAL
EXAMINATI
ON
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 PHYSICAL EXAMINATION
General: The patient is conscious, cooperative, coherent, well developed and well
grown, small build and not in respiratory distress.

Vital Sign: BP = 127/80 mmHg HR: 80 bpm

RR: 19 cpm Temp. = 36.7℃, axilla

Anthropometric measurements
Ht. = 165cm Wt. = 126 lbs BMI =21.0 kg/m2 (Normal)
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 PHYSICAL EXAMINATION
Skin: Brown, smooth, good skin turgor/elasticity. Hair is black, smooth, well distributed.
Nails are pink, no lesions, capillary refill time (<2 secs)

HEENT: Anicteric sclerae, pink palpebral conjunctivae, no nasal discharge, no cervical

lymphadenopathy, frontal and maxillary sinuses are normal.

CHEST & LUNGS: No deformities, no chest lagging, no retraction, symmetrical chest

expansion, Normal tactile fremitus, resonant and no wheezes heard during expiration
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Evardo, Dranreb Juer

 PHYSICAL EXAMINATION
CVS: Adynamic precordium, Apex Beat at 5th left ICS MCL, no palpable thrills, regular
rate and rhythm, normal S1 and S2, no murmur, no carotid bruit, no neck vein distention,
full and equal pulses.
Abdomen: Non-distended, soft, non-tender; normal active bowel sounds.
Extremity: Grossly normal extremities, no tenderness, no joint swelling, no nodules
noted. No cyanosis, no edema with full range of motion
Neurology: No neurodeficit
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THANK YOU!
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