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The patient presents with pain on suprapubic area and radiating pain on
both flanks. He described the pain as severe with an intensity of 9/10.
3 hours PTA he experienced low-grade fever and chills along with nausea,
shortness of breath, chest pain and bright red blood in the urine and dysuria hence
was rushed to the Davao Medical Center by 911. At 11:00 P.M. the patient
decided to be transferred to DMSF hospital.
Past History
Patient had mumps at 9 years old and chicken pox at age of 12.
Adult Illnesses : Medical. Last 2001, patient was diagnosed with tuberculosis
of the lungs. He underwent 6 months of drug therapy. He
also stated that he has high blood pressure as high as
160/120 and was diagnosed last year. He is not taking any
maintenance for his hypertension.
Surgical. None
Psychiatric. None
Health Maintenance. Immunizations. Patient is not able to
recall his immunizations.
Family History
On his paternal side, grandfather died at age of 65 due to stroke. His father
has hypertension and his mother has cardiovascular disease. Both parents are still
alive.
Physical Examination
Vital signs
BP : 130/100 mmHg
HR : 98 beats / min
RR : 21
Temp. : 36.5 C
Skin : Fair – skinned and palms are cold. Nails without cyanosis
and clubbing
Head : Hair – of average texture;
Scalp – no lesions and normocephalic
Eyes : Visual acuity of 20/20 on both eyes
Visual fields full by confrontation
Conjunctiva pink; sclerae are white
Ears : Waxes are seen and no discharges
Nose : No mucosal discharges and sinus tenderness
Throat : Tongue in midline position, no sores and swelling of gums
Neck : Trachea is midline. No palpable masses
Lymph nodes : No palpable lymph nodes.
Thorax : No skin retractions. No palpable masses. Both lungs are resonant
and no wheezing is observed.
Cardio : No irregular bulging. It is dynamic without heaves and thrills. No
murmurs are observed.
Breast : No skin retractions, breast is symmetrical, no nipple discharges.
No masses and lymph nodes were palpated.
Abdomen : No surgical scars were seen and abdomen is flat. No irregular
bowel sounds were heard. Radiating pain towards the right flank
during palpation and percussion. Spleen and liver are not palpable.
Extremities : No varicosities, edema and it is warm to touch. Calves are non
Tender
Presented to
Prepared by