Patient Profile

Patient : Ronel Sigampong

Address : Deca Homes Cabantian, Davao City
Age : 31 years old
Sex : Male
Marital status : Married
Religion : Protestant
Occupation : Self- employed
Educational Attainment : College Graduate – Civil Engineering

Date of Admission : January 4, 2010; 11:00 P.M. – DMSF Hospital

Attending Physician : Dr. Edgar Allan Piatos

Chief Complaint(s) : Pain in urination with blood in the urine

History of Present Illness

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.

Two weeks prior to admission, patient experienced frequent urination in

small volumes. He self medicate it with water and the pain was relieved and
apparently well.

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.

Personal and Social History

Born and raised in Koronadal, South Cotabato. Graduated college, married
at age 28.Worked as a structural designer for 2 years. His family moved to
Canbantian, Davao City last year. They have 2 children and he is also an active
church member.

Exercise . He plays basketball regularly.

Diet . He prefers to eat vegetables and high – carbohydrate foods.
Habits . Patient is a non-smoker. He is an occasional drinker.
 REVIEW OF SYSTEMS

General : Has gained weight

Skin : No skin rashes but there is presence of macules on the face.
HEENT : Head: Normocephalic and hairs are evenly distributed.
Eyes: Vision is good with visual acuity of 20/20 on both eyes
Ears : Hearing is good. No tinnitus
Nose: No discharges noted and sinuses were not inflamed
Throat: No bleeding gums were seen
Neck : No lumps, pain and swollen glands
Breast : No lumps, discharges and nipple retractions
Respiratory : Positive for TB 8 years ago
Cardiovascular : High blood pressure or with hypertension
GI : Appetite is good. Bowel movement about
once daily
Urinary : Presence of blood in the urine and dysuria.
Peripheral Vascular : No history of leg pain
Psychiatric : No history of depression or psychiatric treatment
Neurologic : Memory is good. Fainting was observed.

Physical Examination

Mr. Sigampong is a medium built man who responds quickly to questions.

He is in pain and anxious on the medications given. His hair is fixed and neat. He
is more comfortable in sitting position.

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

Diagnosis : Paitent has Urinary Tract Infection

 Defined
Patient Data Base

Presented to

Edgar Allan A. Piatos, M.D.

Prepared by

Sha Hezra Muhamad

Maridee Sebumpan