History of Present Illness

October 14, 2017, 3 months before admission, while traveling coming from a convention, the
patient experienced an epigastric pain characterized as sharp, 7/10, non-radiating and relieved by rest
which is accompanied by vomiting, nausea and malaise. The patient also passes black tarry stools.
November 2017, 1 month after visiting the hospital, the patient’s complaint still persisted:
epigastric pain, black tarry stools accompanied by nausea, malaise and occasional vomiting. With the
persistence of the said symptoms, he visited a local clinic where he was given ferrous sulphate and said
nothing about further treatment.
On the day of the admission, January 29 2017 the patient experienced the same episode of
epigastric pain, nausea and vomiting but described it as at a severe degree. Alarmed and thinking that he
can’t take it anymore, his family rushed him to CVMC and was admitted.

Past Medical History

The patient was diagnosed with intestinal parasitic infection on October 14, 2017 and was
admitted in their local hospital. He was given antibiotics for the infection. He has no history of surgical
operations and any psychiatric illness. According to the patient, he has been taking NSAIDs for a long
time which he did not specify whenever he felt general body pain.

Family History
His father died of asthma. Four of his siblings died due wot cardiovascular disease. No family
history of diabetes, tuberculosis, kidney disease, anemia, epilepsy or mental illness.

Personal and Social History

He is married and has 7 children, He used to work as a farmer. The patient smokes and drinks
alcohol. Coffee.
 GROUP 2
Members:
RHEA ANGELIE ISLA
MARAH KRYZZIA PURIFICACION
CASEY JON VEA
AHILDEV, DEVADHAS PREMALATHA
RUSHNOL JADE TUPAC
 HISTORY

NAME: MR. J AGE: 31 CIVIL STATUS: MALE

ADDRESS: GATTARAN, CAGAYAN

BIRTHDAY: 042/25/1986 RELIGION: ROMAN OCCUPATION: FARMER

CATHOLIC

DATE/TIME OF ADMISSION: January 29, 2018 10AM

ADMITTING DIAGNOSIS

CHIEF COMPLAINT: Epigastric pain, Vomiting, High fever

HISTORY OF PRESENT ILLNESS:

Dec. 20, 2017, 19 days prior to admission, patient J was cleaning their
backyard after a strong rain when suddenly; he was pricked by a bamboo thorn on his
left sole. He shrugged off the wound and went on doing his chores and even went to
the rice fields to visit his crops. He continued to go to the rice fields with an open
wound on the subsequent days.

Dec. 29, 2017, 10 days prior to admission or 9 days after being wounded, the
patient developed signs and symptoms of fever &chills, loose bowel movement 3x a
day, muscle & leg pain and reddening of the sclera of both eyes. The patient refused
to go the hospital because de did not want to spend the new years eve there. He just
took paracetamol for his fever.

Jan. 3, 2018, 5 days prior to admission, the patient experienced fever noted
at 38 oC,vomiting of previously taken meals and difficulty of urinating with small
amount of urine. The patient also experienced abdominal pain characterized as
sharp, non-radiating and 7/10.

On the day of admission Jan. 8, 2018, the patient woke up and found out that
he cannot stand nor walk because of muscle pain and weakness in his legs. He was
then rushed to CVMC and was admitted.

PAST MEDICAL HISTORY:

The patient has no history of hospitalization, surgical operations and

psychiatric illness and medication.

Medical: None

Surgical: None

Psychiatric: None

Health maintenance: None

FAMILY HISTORY:

Both parents are still alive and well. One of his siblings has cancer. No family history
of diabetes, tuberculosis, heart or kidney disease, anemia, epilepsy, or mental illness.

PERSONAL AND SOCIAL HISTORY:

Born and raised in Gattaran, Cagayan. During highschool he also worked as a
construction worker and now works as a farmer. He is married and has a daughter.
The patient smokes and drinks alcohol. The atient’s diet is usually high in fat and
vegetables.

REVIEW OF SYSTEMS:
GENERAL Fever, chills

SKIN

HEAD,EYES,EARS, Head ache

NOSE,THROAT

NECK

RESPIRATORY

HEART

GI diarrhea

GU

MUSCULOSKELETAL Muscle and joint pains

PHYSICAL EXAM
GENERAL:

BP: 115/70 mmHg

HR: 103 bpm

T: 37.8C

RR: 22 BPM

O2 Sat: 95 %
 SKIN

HEAD,EYES,EARS, Red eyes,

NOSE,THROAT

NECK (-)mass

RESPIRATORY Clear breath sounds

HEART Regular rhythm

GI Soft, non-tender (-) mass

Epigastric pain characterized as sharp, non-radiating and

6/10

GU Oliguria(+)

MUSCULOSKELETAL

NEUROLOGIC Intact

IMPRESSION: LEPTOSPIROSIS