HISTORY OF PAST AND PRESENT ILLNESS

I. Personal Data
Name: EJ

Address: Banna, Ilocos Norte

Gender: Male

Age: 23 years old

Date of Birth: 07/17/1994

Place of Birth: Nueva Ecija

Civil Status: Single

Religion: Catholic

Educational Attainment: High School Graduate

Occupation: Farming

Chief Complaint: Right Lower Quadrant Pain

Admitting Diagnosis: Acute Appendicitis

Date and Time of Admission: 08/24/2017 @04:15 PM

Admitting Physician: Dr. P

Attending Physician: Dr. P, Dr. L

Final Diagnosis: Acute Appendicitis, Ruptured, with Localized Abscess, S/P

Appendectomy 08/24/2017

Date and Time of Discharge: 08/28/2017 @ 8:15 PM

A. Family Health History

The genogram of the family shows that there are certain hereditary diseases

of the immediate family as well as their blood line relatives are experiencing. Certain

hereditary diseases include hypertension and diabetes mellitus.

On the paternal side, 1 family member died due to complications of Diabetes

Mellitus. 1 family member inherit it (DM) and is currently taking maintenance but the

client was not able to enumerate the such drugs. 3 members of the family have

hypertension but not currently taking in maintenance drugs. On the maternal side, the

client is not clear about his relatives since they are living in Agusan Del Sur. His mother

has 5 siblings. He only remembered one but unable to enumerate them all. His mother

had a kidney problem, he was not sure if she is on dialysis treatment. He has no

knowledge regarding this since he was separated from his mother when he was 6 years

old.

The family is commonly experiencing cough and colds, fever, headache and

backache. They managed it with over-the-counter drugs such as Carbocisteine for

cough, Bioflu for colds, Paracetamol for fever and Mefenamic Acid for headache and

backache. These over the counter drugs were effective but when their condition did not

improve or worsen, they go to RHU for check-up. Furthermore, they sometime use

herbal medicines to treat such common ailments such as lagundi and oregano

decoction for cough. The also prepares calamansi juice. They chew garlic cloves and
 ashitaba leaves for lowering their blood pressure for his uncles and as claimed they are

effective.

Some of the family members smoke cigarettes and drink alcohol. The family

sometimes seek treatment from albularyo and as claimed, they are effective. He does

not sure of the immunization of the family members.

B. Past Health History

The patient had experienced childhood illnesses such as chicken pox,

measles and mumps. They managed the chicken pox with traditional way of wearing

black shirt so that all lesions will erupt and will dry the soonest time. The client also

refrained from eating eggs and chicken because they believe that this will worsen the

condition. His chicken pox lasted for weeks and no complications were noted. For

measles, he recalled that they burn dried onion skin and they believe that the smoke

coming from it will halt the eruption of lesions. For his mumps, they just applied it with

gentian violet and “akot-akot” and no complications were noted. The client claimed that

these traditional ways of treatment were effective.

The client also experiences common illnesses like cough and colds, fever

and headache. This is managed by over the counter drugs like paracetamol tablet for

fever and headache, carbocisteine for cough and bioflu for colds. These OTC drugs can

relieve these illnesses as stated above. Furthermore, they supplement it with increasing

water intake, eating green leafy vegetables accompanied with hot soup. However, if

conditions come for worst, they immediately seek consultation at the RHU or nearest

hospital.
 He claimed that he received all primary immunization given by their RHU.

Secondary immunizations such as flu, pneumococcal, dengue, varicella, and others

were not given.

Last March 2016, the client had a minor motor accident. The client sustained

minor abrasion in upper and lower extremities and forehead which prompted him go to

district health facility and was treated as out-patient. Antibiotics and pain reliever were

given and advice wound care. Other than that, the client had no previous hospitalization

and history of blood transfusion.

Earlier this year, he started feeling of bearable epigastric pain. He went to the

RHU and was diagnosed with gastritis. He was just given Aluminum Magnesium

Hydroxide three times a day and claimed that he was relieved from it and was advised

to avoid spicy foods, drink carbonated products and drinking alcoholic beverages.

The client is a known alcoholic drinker since high school years. He also smoke 2-

3 sticks per day started 4 years ago. He also claimed that he is fond of carbonated

drinks.

C. Present Health History

The present condition started last August 8, 2017 when the client felt a tolerable

pain (3/10) on the epigastric area at first then to periumbilical area radiating to right

lower quadrant. He also vomited previously ingested food once. He claimed that he

was not febrile and no other symptoms noted. He went to the district hospital for

consultation and was admitted as a case of gastritis. He was given with unfamiliar IV

fluids and given omeprazole IV medications. He claimed that pain on the abdominal

area was relieved and after 3 days, he was discharged and given with omeprazole 40
mg/ cap OD before breakfast and cefuroxime 750 mg/tab TID as take home

medications.

On August 23, 2017, the client again experienced cramping pain (3/10) on

the hypogastric area with no associated fever or vomiting. The condition persisted on

the night of that day and pain was intensified (5/10) and now associated with fever. No

consultation was done.

On dawn of August 24, 2017, the pain was now then felt on the right lower

quadrant (7/10) accompanied still with fever and an episode of vomiting, no consultation

was done and as claimed it was aggravated when the client inhales. He just stayed in

bed, on a fetal position which he claimed relief and a decrease in pain felt. The morning

that day, the condition persisted and worsen. The pain felt was 10/10 with guarding and

crying. They rushed him at the same district hospital where he was admitted previously.

Present working impression was acute appendicitis. He was hooked D5LR1L and

started on antibiotics. As claimed, no pain reliever was given. He was transferred to the

provincial hospital for immediate operation. He was placed on NPO and was supposed

to be operated but he said that there were no surgeon available. The client was

transferred to nearby referral tertiary hospital for immediate operation. He was seen at

the emergency room by Dr. P, hence the admission, admitted at 04:15 pm, with an

admitting diagnosis of Acute Appendicitis.

Date Performed: August 24, 2017

Time Performed: 5:30 PM

Place: PACU (pre-op area) MMMH and MC

1. General Appearance

The client is a 23-year old male, seen lying on bed, on fetal position. He

is ectomorph in terms of body built. The client is in pain during the assessment.

His face was grimacing, he was moaning and guarding his abdomen. He is

wearing a hospital gown. He has an IV fluid of D5LR 1L at 30 gtts/min inserted

on right cephalic vein via intravenous catheter gauge 18.

2. Vital Signs

Body Temperature: 39.1° C using infrared thermometer

Pulse Rate: 115 beats in one full minute, regular

Cardiac Rate: 115 beats in one full minute, regular

Respiratory Rate: 25 breaths per minute, regular

Blood Pressure: 120/80 mmHg in lying position

3. Head-to-Toe Assessment

a. Head

- Normocephalic

- Scalp lighter in color than complexion

b. Face

- With symmetrical facial features

- Able to move facial muscles at will

- No involuntary muscle movements noted

- Warm to touch

c. Eyes

- With symmetrical and evenly distributed eyebrows

- With upper eyelid partially covering the iris

- With yellowish sclera

- With pinkish upper and lower conjunctiva

- With visual acuity of 20/20, able to read letters from the snellen chart at an

appropriate distance

- Pupils are equal, round and reactive to light and accommodation

d. Ears

- Bean-shaped symmetrical earlobes

- Skin is same color as complexion

- No pain or tenderness upon palpation of mastoid process and auricles

- No lesions or discharges noted

- With good hearing acuity – able to repeat what examiner said through the

voice test

e. Nose

- Nose in midline

- With patent nares

- No discharges noted
 - No alar flaring

- No tenderness, mass or pain noted upon palpation

f. Mouth

- With moist, symmetrical lips, no lesions noted

- With pinkish buccal mucosa

- Complete set of permanent teeth

- Tongue is in midline position

- With pinkish uvula and in midline position

- With intact gag reflex

g. Neck

- No mass or lumps noted upon inspection

- Not distended jugular vein

- With good range of motion

- Warm to touch

h. Chest

- Moves symmetrically when breathing

- Respiratory rate of 25 breaths per minute

- Clear breath sounds, no retractions noted

- No murmur noted upon auscultation

- Cardiac rate of 115 beats per minute

i. Abdomen

- Flat abdomen

- No lesions noted

- Noted exaggerated tenderness and pain upon direct and release of

palpation of the RLQ (Rovsing and Blumberg sign)

LLQ (referred rebound tenderness)

- Noted RLQ pain that is felt upon slow extension of the right thigh with

patient lying on the left side (Psoas sign)

- Noted RLQ pain upon passive internal rotation of the flexed right

thigh with patient in supine (obturator sign).

- Bowel sounds auscultated as follows:

RUQ: 5 bs/min

RLQ: 6 bs/min

LUQ: 6 bs/min

LLQ: 6 bs/min

j. Upper extremities

- Symmetrical

- With BCG scar on right deltoid

- With good skin turgor

- Pinkish nail beds with capillary refill of <2 seconds

- Good ROM

- Warm to touch

k. Lower extremities

- Symmetrical

- With good skin turgor

- Pinkish nail beds with capillary refill of <2 seconds

- Good ROM

- Warm to touch

l. Genital and anus