College of Medicine

Department of Family and Community Medicine

General Data: This is a case of V.C. 44 years old, Male, Married, Roman Catholic, currently
residing at Binan, Laguna, consulted at the OPD for the first time in this institution.

Date of Consult: December 29, 2010

Chief Complaint:
Suprapubic pain

History of Present Illness:

One month prior to consultation patient experienced suprapubic pain. Patient noticed a
blister that eventually getting larger, no other associated symptoms noted. Took Mefenamic Acid
500mg/tab which afforded temporarily relief.
Persistence of symptoms prompted consult.

Past Medical History:

(-) No previous hospitalization
(-) HPN
(-) Asthma
(-) DM
(-) Allergy

Family History:
(-) HPN
(-) DM
(-) CA
(-) Asthma

Personal and Social History:

(-) Smoker
(-) Alcoholic Drinker

Review of Systems:

HEENT: Respiratory:
- Blurring of vision Difficulty of breathing
Ringing of ears Wheezes
Hearing loss Cough
Eye redness Hemoptysis
Cardiovascular: Skin/Integument:

Chest pain Pallor

Orthopnea Cyanosis
Paroxismal nocturnal dyspnea Rashes
Easy fatigability Mottling
Edema
Metabolic/ Endocrine:
Gastrointestinal:
Polyuria
Abdominal pain Polyphagia
Jaundice Polydipsia
Nausea/ Vomiting Tremors
Diarrhea Unexplained weight loss/gain
Melena/ Hematochezia
Neurologic:
Genitourinary:
Weakness
Frequency/ Intermittency Numbness/ Paracentesis
Hematuria Headaches
Passage of Sandy material Dizziness
Dribbling Gait disturbance
Hesitancy

Musculoskeletal:

Muscle pain
Bone pain
Sprain/strain
Joint pains

Physical Examination:

General Survey: Conscious, Coherent, NICRD

Vital Signs: BP 110/70 PR: 86 RR: 20 T: 36°C
Skin: Warm to touch, good skin turgor
HEENT: Anicteric Sclerae, Pink palpebral conjunctivae, (-) Naso aural discharge, (-) tonsillo
pharyngeal congestion, (-) Cervico lymph adenopathy
Chest and Lungs: Symmetrical chest expansion, (-) retractions, Clear breath sounds
Heart: Adynamic precordium, (-) murmurs, Normal rate, Normal rhythm
Abdomen: Flat, Normoactive bowel sounds, epigastric tenderness
Extremities: No gross deformity, full and equal pulses, (-) cyanosis. (-) edema
Genogram:
walde
72yo Polo
66y/o
Unknown
COD

rosie 36 celso 54 oscar 52 molo 48 nita 38 remy 35

Patien Girlie 43yo

t

Joel 17 yo

Assessment:

Common wart

Plan:
- Refer to surgery

Prepared by:

______________________
Catherine Famadico
Medical Clerk
 College of Medicine

Department of Family and Community Medicine

General Data: This is a case of T.B. 39 years old, Male, Married, Roman Catholic, currently
residing at Binan, Laguna, consulted at the OPD for the first time in this institution.

Date of Consult: December 29, 2010

Chief Complaint:
Nape pain

History of Present Illness:

One week prior to consultation patient experienced nape pain, no other associated
symptoms noted. Took Mefenamic Acid 500mg/tab which afforded temporarily relief.
Persistence of symptoms prompted consult.

Past Medical History:

(-) No previous hospitalization
(-) HPN
(-) Asthma
(-) DM
(-) Allergy

Family History:
(+) HPN - father
(-) DM
(-) CA
(+) Asthma - mother

Personal and Social History:

(-) Smoker
(-) Alcoholic Drinker

Review of Systems:

HEENT:
- Blurring of vision Respiratory:
Ringing of ears Difficulty of breathing
Hearing loss Wheezes
Eye redness Cough
Hemoptysis
 Polyuria
Cardiovascular: Polyphagia
Polydipsia
Chest pain Tremors
Orthopnea Unexplained weight loss/gain
Paroxismal nocturnal dyspnea
Easy fatigability Neurologic:
Edema
Weakness
Gastrointestinal: Numbness/ Paracentesis
Headaches
Abdominal pain Dizziness
Jaundice Gait disturbance
Nausea/ Vomiting
Diarrhea
Melena/ Hematochezia

Genitourinary:

Frequency/ Intermittency
Hematuria
Passage of Sandy material
Dribbling
Hesitancy

Skin/Integument:

Pallor
Cyanosis
Rashes
Mottling

Metabolic/ Endocrine:

Musculoskeletal:

Muscle pain
Bone pain
Sprain/strain
Joint pains

Physical Examination:

General Survey: Conscious, Coherent, NICRD

Vital Signs: BP 130/90 PR: 78 RR: 18 T: 36.5°C
Skin: Warm to touch, good skin turgor
HEENT: Anicteric Sclerae, Pink palpebral conjunctivae, (-) Naso aural discharge, (-) tonsillo
pharyngeal congestion, (-) Cervico lymph adenopathy
Chest and Lungs: Symmetrical chest expansion, (-) retractions, Clear breath sounds
Heart: Adynamic precordium, (-) murmurs, Normal rate, Normal rhythm
Abdomen: Flat, Normoactive bowel sounds, epigastric tenderness
Extremities: No gross deformity, full and equal pulses, (-) cyanosis. (-) edema

Genogram:
Remy
69yo
Oscar
44yo
asthma HPN

Nely 42 tony 38 mel 36 lary 30 matt 27 mark 25 laura 21

Patien
t Corazon 42yo

Czarina 2yo Particia 8mos

Pneumonia Pneumonia

Assessment:

Musculoskeletal strain

Plan:
- Mefenamic Acid 500mg every 8 hours PRN as needed for pain
- Advised

Differential Diagnosis:
 Osteoarthritis
 Rheumatoid Arthritis
 Gouty Arthritis
 Prepared by:

______________________
Catherine Famadico
Medical Clerk

College of Medicine

Department of Family and Community Medicine

General Data: This is a case of R.P. 21 years old, Female, single, Roman Catholic, currently
residing at Binan, Laguna, consulted at the OPD for the first time in this institution.

Date of Consult: December 17, 2010

Chief Complaint:
Itchiness

History of Present Illness:

Two days prior to consultation patient experienced itchiness on the upper extremities, no
other associated symptoms,no medication taken, no consult done.
Persistence of symptoms prompted consult.

Past Medical History:

(-) No previous hospitalization
(-) HPN
(-) Asthma
(-) DM
(-) Allergy

Family History:
(-) HPN
(-) DM
(-) CA
(-) Asthma

Personal and Social History:

(-) Smoker
(-) Alcoholic Drinker
Review of Systems:
Melena/ Hematochezia
HEENT:
- Blurring of vision Genitourinary:
Ringing of ears
Hearing loss Frequency/ Intermittency
Eye redness Hematuria
Passage of Sandy material
Dribbling
Hesitancy

Skin/Integument:
Respiratory:
Difficulty of breathing Pallor
Wheezes Cyanosis
Cough Rashes
Hemoptysis Mottling

Metabolic/ Endocrine:

Polyuria
Cardiovascular: Polyphagia
Polydipsia
Chest pain Tremors
Orthopnea Unexplained weight loss/gain
Paroxismal nocturnal dyspnea
Easy fatigability Neurologic:
Edema
Weakness
Gastrointestinal: Numbness/ Paracentesis
Headaches
Abdominal pain Dizziness
Jaundice Gait disturbance
Nausea/ Vomiting
Diarrhea

Musculoskeletal:

Muscle pain
Bone pain
Sprain/strain
Joint pains

Physical Examination:
General Survey: Conscious, Coherent, NICRD
Vital Signs: BP 90/60 PR: 76 RR: 18 T: 36.9°C
Skin: Warm to touch, good skin turgor
HEENT: Anicteric Sclerae, Pink palpebral conjunctivae, (-) Naso aural discharge, (-) tonsillo
pharyngeal congestion, (-) Cervico lymph adenopathy
Chest and Lungs: Symmetrical chest expansion, (-) retractions, Clear breath sounds
Heart: Adynamic precordium, (-) murmurs, Normal rate, Normal rhythm
Abdomen: Flat, Normoactive bowel sounds, epigastric tenderness
Extremities: No gross deformity, full and equal pulses, (-) cyanosis. (-) edema

Genogram:
Telma
47yo ferdy
66y/o

patie Marc
nt o
15yo

Assessment:

Atopic Dermatitis

Plan:
- Cetirizine 10mg, apply on the affected area
- Bethametazone cream

Differential Diagnosis:
 Contact Dermatitis
 Allergic Dermatitis

Prepared by:

______________________
Catherine Famadico
Medical Clerk