Name of Patient: Richard Bactol Preceptor: Dr. Santi Historian: Katrina Cyril M. Macalintal Hospital: UMC Group no.

1B Date of Ward Work: November 21, 2011 Date submitted: November 22, 2011 General Data R.B., a 23 year old was born March 14, 1988 in Dasmarinas, Cavite. Male, Roman Catholic, single, unemployed, and still residing at Dasmarinas, Cavite. Chief complaint Masakit ang tiyan History of Present Illness Patient was apparently well until three months prior to consult when he experienced pain in his abdomen, specifically on the right lower quadrant. He was at a birthday party that time and mentioned that he was eating chicharon and drinking alcoholic beverages. Since then, patient claims he experiences pain in his abdomen every two to three hours. On a scale of 10, he grades the pain as 7/10. Patient also mentioned that the pain is sudden, sharp, radiates to the back, and then gradually lessens. He took Kremil-S to relieve the pain but he claims it did not work. He is sometimes awakened at night by the pain and he would sleep on a "flexing position" to relieve the pain. The pain is severe before eating and is aggravated by eating fatty food. Patient's diet still included fatty food. There is no accompanying fever, nausea, vomiting or diarrhea. The pain is persistent which prompted him to seek consult. Past History Hypertension: (-) Diabetes Mellitus: (-) Previous hospitalization: (-) Dental Extraction: (-) Fever: (-) Family History (+) Hypertension, paternal side (+) Uric Acid, maternal side Personal & Social History The patient is a non-smoker who occasionally drinks. He lives with his family and he mentioned that his brother usually smokes. Review of System General: (-) weight loss, (-) loss of appetite, (-) loss of fatigability Skin: (-)rashes Hematopoietic: (-) anemia Eyes: (-)blurred vision Ears: (-)tinnitus

Upper respiratory tract: (-)cough, (-)flu Mouth: (-)canker sore Respiratory tract: (-)dyspnea GIT: (-)diarrhea, (-) vomiting GUT: (-)polyuria Musculoskeletal: (-) joint pains, (-)muscle weakness Allergies: n/a Emotional/ behavior: (-) anxiety Neurology: (-)headache PHYSICAL EXAMINATION General Survey: Awake, fairly developed, not in cardio respiratory distress GIT Inspection: The abdomen is flat, symmetrical, no visible scars, no visible lesions, no visible masses, no visible peristalsis, no visible pulsations Auscultation: The bowel sounds are normoactive, there is no Bruit, no Venus Hum, and no Friction Rub Palpation: The abdomen is soft and not rigid on light palpation. There is no palpable mass or tenderness on deep palpation. The liver, spleen and both kidneys are not palpable. Percussion: The abdomen is primarily tympanitic. Liver span is 11cm. Spleenic span is 7cm. Tympanitic on Traube's space. Fluid Wave: (-) fluid thrills Shifting dullness: (-) Succussion splash: (-) Murphy's sign: (-) Rovsing's sign: (-) Obturator sign: (-) Psoas sign: (-)