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Patient Profile

Patient : Ronel SigampongAddress : Deca Homes Cabantian, Davao City

Age : 31 years old

Sex : MaleMarital status : Married

Religion : Protestant

Occupation : Self- employedEducational 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 onboth 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 andapparently 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 patientdecided 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 as160/120 and was diagnosed last year. He is not taking any

maintenance for his hypertension.

Surgical. NonePsychiatric. 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 stillalive.

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 activechurch 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.

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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 inflamedThroat: 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 agoCardiovascular : 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 treatmentNeurologic : 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 mmHgHR : 98 beats / min

RR : 21

Temp. : 36.5 CSkin : Fair skinned and palms are cold. Nails without cyanosis

and clubbing

Head : Hair of average texture;

Scalp no lesions and normocephalicEyes : Visual acuity of 20/20 on both eyes

Visual fields full by confrontation

Conjunctiva pink; sclerae are whiteEars : Waxes are seen and no discharges

Nose : No mucosal discharges and sinus tenderness

Throat : Tongue in midline position, no sores and swelling of gumsNeck : 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 flankduring 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

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Defined

Patient Data Base

Presented to

Edgar Allan A. Piatos, M.D.

Prepared by

Sha Hezra MuhamadMaridee Sebumpan