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Appendicitis Case Study Scribd

 

I. Patient Profile

Name:

Bernardo Matobato

Age:

26 years old

Gender:

male

Occupation:

construction worker

Educational Attainment:

grade 4

Civil Status:

single

Nationality:

filipino

Address:

brgy. Dapdap Alang-alang Leyte

Religion:

catholic

C/C:

abdominal pain

Date Admitted:

 july 22, 2010 @ 9:00pm

Admitting Diagnosis:

ruptured appendicitis

Attending Physician:

Dr. Bañez

Source of Information:

patient and mother

Reliability:

90%

II. Present Illness:

14 hours prior to admission, the patient experienced mild pain on his right lowerquadrant abdomen while eating in the morning, followed by a severe pain. The clienttried to eliminate the pain using herbal oil but were not eradicated.Persistence of the noticed pain, prompted his mother to bring him to EVRMC,hence this admission.

III. Past Health History:

 The patient did not receive any vaccination as claimed by the mother, hasexperienced acute respiratory infection such as cough, cold and mild fever and tookbiogesic (250mg) every 4 hours for fever and some herbal plants (decoction of lagundi)for cough relief. Pain in the right lower abdomen 1

st

felt when the client was 25 years oldbut were ignored no history of hospitalization.

IV. Family History:

 The mother claimed that her mother is asthma positive, and noted hypertensionhistory on the paternal side.

V. Birth History:

 The patient is 3

rd

on eight siblings of Mr. and Mrs. Matobato. Born via normalvaginal delivery on their house.

VI.Psychosocialhistory:

 The patient sorrounding is good and there were no lakes, swamp or river nearby. They used a deep well for drinking and taking a bath. He smokes 5 sticks of cigar. Perday, and play basketball in freetime.

 

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