University of the East-Ramon Magsaysay

Memorial Medical Center, Inc.

College of Medicine

Medicine I

Medicine Ward

Preceptorial Report No. 2

I. Patient Profile:

Name: Lyka Sangilan

Age: 32
Gender: Female
Birth date: May 17 1984
Residence: Quezon City
Birth place: Caloocan
Religion: Roman Catholic
Marital status: Married
Educational attainment: Secondary (HS graduate)
Occupation: Sales Lady at L’Oreal Cosmetics (7 years)
Previous occupation: fast food service

The patient's family is composed of her husband and 1 son. But her mother-in-law
currently lives with them. The patient is currently renting at an apartment in Quezon city.
The apartment has the basic facilities such as water and electricity. She’s working for
L’Oreal and the husband works as an assistant coordinator

As for her habits and routines, the patient eats 3 times a day; usually vegetable and fish;
and has access to clean water. No formal form of exercise but commutes everyday to and
from work. And is also a Non smoker and non alcohol drinker
II. Chief Complaint:
The patient verbalized difficulty in breathing, numbness and loss of motor skills (neck
and below; she can only move her head), vomiting
 Date of admission: Tuesday early morning (5am) (aug 23 2016)

III. Source and Reliability: The patient answered the interview

IV. Patient History

History of present illness

4 days prior to admission, the client started to experience fever, body malaise from neck
towards the caudal direction, vomiting, chills and difficulty of breathing. She reported
taking paracetamol (biogesic).

1 day prior to admission, patient went to East Avenue medical center for consultation but
was sent home. of fever and other sx then went to east ave on aug 22 for blood test but
was sent home

On the day of admission, the symptoms persisted so the patient went to UERMMMCI for
admission with a fever of 38 C on aug 23. She was then admitted with suspicion of
infection in the genitourinary tract due to her past history of surgery for stones in the
urinary bladder. She was put on cephalosporin (Ceftriaxone) 2gm IV q24 and Potassium
citrate QID (4x a day) q ad

As of today no results for KUB and CBC has been given. chest x-ray is clear. Currently the
patient is awake, alert, oriented and moblie but she is still experiencing intermittent fever

History of Past illness

 The patient reported experiencing measles, mumps and chicken pox among the
childhood illnesses with unrecalled dates. No allergies reported. immunizations were
unrecalled. no major illnesses and accident reported

Last june 15, 2015 the patient underwent stone removal at NKTI for the stones in her
urinary bladder. no reported complications post-surgery

The patient reported pregnancy on 2005 and have an obstetric history of G1P-T1P0L1A0.
The patient verbalized an uncomplicated pregnancy and gave birth to a baby boy via
NSD on March 6, 2006.

Family history

Review of System
General: The patient is awake, alert, oriented to time and place, mobile. No reportable symptom
except for intermittent fever
Skin: The patient has brown skin. No itching, rashes reported. Nailbed is palepink in color.
HEENT: No visual distubance reported. No ear disturbance reported. No reported sign or
symptom.
Respiratory: DOB as one of the chief complaint
Gastrointestinal: No disturbance reported. The patient verbalizewd 1-2 times a day bowel
movement with regular pattern. Diet is mostly consists of vegetables. Before previous surgery,
patient said that she has high Na diet and low water intake but after surgery the patient takes 2L
of water
Genitourinary: No pain in urination reported. Urinates about 1- 1.5 L a day and described it as
pale yellow. No discharges and bleeding reported.
Reproductive: The patient had menarch at 13 y/o. She had her first sexual encounter in 2013 and
her last sexual encounter was unrecalled. When asked the number of sexual partners she
answered that she only has 1 partner and that is her husband. She also uses oral contraceptives
(althea).