CASE NUMBER 1: Family History:

Mother: Died from myocardial

Patient Name: Maria Santos infarction at age 70
Age: 62 Father:
Gender: Female  Hypertension, still living
Date of Admission: April 15, 2025  Social History:
Hospital Number: 2025-0415-001  Non-smoker
Admitting Physician: Dr. Jonathan  Occasional alcohol use
Reyes  Retired teacher
Ward: Medical Ward – Room 306, Bed  Lives with husband
2  Physical Examination:
 Vital Signs:
Mode of Admission: Emergency Room
(ER)
 BP: 150/90 mmHg
Referral Source: Self-referred via ER
 HR: 102 bpm, irregular
 RR: 24 cpm
Chief Complaint:
 Temp: 36.8°C
Shortness of breath and chest
 O2 Sat: 91% on room air
tightness for 2 days
General: Awake, alert, in mild
History of Present Illness:
respiratory distress
The patient is a 62-year-old female
HEENT: No JVD, anicteric sclera
who presented to the ER with
Chest/Lungs: Bibasal crackles,
complaints of progressive shortness of
diminished breath sounds at bases
breath over the past two days,
Heart: Irregularly irregular rhythm, no
associated with chest tightness,
murmurs
fatigue, and occasional palpitations.
Abdomen: Soft, non-tender, no
Symptoms worsened on exertion and
organomegaly
were not relieved by rest. No history of
Extremities: No edema
trauma. Denies fever, cough, or
sputum production. No recent travel or
sick contacts.

Past Medical History:

 Hypertension – diagnosed 10
years ago, on maintenance
medication
 Type 2 Diabetes Mellitus –
controlled with oral
hypoglycemics
 Hyperlipidemia
 No known allergies
 No previous surgeries

Medications:
 Amlodipine 5mg OD
 Metformin 500mg BID
 Atorvastatin 20mg HS
 No pets

CASE 2: Parents both employed, nonsmokers

Patient Name: Miguel Lopez
Age: 5 years old No family history of asthma, epilepsy,
Sex: Male or tuberculosis
Date of Admission: April 15, 2025
Hospital Number: PED-0415-002 Physical Examination:
Admitting Physician: Dr. Angela Ramos Vital Signs:
Ward: Pediatric Ward – Room 204, Bed Temp: 38.9°C
A HR: 120 bpm
Mode of Admission: Brought in by RR: 26 cpm
parents through ER BP: 90/60 mmHg
Referral Source: Local health center O2 Sat: 98% on room air

Chief Complaint: General: Ill-looking, mildly

Fever and vomiting for 3 days dehydrated, responsive but less active
Skin: No rashes, skin turgor decreased
History of Present Illness: HEENT: Dry lips and oral mucosa, no
Miguel is a previously healthy 5-year- nasal congestion
old male who was brought to the ER Chest/Lungs: Clear breath sounds
due to a 3-day history of intermittent bilaterally
fever (up to 39°C), vomiting (5–6 Heart: Regular rhythm, no murmurs
episodes per day), and decreased Abdomen: Soft, slightly distended,
appetite. On the second day of illness, hyperactive bowel sounds, mild
he also developed loose watery stools tenderness
(3 episodes). The vomiting is non- Extremities: Capillary refill 3 seconds,
bilious and not projectile. The child warm
appears weak and less playful than
usual. No known sick contacts or
recent travel. No history of seizures,
rash, or respiratory symptoms.

Past Medical History:

Full-term, normal spontaneous delivery
Complete immunizations for age
No previous hospitalizations
No known allergies

Nutritional History:
Eats solid food regularly
Drinks milk 2–3 times/day
Weight: 17 kg
Height: 105 cm

Family and Social History:

Lives with parents and one sibling
 Medical History:
CASE 3: No known chronic illnesses
Patient Name: Joanna Dela Cruz Prenatal check-ups were regular (8
Age: 28 years old visits)
Sex: Female Labs and ultrasound during pregnancy
Gravida/Para: G2P1 (Second were unremarkable
pregnancy, one previous delivery) Vaccinated with tetanus toxoid
Date of Admission: April 15, 2025 No known allergies
Hospital Number: OB-0415-003
Admitting Physician: Dr. Melissa Tan Physical Examination:
Ward: OB Ward – Room 108, Bed 2 Vital Signs:
Mode of Admission: Walk-in, referred BP: 120/80 mmHg
from health center HR: 90 bpm
AOG (Age of Gestation): 38 weeks by RR: 22 cpm
last menstrual period (LMP: August 5, Temp: 36.7°C
2024) Fetal Heart Rate: 145 bpm
EDC (Expected Date of Confinement): O2 Sat: 99% on room air
May 12, 2025
General: Awake, oriented, in mild
labor pain
Chief Complaint:
Abdominal Exam:
Labor pains for 6 hours
Fundic height: 36 cm
Fetal lie: Cephalic
History of Present Illness:
Fetal heart tones: 145 bpm, regular
Patient is a 28-year-old G2P1 at 38
Uterine contractions palpated every 8–
weeks AOG who came in due to labor
10 minutes, lasting 30–40 seconds
pains described as regular, increasing
Pelvic Exam:
in intensity, and occurring every 10
Cervical dilation: 3 cm
minutes for the past 6 hours. Pain is
Cervical effacement: 70%
located in the lower abdomen and
Station: -2
radiates to the back. No vaginal
Membranes: Ruptured
bleeding noted, but patient reports a
Clear amniotic fluid
clear fluid discharge beginning an hour
ago, possibly ruptured bag of waters.
Fetal movement is present but
reduced compared to previous days.

No fever, dysuria, or upper abdominal

pain. No signs of pre-eclampsia. No
recent trauma or infection.

Past Obstetric History:

G1: Full-term vaginal delivery, 6 years
ago, uncomplicated

No history of cesarean section,

miscarriage, or stillbirth