patient history guide.docx

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Patient History GUIDE

Date Source of referral

History taken by Informant

% Reliability

IDENTIFYING DATA

Name JR Age 61years old

Sex M

Civil status MARRIED

Nationality FILIPINO

Occupation PASTOR – ALLIANCE GOSPEL JESUS LORD CHURCH in SM VAL and A highway patrol

PREVIOUS WORK – company textile operation and san Miguel in 1990

Religion BORN AGAIN

Date of Birth OCT 23,1953

Place of Birth VALENZUELA

Present address 59 rosales st , villa Theresa Brgy marulas Valenzuela city

# of times admitted to the hospital

of admission – first time 0850 am

CHIEF COMPLAINT ----- COUGH

HISTORY OF PRESENT ILLNESS

Onset of illness: cough for 1 month ( last October )

Gradual/sudden:gradual

Description of each symptom:

P: precipitating/aggravating/pallating: cold

drinks and temperature

Q: type/character : non productive cough

R: location/radiation localized no radiation

S: intensity/progression

T: onset/duration/frequency

-No pain noted

frequency average of 5 cough a day

normal 3 days a ago but on the 4th

day experienced difficulty of breathing especially at night.

medication: 500 mg every 12 hours 2 times a day unrecalled kung ilang araw na baka nasa recordings

solmux tab 500 2 times a day unrecalled how many days na baka nasa recordings

PAST HEALTH/ MEDICAL HISTORY

1. Childhood diseases

(+) Mumps 21 years old siya medication : drinks cilantro and damp warm water on the affected area sa

face

(-) Measles (-) Chickenpox (-) German Measles

2. Adult Past Illness

a. Medical (date, name of hospital, described symptoms or diagnosis and result of Tx)

1986 confine for 1 week because of DOB by dra deduyo unrecalled treatment at Fatima medical center

b. Surgical (type, date, results and complications)

Dec 2013 cataract at immaculate reyes



march 2014 araneta square

d. Psychiatric

No psychiatric condition

f. Blood transfusion

none

g. Allergies

NONE

3. Immunizations received

NONE ( IDK kung totoo tlga nakalimutan natin tignan yung scar sa arms ung meron o wala ngang

immunization)

FAMILY HEALTH HISTORY

Pt no dm no hpn but with childhood asthma

Father – deceased 2 years ago positive dm ( di natin natanong ilang taon yung tatay namatay sbihin na

lang ntin mga 84 years old)mother living , with cardiac dse and asthma 86 years old , bedridden

Sibling 3 boys 1 girl all boys have dm and the girl has positive asthma

PERSONAL AND SOCIAL HISTORY

Educational Attainment : highschool graduate – 4 year philosophy course at pacific bible school

valenzula city graduated last 2004

Occupational History – mechanical – referred to first page

married ; dec 1 , 1974

habits:no difficulty sleeping regular sleep

exercise ; gym and biking (taekwondo) 30 minutes if with time every week

coffee 2 times a day

no otc drugs

diet: fruits and vegetables no pork

eats 3x a day

water- 2pitcher approximately 1 -2 liter everyday

drinking multivitamins once a day

has 5 children; wife – housewife

1975 mary grace living

1979 maria Christina living

1978 maurine died of leukemia

1979 christopher

1987 christian

house : semi with concrete and wood 2 flors



valenzuela city 1 cr buhos type

every wed and sat waste is collected

tubig nawasa

with pets: dog and dove

REVIEW OF SYSTEM

Constitutional symptoms

whole upeer teeth with denture

lower teeth has denture too but with 7 intact teeth

weight 110 lbs

ht 5 feet 7 inches

all negative no heachache no fatigue, no loss of appetite no discharge no change in color no itchiness

dark color skin

positive toothache ( idk kung san specific minarkahan ask honey)

positive gum bleeding

positive sorethroat

Physical Exam

GENERAL SURVEY:

alert conscious

normal gait nourished

VITAL SIGNS

Temperature: _______ BP 140/90 in supine position (right arm) upright (idk? ask the one who do this?)

CR/PR (IDK ask the one who do this) RR 16 cpm

HEAD:

black color

no abnormalities

FACE: brownish color , pale lips

oral: dark brown lips assymmetry hydration dry no lesion pinkish buccal mucosa no swelling red gums

NECK no abnormalities noted

chest and lungs ( positive crackles

cardio

7 mmhg h20

GUYS: ETO LNG NAKUHA KO NSA RECORDING NI ATE AMANDA LAHAT! thnks

patient history guide.docx

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