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    IM Clinics History 2

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    LucyellowOttemoesoe
    - The patient, a 26-year-old Filipino man, presented to the emergency room with dizziness, difficulty breathing, and vomiting over the past 15 hours. - His symptoms began while running upstairs and included multiple episodes of dizziness and difficulty breathing when standing up or after eating. He also experienced vomiting. - His past medical history included hospitalization for body weakness and hematoma from a fraternity activity at age 15. He also had chickenpox at age 24. Both of his parents have hypertension and his father also has diabetes.

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    IM Clinics History 2

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    LucyellowOttemoesoe
    120 views4 pages
    - The patient, a 26-year-old Filipino man, presented to the emergency room with dizziness, difficulty breathing, and vomiting over the past 15 hours. - His symptoms began while running upstairs and included multiple episodes of dizziness and difficulty breathing when standing up or after eating. He also experienced vomiting. - His past medical history included hospitalization for body weakness and hematoma from a fraternity activity at age 15. He also had chickenpox at age 24. Both of his parents have hypertension and his father also has diabetes.

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    - The patient, a 26-year-old Filipino man, presented to the emergency room with dizziness, difficulty breathing, and vomiting over the past 15 hours. - His symptoms began while running upstairs and included multiple episodes of dizziness and difficulty breathing when standing up or after eating. He also experienced vomiting. - His past medical history included hospitalization for body weakness and hematoma from a fraternity activity at age 15. He also had chickenpox at age 24. Both of his parents have hypertension and his father also has diabetes.

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    © All Rights Reserved
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    Flag for inappropriate content
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    120 views4 pages

    IM Clinics History 2

    Uploaded by

    LucyellowOttemoesoe
    - The patient, a 26-year-old Filipino man, presented to the emergency room with dizziness, difficulty breathing, and vomiting over the past 15 hours. - His symptoms began while running upstairs and included multiple episodes of dizziness and difficulty breathing when standing up or after eating. He also experienced vomiting. - His past medical history included hospitalization for body weakness and hematoma from a fraternity activity at age 15. He also had chickenpox at age 24. Both of his parents have hypertension and his father also has diabetes.

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    © All Rights Reserved
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    of 4

    BONAVENTE, Katrina Q.

    2010
    Internal Medicine Clinics

    January

    18,

    Date of interview: January 18, 2010


    Time of Interview: 10:30am
    Informant: patient
    Reliability: 75%
    GENERAL DATA
    Abdon Castillo, 26 years old, widow, male, a Filipino Christian, was born on
    September 4, 1983 at Samar, currently unemployed and residing at #19 Liwayway
    St. Acacia, Malabon City, was admitted for the first time at MCU Hospital ER at
    10:30 in the evening.
    CHIEF COMPLAINT
    Dizziness and difficulty of breathing
    HISTORY OF PRESENT ILLNESS
    The patient was previously well until fifteen hours prior to admission, the
    patient felt dizzy while running upstairs from first to second floor with associated
    difficulty of breathing. He vomited the food he ate during breakfast amounting to
    one cup. After 30minutes, he went up to the third floor and felt dizzy again, he felt
    the urge to vomit but nothing came out, there was associated severe difficulty of
    breathing which prompted one of his brothers to bring him to the Medical office. He
    was given water and oxygen and was asked to take some rest. His blood pressure
    was 160/90mmHg and he was given an unrecalled white tablet which was claimed
    to be an anti-hypertensive drug.
    Eight hours prior to admission, he had his lunch and took some rest at their
    quarters for five hours. When he woke up, he felt dizzy again with associated body
    weakness wherein he cannot stand up and walk. He was given banana and soup to
    eat but he just vomited the food after eating and experienced again difficulty of
    breathing and dizziness. He was brought to the Medical office with blood pressure of
    160/80mmHg, he was asked to take some rest.
    Two hours prior to admission, his blood pressure was down to 150/80 but still
    feeling dizzy with associated difficulty of breathing. No medicines were taken.
    Thirty minutes prior to admission, his dizziness and difficulty of breathing
    were not resolved by rest which prompted the medical staffs to bring him at MCU ER
    hence admission.
    PAST HISTORY
    He claims to have childhood immunizations given in a health center but does
    not know if complete. He had no childhood illnesses like measles, mumps or
    chickenpox. He was hospitalized for two weeks when he was fifteen years old due to
    body weakness and hematoma formation brought about by fraternity activity. When
    he was 24 years old, he developed chickenpox and no medication was taken. He has
    no history of accidents or surgical operations. He has no allergy to drugs but he has
    allergy to sea foods like crabs and shrimps.
    FAMILY HISTORY

    Both of his parents are hypertensive and both are on maintenance drugs. His
    father also has diabetes and is on medication. There are no other heredofamilial
    diseases like cancer, familial hypercholesterolemia or psychological illnesses.
    PERSONAL/SOCIAL HISTORY
    The patient is the eldest in the brood of four. He took three different courses in
    college but was not able to finish any course. He took pharmacy for one semester
    only then electrical engineering for another semester and one year for associate
    computer course. He got married at the age of 17 and he was widowed when his
    wife died while giving birth to their second child in 2007. He is a non-smoker and
    was an alcoholic drinker for a year preferably hard beverages like Tanduay Rhum
    consuming 1 bottle per session. He has no food preferences except for foods that he
    has allergy on. He enrolled himself in a gym before for a year and 3 months but
    now, he does not exercise anymore.
    He lives with 25 other men in a room with 2 common comfort rooms in
    building where they train for gospel studies. Water source is from NAWASA and they
    have mineral water for drinking.
    REVIEW OF SYSTEMS
    General: Patient is awake, conscious, coherent and conversant. He is sitting and
    afebrile. He weighs 63 kilos.
    Skin: Patient has no complaints made regarding rashes and itchiness. He claims to
    have no masses or lesions on the skin.
    Head: The patient has migraine accompanied by bleeding of the nose, no
    medications taken when there is attack. The patient does not experience hair
    shedding and itching of the scalp.
    Eyes: Patient wears reading eyeglasses with a grade of +1.00 on both eyes which
    started in 2007.
    Ears: He claims to have no discharges on both ears and does not have tinnitus.
    Nose and sinuses: He does not have any stuffed sinuses and claims that he has
    good sense of smell. He experiences nose bleeding whenever he has migraine.
    Neck: No complaints made regarding the neck area like swollen lymph nodes and
    pain.
    Mouth and Throat: Patient does not have difficulty of swallowing. No dryness of
    the mouth.
    Respiratory: Patient claims that he experiences occasional difficulty of breathing
    due to stress, cough and phlegm.
    Cardiovascular: The patient feels chest heaviness, easy fatigability and
    palpitations. He does not experience orthopnea.
    Gastrointestinal: The patient claims that he has a good appetite. He does not
    have any food intolerance. Good bowel movement.
    Urinary: Urine is straw to colorless in appearance. Patient does not experience
    dribbling, burning sensation, and pain upon urination. Urine flow is continuous and
    the caliber is of normal size.
    Genital: The patient has no hernia, ulcer or lesions as claimed. He claims to have
    no any form of discharge.
    Peripheral Vascular: Patient does not complain of having cramps and varicosities.
    There are no bruising and edema.
    Musculoskeletal: No complaints made regarding joint and muscle pains.

    Hematologic: The patient claims that he does not easily bruise and he has good
    wound healing.
    Neurologic: Negative for blackouts, seizures and tingling sensations.
    Psychiatric: Patient claims to have no mood swings or depression. He has no
    history of hallucinations and memory changes. No suicidal attempts and ideations.
    Sleep pattern is normal.
    Endocrine: Patient claims to have heat intolerance and excessive thirst.
    PHYSICAL EXAMINATION
    General Survey
    Patient is awake, sitting, coherent and conversant. He responds spontaneously to
    voice stimuli. Patient is 5 feet 3 inches tall and weighs 63 kilos having a BMI of 24.6
    which is normal.
    Vital Signs
    Patients Blood pressure is 120/80mmHg, temperature of 36.2 C, respiratory rate of
    22 breaths per minute, pulse rate of 53 beats per minute and cardiac auscultatory
    rate of 54 beats per minute.
    Skin
    Skin is warm to touch and has a good turgor. Body hair is evenly distributed. Finger
    and toe nails are have good capillary refill time. There are no wounds and lesions
    noted.
    HEENT
    Head: Face is round in shape, symmetric. Hair is of average quantity and texture,
    black in color. No mass, tenderness and any scalp lesions.
    Eye: Pupils are round, equal in size. Both are reactive to pupillary and consensual
    reflexes. Eyebrows are well distributed. Conjunctiva is pale, sclera is white.
    Ear: No lumps, tenderness and redness noted. Ear has no discharges. Tympanic
    membranes were not checked.
    Nose and sinuses: Nose is normal in size and symmetrical. Nasal mucosa, septum
    and turbinates were normal and without any secretions. There is no sinus
    tenderness.
    Throat: Oral mucosa is pink with complete set of teeth. Tongue at the midline on
    protrusion. There were no lesions and tenderness. Lips and mucosa are well
    hydrated. Tonsils were not enlarged.
    Neck
    No cervical lymph node enlargement and no masses noted upon palpation. Trachea
    is at the midline. Lobes of the thyroid glands are not palpable.
    Lymph Nodes
    Cervical nodes were not enlarged. Axillary and inguinal nodes were not palpated.
    Thorax and Lungs
    Chest is symmetrical with limited chest expansion due to abdominal tenderness. No
    tactile fremitus on palpation. Lungs are resonant. Normal breath sounds. No
    wheezes or rales.

    Cardiovascular
    PMI at 5th ICS, MCL. No thrills or heaves. No murmurs or extra sounds.
    Abdomen
    Flat abdomen. Normoactive bowel sounds. Percussion and palpation were not done
    due to tenderness.
    Genitalia: Examination not done
    Rectal: Examination not done
    Extremities
    All extremities of the patient exhibited fair strength and without edema.
    Peripheral vascular
    No varicosities noted. Irregular pulse on radial and dorsalis pedis.
    Musculoskeletal: Patient has a good range of motion on all extremities.

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