FOCUSED HISTORY I. Demographic Data Name: B.G.

Martinez Age: 90 years old Birthdate: October 24, 1921 Gender: Female Civil Status: Single Religion: Roman Catholic Nationality: Filipino City Address: #1 Grant St., Project 8, Quezon City Educational Attainment: High School graduate Occupation: None Ward and Bed No.: 7A 746G Source of Information: G.D.Reyes Relationship to patient: Niece Date and Time of History-taking: September 17, 2012 8:00 am II. Past Medical Illness According to informant, patient does not have any other history of diseases which required hospitalization besides now and her hip injury that she had acquired due to a fall incident that happened at their home last year 2010. The hip injury had required her to undergo Hip replacement which the patient had agreed to. Ms. D.G. Martinez had been diagnosed to have allergic rhinitis since she was a child and was taking antihistamines every time her allergy would exacerbate. She has no history of hypertension, Diabetes Mellitus, any kind of Cancer or any other hereditary diseases that necessitate serious medications. Her parents are both deceased due to old age. All of her siblings are still alive. One of her sisters was, however, diagnosed of having Hypertension. III. Present Medical Illness Chief Complaint: disorientation/cough Admitting Diagnosis: Community Acquired Pneumonia s/p Hip Replacement 2010, Disorientation probably secondary to Benadryl Toxicity Date of Admission: September 11, 2012 Two weeks prior to admission, patient was observed to have productive cough with whitish sputum. Patient did not take any medicine to relieve cough and did not seek any medical consultation. One week prior to admission, due to persistence of productive cough, patient had sought consultation with their family physician and was prescribed to orally take Benadryl 50 mg twice a day and Montelukast 10mg once a day, and nebulize with Duavent nebule twice a day for 5 days. Informant said, Medyo naging okay din naman siya matapos maggamot. However, two days prior to admission, patient became disoriented and confused, was unable to follow simple commands, and was unable to do activities of daily living due to generalized body weakness. Patient also experienced vomiting previously ingested food and loss of appetite. Hence, her niece (the informant) had taken her to Capitol Medical Center for consultation. Upon consultation, patient was noted to have (+) bibasal crackles. Chest X-ray (taken September 11, 2012) revealed signs of pneumonitis at the right lower lobe, with minimal pleural effusion. Patient was assumed to have pneumonia, hence, was advised for admission for further observation and immediate treatment.