DATE & TIME OF HISTORY: December 3, 2015 @ 2:30 PM

SOURCE OR INFORMANT: Patient

RELIABILITY: 90 %
IDENTIFYING DATA:
J.S., a 36-year-old Male, Married, Filipino, Roman Catholic,
presently residing at Sta. Rita, Samar, was admitted for the 2nd time at
EVRMC last November 30, 2015.
CHIEF COMPLAINT:
Dyspnea
HISTORY OF PRESENT ILLNESS:
3 months prior to admission, patient experienced sudden easy
fatigability. This was associated with orthopnea and bipedal edema. Difficulty
in breathing was relieved when lying supine with 2 pillows. Patient also
experienced dizziness and mild headache. Headache was characterized as
dull localized in the frontotemporal region with a pain scale rating of 3.
Maintenance medications were continued but no consult done.
1 week prior to admission, fatigability experienced by the patient
worsened. Still associated with the same symptoms mentioned. No consult
done.
3 hours prior to admission, due to the persistence and worsening
symptoms experienced by the patient, he sought for consult at EVRMC and
was then admitted.
PAST HISTORY
Childhood Illnesses:
-

(-) Measles
(-) Mumps
(-) Chickenpox

Adult Illnesses:
Medical: Known case of VHD since January 2015 with maintenance
medications of Enapril, Digoxin, Bumetanide

Total no. of hospital admissions: 2

Psychiatric: None
Surgeries: none
Immunizations:

fully immunized

Screening Tests: none

FAMILY HISTORY:

Has 7 siblings; all well and alive

Married with 2 children; all well and alive
Both parents have history of Hypertension
There is history of DM in both family sides
No history of Cancer, epilepsy, and mental illness.
No Tuberculosis among family members

PERSONAL AND SOCIAL HISTORY:

Patient is married with 2 children and lives with his wife in Sta. Rita,
Samar. He is a High school graduate. He works at Mining Mcarthur, Leyte but
stopped last January 2015 due to his medical condition. Their house is made
up of wood with 2 bedrooms and 1 comfort room. Their source of water is
from a deep well. He has good relationship with his family. Patient usually
sleeps at 8 pm and wakes up around 6 am. After he wakes up at 5 am, he
does some light exercises like stretching. He is not allowed to do some
strenuous activities. His breakfast usually consists rice and fish. For his lunch
and dinner, he usually eats fish, rice, paksiw and vegetables. He only
consume 3-4 glasses of water a day.
He spends his leisure time by watching TV. He has a siesta time usually
right after his lunch. He is an active church-goer and he always pray before
sleeping. He is a nonsmoker and a nonalcoholic drinker. He doesnt have any
history of allergies and no illicit drugs.
REVIEW OF SYSTEMS:
General

Weight loss noted about 25% since admission.

Presence of generalized body weakness and loss of appetite noted.

No fever.

Skin

no sores, no itching, no dryness

HEENT
Head

Mild Headache and Dizziness noted

Eyes

No double or blurring of vision

No spots, specks, and flashing lights

Ears

Intact hearing.
no pain and no discharge

Nose

No frequent colds, no nasal stuffiness, no nosebleeds, no itching and

no discharge

Throat

no sores dentures, no dry mouth, no sore throat

Neck

No swollen glands, no pain, and no stiffness

Breasts

No lumps, no pain or discomfort, and no nipple discharge

Respiratory

Dyspnea and orthopnea noted

No hemoptysis, no wheezing

Cardiovascular

No chest tightness noted

Palpitations, orthopnea, and bipedal edema noted

Gastrointestinal

No Dysphagia and no heartburn

No Nausea, No constipation or no diarrhea
Bowel movement once daily
o Color and consistency: Brown and solid
No abdominal pain, no food intolerance, and no excessive belching or
passing of gas

Urinary

Frequency of urination noted

o 2x day (1 cup/ 240 ml per urination)
o Color and consistency: yellow and clear
No polyuria, no nocturia, no urgency, no burning or pain during
urination
No incontinence, no hesitancy, and no dribbling

Genital

No hernias, no discharges from penis, no sores on the penis, no

testicular pain or masses, no scrotal pain or swelling

Peripheral Vascular

No intermittent claudication, no varicose veins

No paralysis of lower extremities

Musculoskeletal

No muscle or joint pain, no backache, no paralysis of lower extremities

Neurologic

No history of fainting, blackouts, seizures, and tremors

No changes in mood, attention, or speech

Hematologic

No anemia, no easy bruising

Endocrine

No heat and cold intolerance, no excessive sweating, no polyphagia, no

polydipsia, no polyuria

Psychiatric

No nervousness, tension, depression, memory change or suicide

attempts

PHYSICAL EXAMINATION:
General Survey
The patient was examined sitting on bed, conscious, coherent and
oriented as to place, time, and person, cooperative and pleasant. He is welldeveloped and well-groomed, a mesomorph, with good posture, wellnourished nutritional status and not on any kind of respiratory distress.
Vital Signs
BP: Right-110/80 mmHg
Left- 100/80 mmHg
HR: 110 beats/min
RR: 18cycles/min
Temp: 35.6 oC
Integument
Skin: Brownish complexion, dry and warm, good turgor. No active
lesions, suspicious nevi nor rash. No petechiae, nor ecchymoses.
Nails: With good capillary refill. no clubbing of fingernails and not
cyanotic. Smooth with no ridges nor breaks.
Head
Hair: Short, smooth, and fine in texture. evenly distributed on
scalp, no infestation of lice and ticks.
Scalp: No lumps, lesions, flaking, dandruff, scaling, nor redness.
No tenderness nor engorgement of veins.
Skull: Normocephalic, atraumatic, and no fractures.
Eyes
Eyebrows: Symmetrical, fine, black, no scars, no active lesions.

Eyelids:No edema, redness, crusting, nor any lesions. No lagging

and with adequate closure.
Visual Acuity: can able to read newsprint 12 inches away
Conjunctiva: Pinkish with no hemorrhage, nodules, nor swelling.
Sclera: Anicteric, no hemorrhage.
Cornea and lens: No opacities, scars nor ulcerations.
Iris: Fairly flat. Cast no shadow when lighted directly from
temporal lobe.
Pupils: Symmetrical, 3mm diameter, equally round and brisk
direct and consensual reflex on each eye, intact accommodation
reflex.
EOM: Full extraocular muscle movement, normal conjugate
gazes, and good convergence. No nystagmus nor lid lag.

Ears
Symmetrical. No active lesions nor discharges.
Nose
Pinkish nasal mucosa. No septal deviation nor flaring of ala nasi.
No tenderness of nasal tip, discharges, ulcerations, nor polyps.
Mouth and Throat
Lips: Smooth, pinkish, non-cyanotic. No drying, chapping or
cheilosis.
Oral Mucosa: Pinkish, moist. No bleeding, sores nor nodules.
Gums: Pink. No swelling, ulcerations, nor bleeding.
Tongue: Midline and symmetric upon protrusion. Pinkish, smooth
and no ulcerations.
Teeth: no denture nor missing teeth
Throat:
Uvula at the midline.
Tonsils: no enlarged tonsils
Neck
Supple. Trachea at midline. Thyroid gland not enlarged and
moves with deglutition. No engorged vein or jugular venous
distension. Lymph nodes nonpalpable.
Breast
Symmetrical. Everted nipples. No lumps nor discharges.
Chest and Lungs

Symmetrical and truncal in shape. No intercostal retraction on

inspiration during inspection. Normal tactile fremitus same on both
sides with symmetrical chest expansion. Resonant on both lung fields.
(+) mid to basal rales on both lung fields

Heart
Adynamic precordium, no visible pulsations. Point of maximal impulse is
between the 4th and 5th intercostal space left midclavicular line,
heartbeat was in regular rhythm synchronous to pulse rate, no heaves, no
thrills, Normal S1 and S2, with regular rate and rhythm. S2 > S1 at the
base, S1 > S2 at apex. No Carotid Bruits. No splitting of the heart sounds
heard. (+) systolic murmur best heard at the apex