PATIENTS HISTORY

I. Baseline Information Name: Ms. G Age: 34 years old Sex: Female Address: del Carmen, President Roxas Birthday: June 11, 1976 Birthplace: del Carmen, President roxas Civil Status: Married Religion: Roman Catholic Nationality: Filipino Tribe: Ilonggo Occupation: Saleslady Date of admission: January 12, 2011 Time of admission: 4:00 pm Room: Isolation Ward Attending Physician: Dr. Yasmin Calib Chief Complaint: Dyspnea Admission Diagnosis: Community Acquired Pneumonia moderate risk, Pulmonary Tuberculosis IV Institution: President Roxas Provincial Community Hospital Latest VS: Temperature: Pulse Rate: Respiratory Rate: Blood Pressure:

II.

Chief Complaint

The patient was admitted at President Roxas Provincial Community Hospital last January 12, 2011 at 4:00 in the afternoon due to the complaint of dyspnea. She arrived in the hospital via wheelchair from home and was attended at the Emergency Department and had taken clinical history and physical assessment. She was transferred in the isolation ward of the hospital for further evaluation of the complaint. She was attended by Dr. Calib, a resident physician of the said hospital.

III.

History of Present Illness

Patients condition started about 4 months ago prior to consultation, as onset of productive cough and fever, night sweats and weight loss, which are not documented. According to her, it was relieved by an increase drinking of water and regular intake of Ascorbic Acid. Prior to admission, the patient experienced worsening of the condition in which her cough progresses with dyspnea. The patient cant eat properly because she has no appetite for food. She also experienced stabbing pain on her chest. On the day of January 12, 2011, she was rushed to the hospital because of difficulty of breathing. Previously when she started experiencing these conditions, she does not seek for any medical care because according to her it is still tolerable.

IV.

Past Medical History

The patient has been hospitalized on 1997 due to typhoid fever. According to her mother, she has complete immunizations. She experienced having mumps, chicken pox and measles when she was a child. She has no history of hypertension and Diabetes Mellitus. She does not have any regular medical and dental check-ups. She has an irregular menstrual flow before she got married. According to her, she does not have her menstruation yet for almost a year after she gave birth to her youngest child. She does not have allergies to whatever kind of foods and medications as far as she knows. She does not experience any severe accidents before.

V.

Familial History

On the side of the patients father, they have a history of hypertension and heart disease. Her father even has experienced stroke. But aside from her, no one in her family has been experiencing her conditions.