Sie sind auf Seite 1von 3

History #1 SEC B - Group #9

Name of Patient: Ricardo de Guzman Preceptor: Dr. Alfonso


Informant: Ricardo de Guzman Date of interview:
Jan. 11, 2017 (Wed)
Reliability: 100% Date submitted: Jan. 18, 2017
(Wed)
Historian: IBAY, JENNESSE MAY G.

I. General Data

Ricardo de Guzman, 47 years old, male, married but separated,


Filipino, High school graduate, pedicab driver, tourist bus conductor
and laundryman, Roman Catholic, born in the province of Bohol on
March 17, 1968, and presently residing in #81 Kamia, Villa Theresa,
Valenzuela City.

II. Chief Complaint

Cough with phlegm

III. History of Present illness

A week prior to consultation, the patient was doing the laundry


outside their house and it rained. He then experienced cough with
phlegm. At first, the phlegm was clear and whitish then after 3 days, it
became thick and yellowish. He has no difficulty swallowing, no
abdominal pain, but his cough would awaken him when he sleeps at
night. To relieve the symptom, he would rest and drinks water.
However, the persistence of the cough prompted the patient to seek
consult.

IV. Past Medical History

The patient had received childhood immunization in a center but


could not remember the vaccines he had. He had chickenpox at the
age of 30s, tigdas and mumps at age 7. He also have undergone cyst
operation when he was a child at Jose Reyes. No accidents nor blood
transfusion. The patient has not reported allergies and no history of
psychiatric illnesses.

V. Family History

Patient has no pertinent information regarding his father Jesus


de Guzman because he left them when he was still a child. He doesnt
know if his father is still alive. Her mother, Mary Lavutab, is 65 years
old, has hypertension and taking medications.

VI. Personal and Social History

The patients highest educational attainment is High School. He


is working as a pedicab driver, tour bus conductor and also a
laundryman. He also works as a barangay tanod every Tues, Wed and
Sat at 6:00-10:00pm or 7-11pm. He is married but separated and
currently living with his live-in partner, Carmelita Aleta, 50 y/o, for 7
years. He serves as the familys breadwinner. He sleeps usually from
12 to 6 AM (total of 6 hours of sleep per day). He eats regularly and his
diet consists of rice every meal. Hes a hard drinker and a chronic
smoker. He started drinking and smoking when he was 12.
He lives in a cemented bungalow house built with windows, 2
bedrooms and a common bathroom. Their space is enough for him and
his live-in partner. Collection of garbage is done twice a week. Water is
from NAWASA. They have 3 cats inside the house. Patient always stay
outside but had never travelled far.

VII. Review of Systems


Constitutional symptoms:
(-) weight loss/gain, (-) generalized body weakness, (-) fever, (-)
fatigue, (-) chills,
(-) loss/gain in appetite
Skin:
(-) excessive dryness or sweating, (-) itchiness, (-) cyanosis, (-) pallor,
(-) erythema,
(-) jaundice
Head:
(+) vertigo, (+) headache, (-) lightheadedness, (-) tenderness, (-)
trauma

PHYSICAL EXAM
General Survey
The patient is conscious and coherent, oriented to time, place
and person. He is calm and responds to questions with an appropriate
facial expression, behavior and mood. Has develop medium body and
has no apparent gross deformities. He is clear in speech, ambulatory,
normal in gait, normal in posture, normal in grooming and is not in
cardio-pulmonary distress.
Vital Signs
Temperature: 36 BP: 129/90
PR: 68 RR: 19

Skin
Skin is brown in color, dry, warm, elastic, with areas of pigmentation or
discoloration. Hair is black in color, smooth and well distributed. Nails
are pink with capillary refill.