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Date of Interview: January 13, 2017

Time of Interview: 2:30pm


Date of admission: December 30, 2016
Time of Admission: 11:00am

Patient GS is a 58 year old female, Catholic and Married. She was born on October 04, 1964
and is currently living Malabanias, Angels City.

The primary informant of the history is the patient herself. The reliability is at 85%.

HPI

4 days prior to admission, patient GS was collecting garbage around diamond subdivision in
Balibago when she experienced sudden loss of consciousness. She fell face down to the floor
with the right chest as the point of contact. There were no injuries sustained in the head area.
The fall was preceeded by blurring of vision. The patient was brought to her house and was
allowed to rest. She regained her consciousness the day after.

3 days prior to admission, patient experienced difficult of breathing upon waking up. She drank
1 Salbutamol tablet that provided her with some relief. There were no other accompanying signs
and symptoms.

On the day of admission, patient experience difficulty of breathing again. She drank 1
Salbutamol tablet but did not provide her with relief. There was progressive difficulty of
breathing that prompted the patient to seek consult at the emergency department of ONA.

OBSTETRIC AND GYNECOLOGIC HISTORY


Patient had her menarche at the age of 14. She described her menstrual period as regular with
a 28 to 30-day interval and a 6- to 7-day duration. She can consume 3 moderately soaked pads
per menstrual day during the first 2 days and 1-2 minimally soaked pads on the remaining days.
She reported associated menstrual symptom such as dysmenorrhea. She had her menopause
at the age of 40.
She had her first sexual contact at 13 yrs old and has had only one sexual partner. She denied
taking oral contraceptive pills.

Patient has been pregnant 5 times, four of them were born term via normal spontaneous vaginal
delivery at home (1978, 1979, 1996, 1998) with no associated complications. The last
pregnancy (2005) was aborted at 16 weeks age of gestation. OB score: G5P4 4014.

PAST MEDICAL HISTORY


The patient received BCG vaccination. She claimed of having childhood illnesses such as
measles and mumps. She has no known allergies to food or medication, but reported allergies
to dust and pets that would trigger asthma attacks. She is a hypertensive only diagnosed on the
present admission with a systolic blood pressure of 160 mmHg. She denied history of diabetes,
tuberculosis, and other medical conditions. She has no history of previous hospitalization and
has not had undergone any surgical procedure.

FAMILY HISTORY
The patient father died at the age of 72 while the mother is still living, 60 years of age. Both the
paternal and maternal side have history of hypertension and cardiovascular diseases. Patient
has 12 siblings and is the 2nd child and denied any remarkable medical problems among her
siblings. Grandparents on both sides were not recalled. And three of her grandchildren have
asthma.

PERSONAL AND SOCIAL HISTORY


Patient is a housewife and was able to study up to first grade of elementary. She worked as a
domestic helper in Australia for 4 years when was 19 to 23 years old, then she worked as a
laundrywoman until 2016. One month prior to admission, she became a garbage collector in
which her asthma attack became more frequent and relieved by intake of Ventolin inhaler as
advised by her sister-in-law. She denied cigarette smoking, alcohol intake and illicit drug use.

DIET, ENVIRONMENT, AND LIFESTYLE


Patient is currently with her husband in a bungalow type house which was burned last
December 23, 2016. There were not able to find another place to stay and was forced to live in
their house while they are trying to repair it. Patients regular diet is mainly composed of rice,
meat, fish and vegetables. They obtain utility water from a local water supply. Garbage is
collected regularly and there are no factories within the vicinity.

EVIEW OF SYSTEMS
General: Denies weight gain or weight loss but complains fatigue, weakness and fever.
Skin: Denies pruritus, rashes, dryness, jaundice, cyanosis, abnormal nail changes, or alopecia.
Head: Denies headache but complains dizziness and light-headedness.
Eyes: Denies eye pain, itching, irritation, double vision, abnormal discharges, excessive tearing,
glaucoma, or cataract.
Ears: Denies hearing problem, tinnitus, vertigo, pain, or abnormal discharges
Nose: Denies nasal flaring, congestion, stuffiness, itching, or nasal discharge.
Throat, Mouth and Pharynx: Denies hoarseness of voice, dysphagia, sore tongue, dryness of
mouth, oral thrush, or no bleeding gums but reports sore throat.
Neck: Denies lump, goiter, pain, stiffness, or swollen glands.
Respiratory: Denies hemoptysis but reports dyspnea and shortness of breath.
Breast: Denies lump, pain/discomfort, or discharge
Cardiovascular: Reports chest pain/ discomfort, chest tightness, difficulty of breathing when
lying down and walking with shortness of breath
Gastrointestinal: Denies difficulty in bowel movement and constipation, epigastric pain, change
in appetite, diarrhea, or rectal bleeding.
Genitourinary: Denies vaginal discharge, flank pain, or bleeding after intercourse.
Musculoskeletal: Denies muscle pain, joint pain, redness, swelling, or muscle stiffness
Neurologic: Denies numbness, tingling sensation, tremors, or memory loss.
Endocrine: Denies thyroid enlargement, temperature intolerance, polyphagia, or polydipsia

Skin, Hair, and Nails

Color dark brown, skin,warm and moist, with good skin turgor. Nails without clubbing and
cyanosis. No suspicious nevi, rash, petechiae, or ecchymoses.

HEENT

HeadThe skull is normocephalic/atraumatic (NC/AT). Hair with average texture. Eyespoor


visual acuity. Patient can count fingers from 6 meters. Sclera white; conjunctiva pink. Pupils
constrict 4 mm to 2 mm, equally round and reactive to light and accommodations. EarsAcuity
good to whispered voice. Tympanic membranes (TMs) with good cone of light. NoseNasal
mucosa pink, septum midline; no sinus tenderness. Throat (or Mouth)Oral mucosa pink;
dentition is not good, two permanent maxillary second premolars left; pharynx without exudates.
NeckTrachea midline. Neck supple; thyroid isthmus palpable, lobes not felt. Lymph
NodesNo cervical, axillary, epitrochlear lymphnodes.

Breasts

Breasts pendulous, symmetric and smooth, without masses. Nipples without discharge.

Peripheral Vascular

No pitting edema noted on both feet. The capillary refill time is 2 seconds. The radial, brachial,
femoral, poplitieal, dorsalis pedis and posterior tibial pulses are grade 1+. Upon dorsiflexion of
calves, tenderness was not elicited. No discoloration on patients skin and ulcers noted.

PHYSICAL EXAMINATION

General Appearance: Patient was seen lying in bed, conscious, ambulatory, coherent, oriented
to time, place, and person and not in respiratory distress.

Vital Signs: Temperature: 36.5C; PR: 99 bpm ; RR: 24 cpm; BP: 160/90 mmHg right arm,
sitting.

Examination of the Skin: Skin is fair with good turgor. No discoloration, jaundice, rashes, or nail
clubbing noted. A tattoo was noted on the right upper quadrant of the breast.

Examination of the Head and Face: Hair is black. Head is rounded/normocephalic atraumatic.
No lesions on the face.

Examination of the Eyes and Vision: Patient has cataract on both eyes. Anicteric sclerae ,
pinkish conjunctiva and normal peripheral field of vision. Pupils are black in color, equally round
and reactive to light and accommodation.

Examination of the Ears and Hearing: Both auricles are symmetrically aligned to the outer
cantus of the eyes, elastic, easily recoils when folded. The auditory canals contain some
cerumen, with no foul smell. Patient was able to hear and repeat the spoken and whispered
words.

Examination of the Nose and Sinuses: Patients nose has no lesions, flaring or discharges
noted. Mucosa is pink and septum is in the midline. No tenderness upon palpation and with
smooth consistency. Sinuses appear to be unobstructed.

Examination of the Mouth and Throat: Patient has pink and moist buccal mucosa. Lips are
symmetric, moist and have the ability to purse. Gums are pink with no sores seen upon
inspection. No tonsillopharyngeal congestion or exudates. Gag reflex is intact. Tongue in the
midline.

Examination of the Neck and Lymph Nodes: Neck is supple. No lesions and lumps were seen
during inspection and palpation. Trachea is located in the midline. Tenderness elicited during
palpation. No swollen/enlarged lymph nodes

Examination of the Cardiovascular System: No jugular vein distention noted. PMI was best
assessed at the 5th ICS, midclavicular line upon auscultation with adynamic precordium. No
murmurs heard upon auscultation. Has a normal heart rate and regular rhythm.

Examination of the Chest and Lungs: No signs of respiratory distress such as use of accessory
muscles in breathing and retractions. Symmetric chest expansion. Wheezes on both lung fields
was noted.

Examination of the Breast: Breasts are symmetric. Both breasts have no masses, without
discharge. The patients axillas are free from rashes, unusual pigmentation or palpable masses.

Examination of the Abdomen: Abdomen is globular and distended. There were no scars, visible
pulsations or lumps seen. There was tenderness on the upper quadrant upon percussion.
Examination of the Extremities: Warm and without edema. Calves are supple and non-tender.

Examination of the Peripheral Vascular: No edema on both ankles. No varicosities on both


lower extremities. No stasis pigmentation or ulcers.

Examination of the Musculoskeletal: No joint deformities. Good range of motion in hands, wrists,
elbows, shoulders, spine, hips, knees, ankles. Muscle strength of 4/5.

Neurologic Examination: Mental Status The patient is alert, conscious and thought coherent.
She is cooperative, oriented to person, place and time.

Cranial Nerves:
CN I not assessed
CN II intact visual acuity
CN III pupils equally reactive to light and accommodation, EOMs intact
CN IV EOMs intact
CN V- intact pain sensation at forehead, cheeks and jaw; has masseter contraction upon
clenching of teeth; (+) corneal reflex
CN VI EOMs intact
CN VII can raise both eyebrows, can show teeth; reported to taste food
CN VIII responds during the interview; responds when called
CN IX (+) elevation of the palate upon saying Ahhhhhhh
CN X Gag reflex not done since patient is dizzy
CN XI (+) shoulder resistance upon force application
CN XII can protrude tounge, can state La La La

Motor: Good muscle bulk and tone on both lower extremities (grade 4 muscle strength)
Sensory: Pinprick, light touch intact