Quilicot, Sinclair Joseph.

Date of Interview: January 21, 2019

SEC. F/ Group 10 Dr. Lopez
Monday/Wednesday History and PE #1

I. GENERAL DATA

Dante Soriano, 31 years of age, male, single, Filipino, Roman Catholic, machine
operator, born on December 29, 1988 in Manila City, currently residing at 61 Tampuy 1,
Marulas, Valenzuela City, consulted for the fifth time at Our Lady of Fatima Medical Center on
January 21, 2019.

II. CHIEF COMPLAINT

Cough

III. HISTORY OF PRESENT ILLNESS

Two days prior to consultation, the patient started having a non productive cough caused
by installation of smoke from malfunctioning machine at his work place accompanied by colds
with watery discharge and an aching throat with a pain scale of 7/10, constant and non
radiating. Patient also mentioned nocturnal difficulty of breathing and has trouble sleeping
unless aided by 2-3 stacked pillows. No other associated symptoms were noted such as
headache and fever. No medications were taken.
One day prior to consultation, non productive cough, colds and difficulty of breathing is
still present at night along with throat pain with identical characteristics but with of 4/10. Still, no
other associated symptoms were noted such as fever and headache. Still, no medications were
taken.
Two hours prior to consultation, the patient still had a non productive cough and colds.
Other associated symptoms were still not noted such as fever, headache, throat pain. No
medications are still taken. The symptoms persisted, which prompted the patient to seek consult
at Fatima University Medical center

IV. PAST MEDICAL HISTORY

Chicken pox and Mumps were reported by the patient at age of 8 years and measles at
age 10 years. As per patient’s recollection, he has complete immunizations but presence of
BCG scar was not noted. Immunization during adult life was not reported. No presence of
present illness such as hypertension, renal disease, asthma, tuberculosis, diabetes, cardiac
disease, gastrointestinal and sexually transmitted disease were reported. Patient had a previous
motorcycle accident last 2013 left him hospitalized. Left leg of the patient was casted. He
reported to have allergies in chicken, egg and fish (malalangsa) during his childhood. No allergy
to any medication was reported. No history of blood donation and transfusion. Patient is
currently not on any medication.
V. FAMILY HISTORY

The patients mother has hypertension at the age of 56 but has no maintenance medication. His
father died at age of 46 due to an electrocution accident and was noted to be also hypertensive.
Patients eldest sibling died at age of 7 due to heart complications. No heredofamilial disease
were reported such as diabetes, stroke, cancer, psychiatric and hematologic disorders.

VI. PERSONAL AND SOCIAL HISTORY

The patient finished primary education. He is employed at XY plastic corporation as a machine

operator. He also drove a tricycle for six years. He has no preffered sports or physical activity
and is deeply hooked to social media to pass time. He eats four times a day with preference
towards fish, meat and vegetables. He is fond of drinking energy drinks and soda over water
and is taking no nutritional supplements. The patient smokes 1 pack a day of cigarette which
started at age 7. He drinks alcohol occasionally around once a month. He confirms usage of
illegal narcotics (shabu) and marijuana at the rate of 3-4 times a week at the age of 14. On
average, he gets 6 hours of sleep a day. He is currently residing with his mother in a bungalow
concrete house. It has no room but has 2 windows. They have a manual commonal toilet. A pet
cat was reported and so as vectors such as mosquitoes and cockroaches. Utilities were
provided by Meralco and Maynilad. Filtered water is consumed as drinking water. Their garbage
disposal is everyday snd is collected twice a week. No known commonly prevalent disease were
reported in their neighborhood.

VII. REVIEW OF SYSTEMS:

 General
[-]fever [-]chills [-]malaise [-]weight change

 Integumentary
[-]pruritus [-]pigmentation [-]texture change

*Patient has tattoo all over the body except right and left anterior lower legs
*Patient has piercing on both ears

 Hair
[-] baldness [-] excess hair

 Head and Neck

[-]headache [+]dizziness [-]head injuries [-]trauma
[-]syncope [-]tenderness [-]light-headedness

*Dizziness after 12-hour shift

 Eyes
[-]eye pain [-]photophobia [-]diplopia [-]blurring of vision
[-]discharge [-]use of glasses/lens [-]redness

 Ears
[-]hearing problem [-]discharge [-]pain [-]vertigo
[-]tinnitus
 Nose
[-]pain [-]discharges [-]nasal obstruction [-]nasal flaring

 Mouth and Throat

[+]use of dentures [-]pain [-]hoarseness
*Patient has dentures (2 medial incisors)

 Respiratory
[-]dyspnea [-]chest pain [-]hemoptysis [+]cough
[-]back pain [-]orthopnea [-]trepopnea

 Cardiovascular
[-]chest pain [-]palpitation [-]PND [-]orthopnea
[-]easy fatigue [-]SOB

 Gastrointestinal (bowel movement: 2x a day)

[-]poor appetite [-]dysphagia [-]nausea [-]vomiting
[-]diarrhea [-]constipation [-]abdominal pain [-]flatulence
[-]abdominal enlargement [-]steatorrhea [-]melena
[-]hematemesis [-]hematochezia

 Genitourinary
[-]Dysuria [-]flank/suprapubic pain [-]frequency [-]dribbling
[-]incontinence [-]hematuria [-]oliguria [-]polyuria
[-]passage of stone [-]discharge

 Musculoskeletal
[-]muscle pain [-]joint pain and stiffness [-]swelling
[-]bone deformity [-]weakness
[-]atrophy [-]hypertrophy [-]restriction of movement

 Neurologic
[-]syncope [-]seizures [-]headache
[-]tremors [-]loss of memory [-]dizziness

 Endocrine
[-]weight change [-]goiter [-]temperature intolerance
[-]polyuria [-]polydipsia [-]polyphagia [-]abnormal growth

 Hematologic
[-]easy bruisability [-]easy fatigue [-]pallor
VIII. PHYSICAL EXAMINATION:

A. General Survey
Patient is awake, conscious, and coherent. He is cooperative, speaks clearly and responds
appropriately to questions. He is well nourished and has medium body built. He is well
developed. He has nicely combed hair and dressed appropriately. He is ambulatory with good
posture and normal gait. He is calm, afebrile and not in cardio respiratory distress.

B. Vital Signs

BP: 110/90mmHg (Left arm, sitting)

PR: 78bpm
RR: 18cpm
TEMP: 36°C

C. Skin

The skin is brown in color, smooth, dry and warm to touch. It is elastic, with normal mobility and
good skin turgor. Scars are noted at both upper and lower extremities.
The hair is black in color, evenly distributed and no signs of hair loss noted. The nail beds are
pinkish. No clubbing or cyanosis noted. With capillary refill time of 1-2 seconds

IX. HEENT

A. Cranium

The hair is black in color, smooth, thick and evenly distributed. No lumps, lesions, and parasites
noted on the scalp. The cranium is normocephalic, symmetrical and has no deformities. No
tenderness or abnormal masses noted upon palpation. Temporal arteries are palpable but not
visible with normal pulsation.

B. Face
The face is symmetrical. Skin is brown in color, fairly smooth, with small areas of
hypopigmentation on the left side of the face. Facial hair is thin with slight pattern loss on the left
upper lip. No abnormal facies, involuntary facial movements, edema and masses noted.

C. Eyes
Eyebrows are black in color and well distributed. Patient has a scar on his left eyebrows.
Eyelashes are black, short, and are present in both upper and lower eyelids. Eyelids do not have
any lesions and edema, and are negative for lid lag. No widening or narrowing of the palpebral
fissure noted. There is no ptosis, exophthalmos, and enopthalmos noted. No swelling and
hematoma are noted. Palpebral conjunctivae are pinkish in color with minute vessels. No edema,
lesions and dicharges noted. Sclera is white in color with minute vessels and has no
discolorations and lesions noted. Cornea is transparent and clear. No lesions, opacities, ulcers,
and foreign bodies noted. Iris is round and black in color. Pupils are symmetrical, round, about 2
to 3 mm in diameter upon constriction. There is normal accommodation reflex and is reactive to
both direct and consensual light. Lenses are transparent. Tenderness upon palpation is absent
Fundoscopy is positive for red orange reflex. Patient was able to read the smallest font in a
printed newspaper.

D. Ears
The external ears are triangular in shape and symmetrical. With right trugal deformity noted. No
lesions and tenderness upon palpation of auricles and mastoid area. External auditory canals
are patent, and do not have discharges and foreign bodies. Walls are pinkish in color. Tympanic
membrane is pearly white in color, no bulging and no perforations were noted. Patient was able
to hear the words that were whispered to him.

E. Nose
The nose is symmetrical and pointed. No gross deformities noted. Flaring of ala nasi is absent.
Vestibule is patent. Mucosa is pinkish in color, no secretions and bleeding noted. Nasal septum
is straight at the midline and does not have any perforation. Turbinates are slightly moist. No
edema, no swelling and no secretions were noted. No tenderness of the paranasal sinuses upon
palpation and there is no clouding of the paranasal sinuses upon transillumination.

F. Mouth and Throat

The lips and buccal mucosa are symmetrical, pink and moist. Lesions and swelling are absent.
Tongue is in the midline. It can move without difficulty upon protrusion and retraction.
Hypertrophy, atrophy and lesions are absent. Gingiva is pale, and has no bleeding and
hypertrophy. Palate is pinkish and does not have lesions. Uvula is in midline. Palate wall has
symmetrical elevation. Tonsils are small and pale. Posterior pharyngeal wall is pale and does not
have any lesion, swelling and exudates. Upper and lower molars are absent, premolars in the
upper left, upper right, lower left and lower right have dental caries. 4 lower incisors are present.
Patient has dentures for 2 upper incisors.

G. Neck
The skin is brown, with tattoo on the anterior, posterior and left portion of the neck. The neck is
normal in size, symmetrical and has well developed muscles. Deformity and deviation are
absent. Trapezius and sternocleidomastoid are well developed and no tenderness. The patient
has full range of motion of the neck as to flexion, extension, and lateral bending. Trachea is in
midline. Thyroid gland is not visible and palpable. There is no submental, preauricular, posterior
auricular, occipital, tonsillar, submandibular, superficial cervical, posterior cervical, deep cervical
and supraclavicular adenopathy.