Kathlyn A.

Sunico Group 3
UV- Gullas College of Medicine

Health History and Physical Examination Report

Patient: A.S
Date and Time of Admission: November 24, 2018 at 2am
Source: Patient
Reliability: 85%
Date and Time of Interview: November 28, 2018 at 10:45AM

General Data:

A.S, a 59-year-old male, married, Filipino, Roman Catholic, currently

working as a traffic enforcer and lives in Lapu-Lapu City, was admitted for the
second time on Monday, November 24, 2018, 2am at Vicente Sotto
Memorial Medical Center.

Chief Complaint: Chest pain

History of Present Illness:

One day prior to admission, A.S was doing his household chores and
had a sudden episode of chest pain at around 9am. The pain was described
as “stabbing pain” behind the chest or retrosternal area with a pain scale of
10/10 according to the patient. He had cold sweats and felt weak when the
chest pain occurred. It was not noted to radiate nor increase with exertion.
He denied having nausea, vomiting, dizziness, or loss of consciousness. A.S
stated that he massaged his chest to somewhat relieve the pain and had not
taken any pain relievers.
Few hours prior to admission, A.S had another episode of chest pain
still at the retrosternal part of the chest at around 10pm which led him to
seek medical assistance. Patient is not taking any maintenance medications.

Past Medical History

Childhood Illness: Measles, Chickenpox and Mumps. Complete
immunizations
Adult Illness: He was hospitalized for the first time due to drug overdose
(Alaxan and Biogesic for fever) but fails to recall what year. Patient claims
that he doesn’t have diabetes, hypertension nor asthma
Surgical: Patient did not undergo any surgeries

Family History

Patient’s parents both had history of hypertension. His father died at

the age of 61 due to heart attack. His mother is alive and well and now 84
years old. The patient is the 3rd child among the 9 children. Some of his
siblings also has hypertension. Three of his siblings died because of suicide,
heart attack and stab wound. Patient’s wife and kids are all healthy

Personal and Social History

Patient is living in a boarding house along with his family and he claims
it is safe. He usually works for 8 hours and sometimes 16 hours. He eats 3
times a day with snack in between meals. Patient’s diet is food high in protein
and fat. He considers work as his exercise. Patient takes food supplements,
Koi and Vitamin D. His source of stress is work and financial problems. He
was a cigarette smoker before and consumes one and half packs and an
occasional drinker. Patient’s urination/defecation is normal.

Review of Systems

General: No fever, chills and night sweats. No significant weight loss.

Skin: No rashes, bruising, sores, lumps or color changes.
HEENT: No history of head trauma. Patient is nearsighted and is wearing
eyeglasses with a grade of 200/20. Hearing is good, no tinnitus. No sinus
trouble. No gum bleeding.
Neck: No lumps, goiter, pain. No swollen glands.
Respiratory: No cough, wheezing, shortness of breath.
Cardiovascular: Recent chest pain- retrosternal. No shortness of breath, no
palpitations, no edema. No syncope.
Gastrointestinal: Appetite is good; no nausea, vomiting, indigestion. No
abdominal pain.
Urinary: No frequency, dysuria, hematuria.
Genital: Not assessed.
Peripheral vascular: No varicosities.
Musculoskeletal: No pain or swelling of joints. No cramps.
Psychiatric: No history of depression or treatment for psychiatric disorder.
Neurologic: No fainting, seizures, motor or sensory loss.
Hematologic: No easy bleeding. No anemia
Endocrine: No known thyroid disorders or heat or cold intolerance. No
symptoms or history of diabetes.

Physical Examination

General Survey

A.S, a well appearing old man was sitting on a bench. Conscious, alert
and responds quickly to questions and oriented to time, place and person.
Patient is not in distress nor pain.

Vital Signs:
Blood pressure: 100/80 mmHg
Temperature: 35.7ºC
Respiratory: 20 breaths per minute
Pulse Rate: 76 beats per minute
O2sat: 97%

Skin: Skin is warm and dry, with good turgor and mobility. Nails are without
clubbing or cyanosis.
Head: Skull is normocephalic. Patient has hair loss or alopecia.
Eyes: Patient is wearing eyeglasses with a grade of 200/20. Non-icteric sclera,
pink conjunctiva. Pupils are both at 5mm, reactive to light and
accommodation. Extraocular muscles intact for both eyes.
Ears: Normal hearing. No lesions or dischargers noted.
Nose: Mucosa pink, septum midline. No sinus tenderness.
Throat: Oral mucosa is pinkish. No lesions or discharges noted. Tonsils are
non-erythematous, uvula at midline. Tongue is at the midline. Pharynx is
non-erythematous, no exudates noted.
Neck: Supple. Trachea is at the midline. Thyroid is palpable but not enlarged,
firm nor tender.
Thorax and lungs: Clear to auscultation. No wheezes, rales or stridor. Thorax
symmetric with good excursion.
Cardiovascular: Regular rate and rhythm.
Abdomen: Abdomen is protuberant. No further assessment made.
Genital: Not assessed.
Rectal: Not performed.
Peripheral vascular: Extremities are warm. No edema or varicosities.
Musculoskeletal: No joint deformities. Good range of motion in hands,
wrists, elbows, shoulders, spine, hips, knees, ankles.
Motor: deferred
Neurologic:
Mental status: Alert and cooperative. Thought coherent and is
oriented to person, place and time
Cranial Nerves:
CN I – not assessed.
CN II – reactive to light.
CN III, IV, VI – intact extraocular movements.
CN V – not assessed.
CN VII – face symmetrical, can frown, smile can close eyes tightly
CN VIII – normal hearing
CN IX, X – can swallow without difficulty
CN XI – not assessed
CN XII – tongue is in the midline, no deviation. No tongue
fasciculation noted upon protrusion
Sensory: Deferred
Cerebellar: Gait and stance not assessed.
Reflex: Not assessed.