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MEDICAL HISTORY-QCGH

Historian: Capitle, Caraan, Cariaga


Proctor: Dr. R. Dela Cruz Date of History:01/27/2020
Informant: partner Date of Submission: 01/27/2020
Reliability: 75%

GENERAL DATA
Name: A.G.I.
Address: Desire, Sunville, Culiat, Quezon City Date of admission: 01/27/2020
Age: 50 Birthdate: May 24, 1969 Birth Place: Bato,Camarines Sur
Sex: F Religion: Roman Catholic
Marital Status: Single
Occupation: former baker Nationality: Filipino

CHIEF COMPLAINT: Dizziness and blurring of vision

HISTORY OF PRESENT ILLNESS

2 days PTA, patient noted to have blurring of vision, dizziness and pale skin after eating
“kakanin” in the morning, applied “Katinko” ointment and rested which provided temporary
relief. No medications taken. BP measured by neighbor: 140/100. Went to a private clinic in
Tandang Sora, QC in the afternoon, BP: 190/100 and given BP lowering medication.

1-day PTA, patient still dizzy and with loss of balance when walking. Went to Ramos Hospital
because worsening of condition was referred to Quezon City General Hospital for further
management and treatment hence this admission.

PAST MEDICAL HISTORY


Immunizations: BCG
Childhood Diseases: NONE
Allergies: Seafoods
Past Illnesses: Dengue
Accidents: NONE
Blood Transfusion: NONE
Surgical Operations: NONE

FAMILY HISTORY
 Mother - DM
 Father - Hypertension
 Siblings – Sister: DM
6/10 siblings: obese

PERSONAL & SOCIAL HISTORY


Educational Attainment: College Level
Occupational Hx: baker from 2009-2017
Nature of work: managerial, manual
# of hours:10-12 hrs of work

Marital Status: single


Exposure to STD:

Habits:

Diet: meat and fast food


Coffee: cups per day
Alcohol: NONE

Smoking: NONE
Use of drugs: NONE

Exercise: NONE
Living conditions:
Living with: common law partner
House: 2 storey
Source of water supply: Manila
Water
Waste disposal: garbage truck

OBSTETRICAL HISTORY
Menarche: 13 years old Duration: 4 days Amount of flow: scanty
Interval: regular Duration: 4 days
Amount of flow: scanty
Last Menstrual Period: 01/27/2020
Gravidity & Parity: Gravidity:0 Parity:0

REVIEW OF SYSTEMS

GENERAL (+) weakness, (-) fatigue, (-) weight change, (-) fever, (-) chills, (-) sweats
SKIN (-) rash, (-) pruritus, (-) pigmentation, (-) lumps, (-) sores, (-) dryness, (-)
change in hair & nails
HEENT
HEAD (-) headache, (-) dizziness, (-) light headedness
EYES (-) vision, (-) glasses or contact lenses, (-) pain, (-) redness, (-) itching, (-)
excessive tearing,
(-) double vision, (-) blurred vision, (-) spots, (-) specks, (-) flashing lights,
(-) glaucoma, (-) cataracts
EARS (-) hearing, (-) tinnitus, (-) vertigo, (-) earaches, (-) discharge
NOSE & SINUSES (-) colds, (-) discharge, (-) itching, (-) dryness, (-) nosebleeds, (-) sinus
trouble, (-) pain, (-)obstruction,
(-) sense of smell, (-) sneezing
THROAT (OR MOUTH (-) pain, (-) dry mouth, (-) hoarseness, (-) sore throat, (-) bleeding gums, (-
& PHARYNX) ) dentures (if any & how they fit),
(-) sore tongue, (-) difficulty of swallowing
NECK (-) lumps, (-) swollen glands, (-) pain, (-) stiffness
BREASTS (-) Lumps, (-) pain, (-) discomfort , (-) nipple discharge, (-) bleeding , (-)
self-examination practices
RESPIRATORY (-) cough, (-) hemoptysis, (-) dyspnea, (-) pain, (-) wheezing, (-) sputum
CARDIOVASCULAR (-) heart trouble, (-) heart murmurs, (-) chest pain or discomfort, (-)
palpitations, (-) dyspnea, (-) orthopnea,
(-) paroxysmal nocturnal dyspnea, (-) edema
GASTROINTESTINAL (-) trouble swallowing, (-) heartburn, (-) appetite, (-) nausea, (-) vomiting ,
(-) bowel movements
(-) color, (-) size of stools, (-) change in bowel habits, (-) rectal bleeding, (-
) melena, (-) hemorrhoids,
(-) constipation, (-) diarrhea, (-) abdominal pain, (-) food intolerance, (-)
excessive belching or passing of gas.
URINARY frequency of urination: (-) polyuria, (-) nocturia, (-) urgency, (-) dysuria, (-
) hematuria, (-) incontinence, (-) stones
GENITAL
MALE (-) Hernias, (-) discharge from or sores on the penis, (-) testicular pain or
masses, (-) swelling, (-) ulcer,
(-) itching, (-) sexual habits and problems, (-) exposure to HIV infection
FEMALE (-) dysmenorrhea, (-|)premenstrual tension, (-) vaginal discharge, (-)
bleeding, (-) itching, (-) sores,
(-) lumps, (-) sexual habits and problems, (-) exposure to HIV infection
PERIPHERAL (-) Claudication, (-) varicose veins, (-) past clots on veins
VASCULAR
MUSCULO- (-) muscle or joint pains, (-) cramps, (-) stiffness, (-) sweating, (-)
SKELETAL tenderness, (-) limitation of motion,
(-) trauma, (+) weakness
NEUROLOGIC (-) syncope, (-) blackouts, (-) seizures, (-) paralysis, (+) numbness, (-)
tingling or “pins or needles”,
(-) tremors and other involuntary movements, (-) pain, (-) sensory, (-)
memory
HEMATOLOGIC (-) anemia, (-) easy bruising, (-) bleeding
ENDOCRINE (-) cold intolerance, (-) excessive sweating, (-) excessive thirst or hunger, (-
) change in glove or shoe size
PSYCHIATRIC (-) nervousness, (-) tension, (-) mood, (-) depression, (-) memory change, (-
) suicide attempts (if relevant)

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