Cagayan State University- Carig Campus

College of Medicine and Surgery

Medicine Ward 1
History Taking
Group 3 members:
AFALLA, JOYCE ANNE
ALFONSO, FEBE
CONAG, RICH MARK
MARCUS, IDA PRISCILLA
MALLILLIN, CHRISTINE JOY
PARONG, MA. STEPHANIE
Date of Assessment: December 2, 2016 - time: 1:30 pm
Date and Time of Admission: November 30, 2016 2:00pm
Ward: Medicine ward
Name: Mr. RS
Age: 50 y/o
Sex: Male
Marital status: Married
Occupation: Former farmer
Religion: Roman Catholic
Present Address: Sta. Maria, Isabela
Source of Information: Patient and his wife
Reliability: The patient exhibit 80% reliability - the patient was conscious.
CHIEF COMPLAINT: Difficulty of breathing with productive cough (yellow tinged sputum)
PRESENT ILLNESS:
November 26, 2016, 5 days prior to admission, the patient experienced productive cough with
sputum which he described as white and viscous. It was continuous for days and he managed it by resting
and increasing his fluid intake up to 10-15 glasses of water.
November 28, 2016, 3 days prior to admission, the patient started experiencing difficulty of
breathing and Orthopnea requiring him to sleep with 2-3 pillows. His symptoms according to his wife were
relieved by resting and by increasing his oral fluid intake (OFI) up to 10-15 glasses of water.
November 30, 2016, 5 hours prior to admission, while helping his wife cook for lunch, the patient

experienced chest pain and difficulty of breathing while coughing spontaneously. This prompted his wife to
rush her to CVMC, hence admitted.
PAST MEDICAL HISTORY
CHILDHOOD ILLNESS
The patient had asthma triggered by environmental irritants like smoke, pollen and the like
subsequently causing difficulty of breathing. Due to financial constraints he would usually relies on resting
and or fluid intake when accompanied by cough. When asked further, he could not recall any childhood
diseases other than occasional fever, cough and colds which he managed through over the counter drugs
like neozep, paracetamol and the likes.
ADULT ILLNESS
Mr. RS was first diagnosed with COPD 5 years ago in a clinic at Sta. Maria, due to frequent asthma
attack and pneumonia with a presenting signs of chest pain and difficulty of breathing. His doctor then
advised him to buy a nebulizer to alleviate his difficulty of breathing, during his asthma attacks, but due to
financial instability he ought not buy the nebulizer and just relieve his DOB by resting and increasing his
water intake.No other diseases or illnesses noted.
FAMILY HISTORY
Mr. RO is married with 3 children. The patient said that he has a history of Asthma on both sides of
the family. His wife and children were never hospitalized of the same case or for any other cause. The
patient also said that his father died of Chronic Kidney Disease 3 years ago and his mother died of
hypertension a year ago. Both died in CVMC.
SOCIAL AND PERSONAL HISTORY
Mr. RS is from Sta. Maria, Isabela and lives together with his wife. The wife said that they usually
cook with firewood and that his husband is a chronic smoker since he was 20 years old, who regularly
consumes 2 packs of cigarettes per day. He just stopped smoking 5 years ago. These were seen as
reasons that might have contributed to his current health status.
REVIEW OF SYSTEMS:
GENERAL: has weight loss of 10kg in the past 5 years.
HEENT
Eyes: (+) poor vision
Ears: Optimum hearing function
RESPIRATORY:
(+) productive cough, (+) difficulty of breathing
CARDIAC:
(+) chest pain, (-) palpitation

VASCULAR:
No history of leg pain or any signs of phlebitis
G.I.:
Regular bowel movement
G.U.:
No pain during urination
MUSCULOSKELATAL:
(+) mild back ache, (-) arthritis and gout
NEUROMUSCULAR:
No history of seizures and memory changes
PSYCHIATRIC:
No history of depression
HEMATOLOGICAL:
(-) anemia
DERMATOLOGIC:
(-) rashes, (-) allergies and dry skin
PHYSICAL EXAMINATION: Mr. RS is a thin and well groomed adult
VITAL SIGNS:
Temperature: 36.8 degree C
Pulse rate: 80bpm
Respiratory rate: 20cpm
Blood pressure: 110/80mmHg
Auscultation:(+) crackles on both lungs
SKIN: Dry. Nails without clubbing or cyanosis
RESPIRATORY: Expiratory wheeze and inspiratory coarse crackles on both lungs
IMPRESSION: Chronic Obstructive Pulmonary Disease (COPD)