Date of History: July 17, 2014

Source of History: Patient

Reliability : 95%
General Data
Mr. J.S., 64 y.o., male, married, Roman Catholic, a farmer presently living at
Brgy. San Agustin, Dulag, Leyte, was admitted for the third time at EVRMC on July 12,
2014 at around 5 p.m.
Chief Complaint
Dyspnea
History of Present Illness
1 day prior to admission, patient had difficulty of breathing but was relieved by
resting.
4 hours prior to admission, he was resting after working in the morning when
suddenly he experienced difficulty of breathing, chest pain, abdominal pain, and pain in
the back of his neck. He sat down immediately but was not relieved so he decided to just
walk outside thinking that it will just go away. But it just got worse so they decided to go
to the hospital but still waited for the transportation. He was brought at EVRMC at
around 5 pm and was admitted.
Medications: maintenance drug for hypertension ( could not recall the name of
the drug)
Allergies: none
Tobacco use: cessation of smoking last June 2014
Alcohol/Drug: drinks tuba
Past History
Childhood Illnesses:
(-) immunization
(-) chicken pox, (+) measles,(+) mumps
Adult Illnesses:
Medical: 2 previous admissions, last October and december 2013 due to
dyspnea.
Surgery: removal of foreign object at left foot when he was 14
Psychiatry: None
Transfusion: none
Drug reactions: None

Family History
Patients father died at the age of 46 due to cancer. His mother died at the age of
77 due to asthma. He has 8 siblings, the 2 nd sibling is asthmatic, the eldest female sibling

have kidney problems and asthma, and their youngest sibling has hemorrhoids. 2 of his
siblings already died. one was due to dog bite and the other due to malnutrition.
Personal and Social History
Patient is the eldest among 8 siblings. He is married with her wife who is
already 47 years old. They have 6 children and 4 are boys and 2 are girls. They all
have complete immunizations. He was able to finish up to Grade 3. He is a farmer.
He usually wakes up at 2am and sleeps at 8pm. He can consume 1 gallon of water
per day. their source of water is form nawasa. He drinks 5-6 cups of coffee everyday.
He started drinking alcohol when he was 12 years old. He drinks 3-5 glasses of tuba
everyday because he is a tuba farmer as well. He needs to taste their tuba before
selling it. He claimed that he already stopped drinking after typhoon HAIYAN. He
already stopped smoking as well just last june 2014. He started smoking tobacco
when he was just 12 years old and consumes 5-6 sticks of tobacco everyday. When
he was 15 years old already he tried smoking cigarette and consumes 5-6 sticks
everyday.

REVIEW OF SYSTEMS
GENERAL: No current weight loss observed, no fever. Weakness
noted.
SKIN: bruises were present
HEAD: Headaches, dizziness and lightheadedness were not present
EYES: No eye pain, no redness, no double vision or blurred vision
noted. No excessive tearing. patient uses corrective lenses
EARS: no tinnitus, no hearing loss, no vertigo, no discharges.
NOSE AND SINUSES: Nasal discharges were present due to her colds;
no other concerns noted
MOUTH AND THROAT: Dry mouth, bleeding gums, sore tongue, sore
throat and hoarseness were not present
NECK: There were no lumps, pain or stiffness in the neck noted
BREAST: Nipple discharges, lumps and pain were not present
RESPIRATORY: Cough with sputum was evident as well as dyspnea;
patient is asthmatic
CARDIOVASCULAR: Chest pain and dyspnea were present; no other
concerns noted
GASTROINTESTINAL: There were no nausea and vomiting, heartburn,
constipation, diarrhea, abdominal pain or jaundice noted
URINARY: Polyuria, nocturia, burning sensation in urination, hematuira
and incontinence were not present
GENITAL: no sores, no lumps, no discharges.
PERIVASCULAR: Varicose veins present, no leg cramps, no edema, no
varicose veins, no intermittent claudication.
MUSCULOSKELETAL: There were no muscle or joint pains, stiffness,
arthritis, gout and backaches noted
PSYCHIATRIC: There were no concerns regarding her mental status
NEUROLOGIC: Fainting, blackouts, seizures, tingling or loss in
sensation, paralysis, weakness and trembles were not noted
HEMATOLOGIC: Bruises were present but no evidence of anemia or
external bleeding
ENDOCRINE: Excessive sweating, excessive thirst or hunger, heat and
cold intolerance were not noted