What is wrong with the history?

:
A Medical Students’ History Write up #2

Name: ____________________________________________________ Subsec: ______ Date: __________

Instructions: At the end of each part of the history write-up, encircle what is
wrong/lacking/should not be included and explain why at the space provided. You
may also add what is lacking in the history. This must be submitted to your
facilitator at the end of the allotted time.

General Data:

Name: Remedios Tan Age: 63 Gender: Female

Address: Taguig City Civil Status: Married
Birthday: Dec 15, 1952 Religion: Christian
Birthplace: Quezon City Nationality: Filipino
Educational Attainment: College graduate Occupation:

Comments:

Chief Complaint: Chest heaviness or “masakit ang dibdib”

HPI:
4 weeks PTA, while doing the laundry, she complained of chest heaviness. There were no palpitations or
light-headedness. The patient just took a rest and it relieved the symptom. No consult, no meds were taken
during this time.

3 weeks PTA, there was recurrence of chest heaviness while sweeping the floor. She took Alaxan to relieve
the pain. There was slight relief of symptom. She again took a rest. She did not seek consult during this
time.

2 weeks PTA, while washing the dishes, she again complained of chest heaviness accompanied by difficulty
of breathing. She also claims to have cold sweats. This prompted her to seek consult at a local clinic
wherein she was given Isordil placed under the tongue. She was apparently well after that.

Few Hours PTA, she again experiences chest heaviness while watching TV. This was accompanied by pain
at the jaw area and difficulty of breathing. This prompted her to seek consult at UST Hospital.

Comments:
General: positive weight gain, denies change in sleeping pattern, no fever, on and off bipedal edema
Skin, Hair, Nails: no itchiness, no color change, no rashes, no abnormal nail growth
Eye: has blurring of vision, no photophobia, no itchiness, no lacrimation, no swelling
Ear: no deafness, discharge, tinnitus, pain
Nose: No epistaxis, discharge, obstruction, abnormal sense of smell
Mouth: no bleeding gums, dental carries, metallic taste
Past History:
Throat: no pain, hoarseness, change in voice
Neck:
Birth No
andstiffness/limitation of motion,
Developmental History: no mass
Unrecalled
Breast: No mass, discharge, change in
Childhood illness/hospitalization: Asthma,color,
lastskin dimpling,
attack tendernesss,
at 5 years old trauma
Pulmonary:
Adult Illness:noHypertension
dyspnea, shortness of breath,
> 10 years. Highestcough, hemoptysis,
BP 180/100 Usualwheezing, back pain, abnormal chest
BP: 130/80
wall, difficulty of breathing
Tx: Norvasc 10 mg/tab OD, Lifezar 50 mg/tab OD, compliant
Cardiac: see HPI Diabetes Mellitus > 15 years
Gastrointestinal: No Tx:abdominal
Metforminpain, no retching,
500 mg/tab melena, hematochezia,
TID, Diamicron dysphagia,
60 mg/tab 1 tab belching, diarrhea,
OD, compliant
constipation, indigestion,
Surgeries: None abdominal enlargement.
Genitourinary: no urinary
Injuries/Accidents: None frequency, urgency, hesitancy, urinary retention, incontinence, dysuria, tea
colored urine, genital
Transfusions: None discharge, perineal mass, perineal pain, hernia, erectile dysfunction
Musculoskeletal:
Allergies: ShrimpsNo joint stiffness, no pain, cramps, weakness, trauma
Neurologic: No headache, seizure, loss of consciousness, motor dysfunction, weakness, paralysis, speech
disturbance, mental changes, behavioral changes
Vascular: No phlebitis, varices, claudication, leg discoloration
Endocrine: No heat-cold intolerance, no tremors, palpitations, has polydipsia, has polyphagia, has polyuria,
no slowness in mentation, no abnormal enlargement of facial features, hands or feet
Hematologic: No bleeding, easy bruisability, pallor or adenopathy
Psychiatric: No anxiety, depression, hallucinations, violent behavior, mood changes, and suicidal thoughts

Comments:

Past History:

Birth and Developmental History: Unrecalled

Childhood illness/hospitalization: Stroke 2010
Adult Illness: Hypertension > 10 years. Highest BP 180/100 Usual BP: 130/80
Past History: Tx: Norvasc 10 mg/tab OD, Valsartan 150 mg/tab OD, compliant

Birth and Developmental History: Unrecalled

Childhood illness/hospitalization: Asthma, last attack at 5 years old
Adult Illness: Hypertension > 10 years. Highest BP 180/100 Usual BP: 130/80
Tx: Norvasc 10 mg/tab OD, Lifezar 50 mg/tab OD, compliant
Diabetes Mellitus > 15 years
 Diabetes Mellitus > 15 years
Tx: Metformin 500 mg/tab TID, non-compliant

Surgeries: None Allergies: none

Injuries/Accidents: None Transfusions: none

Comments:

Current Health Status/Risk Factors:

Sleep pattern: sleeps 4-5 hrs a day
Exercise: walking 1 block from the house, cleaning the house
Smoking: none
Alcohol: none
Environmental exposures: No recent travel
Medications: see above data
Herbal Medications: MX3 capsules OD
Illegal drugs/substance abuse: none
Immunization: Unrecalled

Comments:

Family History:
Hypertension: father & mother
Diabetes Mellitus: mother, brother
Stroke: father
Cancer: none
Asthma: brother
Tuberculosis: none
Heart Disease: Father

Comments:
Personal & Social History:

Marital status: married with 3 children

Living condition: lives in an apartment with good environment. Have good relationship with the neighbors. 1
single daughter is still living with her
Support: Support from family and friends
Employment/job satisfaction: retired
Sexual History: no contact
Significant life event: recent sickness

Comments:

Physical Examination:

General Survey: conscious, coherent, agitated.

Vital Signs: RR: 22, T: 36.1, BP: 140/90 PR: 90 02 sat: 96%

Skin: No cyanosis, no jaundice, no petechial, cold and clammy

Hair: No alopecia, evenly distributed
Nails: no signs of clubbing
HEENT:
Head: No lesions, symmetrical facial features, no facies
Eyes: no lesions, no discharge, no edema. EOMS full and intact. NO visual field defects. Pink palpebral
conjunctivae, anicteric sclerae, Pupil OS: white, reactive to light at 3-4 mm, Pupils OD: reactive to light 3-4
mm, both eyes were able to accommodate.
Ears: No deformities, no masses, no lesion, no tenderness. External auditory canal are non-hyperemic with
minimal cerumen. No foreign bodies. Intact tympanic membrane both ears.
Nose: nasal septum is midline, no signs of congestion, no polyps. Frontal and maxillary sinus are non
tender.
Mouth: No active lesions, no cyanosis. Moist buccal mucosa, pinkish gingivae, no bleeding, no dental
caries. Tongue and uvula are midline, Tonsils not enlarged, non-hyperemic posterior pharyngeal wall
Neck: No palpable masses, no scars, trachea is midline, thyroid gland moves with deglutition

THORAX/BREAST/LUNGS
There was symmetrical chest expansion. No chest wall tenderness or masses. Equal tactile fremitus.
Resonant on all lung fields. Normal breath sounds and no adventitious lung sounds heard.

Cardiovascular:
Adynamic precordium, no heaves, lifts, thrills. Cardiac rhythm is regular. Apex beat is at 5th LICS,
MCL, loud S1 followed by soft S2 at the apex, soft S1 followed by loud S2 at the base, no
abnormal heart sounds and no murmurs heard.
 CARDIAC AUSCULTOGRAM

Precordium: Apex beat:

Adynamic precordium 5 th LICS, MCL
No heaves, lifts, or thrills

GASTROINTESTINAL
The abdomen is symmetrical, soft, no bulging masses, no distention, no visible peristalsis, no
visible vessels, normoactive bowel sounds, no bruit on all areas, tympanitic on all quadrants upon
percussion, no abdominal tenderness with deep and light palpation. No nausea, vomiting, retching,
hematemesis, melena, hematochezia, dysphagia, belching, indigestion, food tolerance, heartburn,
flatulence, diarrhea, and constipation. Rectal examination was not performed. Liver is non-tender
and smooth. Traube’s space is not obliterated. Kidneys are not palpable.

MUSCULOSKELETAL

Temporomandibular joint: No skin change, no bony or soft tissue deformity or tenderness, with
good muscle tone, able to close and open mouth with ease, no malocclusion
Cervical spine: No skin change, movement not assessed
Shoulder joints: No skin change, no bony or soft tissue deformity or tenderness, with good
muscle tone, able to do active and passive range of motions with ease, MMT 5/5
Elbow joints: No skin change, no bony or soft tissue deformity or tenderness, with good muscle
tone, able to do active and passive range of motions with ease, MMT 5/5
Wrist joints: No skin change, no bony or soft tissue deformity or tenderness, with good muscle
tone, able to do active and passive range of motions with ease, MMT 5/5
Hand and Fingers: No skin change, no bony or soft tissue deformity or tenderness, with good
muscle tone, able to do active and passive range of motions with ease, MMT 5/5
Hip joints: No skin change, no bony or soft tissue deformity or tenderness, with good muscle tone,
able to do active and passive range of motions with ease
Knee joint: No skin change, no bony or soft tissue deformity or tenderness, with good muscle
tone, able to do active and passive range of motions with ease, MMT 5/5
Ankle & feet: No skin change, no bony or soft tissue deformity or tenderness, with good muscle
tone, able to do active and passive range of motions with ease, MMT 5/5
EXTREMITIES:
Pulses are full and equal, (+) edema on both feet, no deformities on both upper and lower
extremities, no joint swelling and tenderness, no presence of tophi. Her skin integrity and nail
conditions are good.

NEUROLOGICAL:
Patient is conscious, coherent, and oriented as to time, place, and people. She is cooperative with
GCS of 15 (E4V5M6).
Cerebellum: No tremors, no dysdiadochokinesia, no dysmetria
Cranial Nerves:
 CN I – not assessed
 CN II – pupils 2-3mm equally round and reactive to light and accommodation
 CN III, IV, VI – intact and full extraocular muscles
 CN V – no sensory deficit V1-V3, able to clench her jaw
 CN VII – can raise eyebrows, closes eyes tightly, symmetrical upon smiling, able to puff
cheeks and clench teeth
 CN VIII – gross hearing is intact
 CN IX, X – soft palate rises on phonation, uvula in midline on phonation, able to swallow
 CN XI – able to shrug shoulder against resistance, can turn face against resistance
 CN XII – tongue is in midline and symmetrical upon protrusion
Sensory: No sensory deficit on all extremities
Reflexes: 2+ on all extremities
Meningeal: No nuchal rigidity, (-)Babinski, (-)Kernig, (-)Brudzinski