Patient Paquito was brought to the hospital accompanied by her wife with a chief complaint of DOB, productive cough. Vital signs: BP 140/90 mmHg , RR 22cpm, PR 90 bpm , Temp: 38.5 Patient was seen and examined by Dr. Macabalug and was diagnosed with Asthma. Upon assessment, he is conscious and coherent and has mentioned that he has been experiencing easy fatigability. Upon auscultation, wheezes were noted at the lower chest and still complaining of DOB. According to the him it was his second time to be hospitalized. . He often experience colds, cough, headache and fever. And according to him he has allergies in “malalansang pagkain” such as fish, eggs, chicken, shell fish. He often takes OTC drugs to treat his illness. He was hospitalized last December 2005 due to pain in the chest area and DOB at GFND for a week. He was born in Ilagan, Isabela on the year 1941, he got married at the age of 22 at Ilagan and was blessed with 5 child and 26 grand children. He currently lives at San Lorenzo Ilagan, Isabela with his wife. He is under graduate of tertiary level. Presently their source of income is farming. He loves eating vegetables, fruits, and fatty food. And according to him he was a smoker and drinker before but he stopped it since he got ill. He and his son Edwin has hypertension. And his mother died due to breast cancer. His 3rd daughter was hospitalized for 1 week in 1998 due to malaria . His father died in June 1978 due to Leukemia. Using the situation, Identify the following : Present Medical History Past Medical History Family History Social History
Patient Paquito was brought to the hospital accompanied by her wife with a chief complaint of DOB, productive cough.
Vital signs: BP 140/90 mmHg , RR 22cpm, PR 90 bpm , Temp: 38.5
Patient was seen and examined by Dr. Macabalug and was diagnosed with Asthma. Upon assessment, he is conscious and coherent and has mentioned that he has been experiencing easy fatigability. Upon auscultation, wheezes were noted at the lower chest and still complaining of DOB.
According to the him it was his second time to be hospitalized. . He often experience colds, cough, headache and fever. And according to him he has allergies in “malalansang pagkain” such as fish, eggs, chicken, shell fish. He often takes OTC drugs to treat his illness. He was hospitalized last December 2005 due to pain in the chest area and DOB at GFND for a week. He was born in Ilagan, Isabela on the year 1941, he got married at the age of 22 at Ilagan and was blessed with 5 child and 26 grand children. He currently lives at San Lorenzo Ilagan, Isabela with his wife. He is under graduate of tertiary level. Presently their source of income is farming. He loves eating vegetables, fruits, and fatty food. And according to him he was a smoker and drinker before but he stopped it since he got ill. He and his son Edwin has hypertension. And his mother died due to breast cancer. His 3rd daughter was hospitalized for 1 week in 1998 due to malaria . His father died in June 1978 due to Leukemia.
Using the situation, Identify the following :
Present Medical History
Past Medical History
Family History
Social History
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