BONAVENTE, Katrina Q.

January 18, 2010Internal Medicine Clinics

Date of interview: January 18, 2010Time of Interview: 10:30amInformant: patientReliability: 75%

GENERAL DATA

Abdon Castillo, 26 years old, widow, male, a Filipino Christian, was born on September 4, 1983 at Samar, currently unemployed and residing at #19 Liwayway St. Acacia, Malabon City, was admitted for the first time at MCU Hospital ER at 10:30 in the evening.

CHIEF COMPLAINT

Dizziness and difficulty of breathingHISTORY OF PRESENT ILLNESS

The patient was previously well until fifteen hours prior to admission, the patient felt dizzy while running upstairs from first to second floor with associated difficulty of breathing. He vomited the food he ate during breakfast amounting to one cup. After 30minutes, he went up to the third floor and felt dizzy again, he felt the urge to vomit but nothing came out, there was associated severe difficulty of breathing which prompted one of his brothers to bring him to the Medical office. He was given water and oxygen and was asked to take some rest. His blood pressure was 160/90mmHg and he was given an unrecalled white tablet which was claimed to be an anti-hypertensive drug.

Eight hours prior to admission, he had his lunch and took some rest at their quarters for five hours. When he woke up, he felt dizzy again with associated body weakness wherein he cannot stand up and walk. He was given banana and soup to eat but he just vomited the food after eating and experienced again difficulty of breathing and dizziness. He was brought to the Medical office with blood pressure of 160/80mmHg, he was asked to take some rest.

Two hours prior to admission, his blood pressure was down to 150/80 but still feeling dizzy with associated difficulty of breathing. No medicines were taken.

Thirty minutes prior to admission, his dizziness and difficulty of breathing were not resolved by rest which prompted the medical staffs to bring him at MCU ER hence admission.

PAST HISTORY

He claims to have childhood immunizations given in a health center but does not know if complete. He had no childhood illnesses like measles, mumps or chickenpox. He was hospitalized for two weeks when he was fifteen years old due to body weakness and hematoma formation brought about by fraternity activity. When he was 24 years old, he developed chickenpox and no medication was taken. He has no history of accidents or surgical operations. He has no allergy to drugs but he has allergy to sea foods like crabs and shrimps. FAMILY HISTORY

Both of his parents are hypertensive and both are on maintenance drugs. His father also has diabetes and is on medication. There are no other heredofamilial diseases like cancer, familial hypercholesterolemia or psychological illnesses.

PERSONAL/SOCIAL HISTORY

The patient is the eldest in the brood of four. He took three different courses in college but was not able to finish any course. He took pharmacy for one semester only then electrical engineering for another semester and one year for associate computer course. He got married at the age of 17 and he was widowed when his wife died while giving birth to their second child in 2007. He is a non-smoker and was an alcoholic drinker for a year preferably hard beverages like Tanduay Rhum consuming 1 bottle per session. He has no food preferences except for foods that he has allergy on. He enrolled himself in a gym before for a year and 3 months but now, he does not exercise anymore.

He lives with 25 other men in a room with 2 common comfort rooms in building where they train for gospel studies. Water source is from NAWASA and they have mineral water for drinking. REVIEW OF SYSTEMS

General: Patient is awake, conscious, coherent and conversant. He is sitting and afebrile. He weighs 63 kilos.Skin: Patient has no complaints made regarding rashes and itchiness. He claims to have no masses or lesions on the skin.

Head: The patient has migraine accompanied by bleeding of the nose, no medications taken when there is attack. The patient does not experience hair shedding and itching of the scalp.

Eyes: Patient wears reading eyeglasses with a grade of +1.00 on both eyes which started in 2007. Ears: He claims to have no discharges on both ears and does not have tinnitus.

Nose and sinuses: He does not have any stuffed sinuses and claims that he has good sense of smell. He experiences nose bleeding whenever he has migraine. Neck: No complaints made regarding the neck area like swollen lymph nodes and pain.

Mouth and Throat: Patient does not have difficulty of swallowing. No dryness of the mouth.Respiratory: Patient claims that he experiences occasional difficulty of breathing due to stress, cough and phlegm.Cardiovascular: The patient feels chest heaviness, easy fatigability and palpitations. He does not experience orthopnea.

Gastrointestinal: The patient claims that he has a good appetite. He does not have any food intolerance. Good bowel movement.Urinary: Urine is straw to colorless in appearance. Patient does not experience dribbling, burning sensation, and pain upon urination. Urine flow is continuous and the caliber is of normal size.

Genital: The patient has no hernia, ulcer or lesions as claimed. He claims to have no any form of discharge.Peripheral Vascular: Patient does not complain of having cramps and varicosities. There are no bruising and edema.

Musculoskeletal: No complaints made regarding joint and muscle pains.

Hematologic: The patient claims that he does not easily bruise and he has good wound healing.Neurologic: Negative for blackouts, seizures and tingling sensations.

Psychiatric: Patient claims to have no mood swings or depression. He has no history of hallucinations and memory changes. No suicidal attempts and ideations. Sleep pattern is normal.Endocrine: Patient claims to have heat intolerance and excessive thirst.PHYSICAL EXAMINATION

General SurveyPatient is awake, sitting, coherent and conversant. He responds spontaneously to voice stimuli. Patient is 5 feet 3 inches tall and weighs 63 kilos having a BMI of 24.6 which is normal. Vital SignsPatients Blood pressure is 120/80mmHg, temperature of 36.2 C, respiratory rate of 22 breaths per minute, pulse rate of 53 beats per minute and cardiac auscultatory rate of 54 beats per minute.SkinSkin is warm to touch and has a good turgor. Body hair is evenly distributed. Finger and toe nails are have good capillary refill time. There are no wounds and lesions noted.HEENTHead: Face is round in shape, symmetric. Hair is of average quantity and texture, black in color. No mass, tenderness and any scalp lesions. Eye: Pupils are round, equal in size. Both are reactive to pupillary and consensual reflexes. Eyebrows are well distributed. Conjunctiva is pale, sclera is white.

Ear: No lumps, tenderness and redness noted. Ear has no discharges. Tympanic membranes were not checked.

Nose and sinuses: Nose is normal in size and symmetrical. Nasal mucosa, septum and turbinates were normal and without any secretions. There is no sinus tenderness.

Throat: Oral mucosa is pink with complete set of teeth. Tongue at the midline on protrusion. There were no lesions and tenderness. Lips and mucosa are well hydrated. Tonsils were not enlarged.

NeckNo cervical lymph node enlargement and no masses noted upon palpation. Trachea is at the midline. Lobes of the thyroid glands are not palpable.

Lymph Nodes

Cervical nodes were not enlarged. Axillary and inguinal nodes were not palpated.Thorax and Lungs

Chest is symmetrical with limited chest expansion due to abdominal tenderness. No tactile fremitus on palpation. Lungs are resonant. Normal breath sounds. No wheezes or rales.

Cardiovascular

PMI at 5th ICS, MCL. No thrills or heaves. No murmurs or extra sounds.Abdomen

Flat abdomen. Normoactive bowel sounds. Percussion and palpation were not done due to tenderness. Genitalia: Examination not done

Rectal: Examination not done

Extremities

All extremities of the patient exhibited fair strength and without edema. Peripheral vascular

No varicosities noted. Irregular pulse on radial and dorsalis pedis.Musculoskeletal: Patient has a good range of motion on all extremities.