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Vital signs
Temperature 36.5
HR 62
RR 16
BP 180/90 on the left (also supine) and 170/100 on the right (also standing)
Present Illness
Location
Quality - Feeling of loss of oxygen
Severity
Timing (onset, dur., freq.) - Heaviness of chest started in 2008, lasts anywhere from seconds to
up to 15 minutes and occurs about 3x a week
Precipitating factor -
Aggravating factor - physical exertion (climbing up stairs, washing clothes), kapag masama ang
loob (hindi daw nangyayari pag masaya siya), ---
Alleviating factor - Patient uses pillows to elevate her head, drinks a glass of water, massage
Associated (positives) - palpitation, shortness of breath, easily fatigued, wakes up in the middle
of sleep with a feeling of drowning
(negatives) - no dizziness, falls, pain, coughing
Other symptoms
Medications - metformin 500 mg 2x, simvastatin 20 mg 2x, isosorbide 30mg 1x, Aspirin 80mg
1x (Diltiazim was removed a year ago)
Allergies
Smoking, Alcohol, Drugs - None
Past History
Childhood illnesses - Chicken pox, measles, Beke
Adult illnesses -
Medical - diabetes (2008), hypertension (2008), malaki ang puso (2008) Commented [1]: was she hypertensive? in my notes
Surgical - Carpal tunnel (3 years ago), Trigger finger? (2 years ago) kasi, she was given medicine to prevent that but then
they stopped giving her medicine kasi she didn't need it
Obstetric - no children, pregnancies naman
Psychiatric - no history of mental illness
Commented [2]: this was trigger finger pala, i couldnt
Health maintenance understand what she said kasi rh haha
Immunizations - flu vaccine given 3 years ago
Screening tests
Family History
Parents - mother died at 64 y/o due to 27 stab wounds from hold-up accident, father died at 73
(may sakit sa puso, natumba sa labas - pano to sa english haha)
Grandparents
Siblings - 4th of 5,
Children - no children, has adopted 19 y/o daughter or son?
Grandchildren - none
Family conditions
1st sibling - male, hypertension, enlarged heart
2nd sibling - female, diabetes, heart problem
3rd sibling - male, diabetes
5th sibling - male died at 40 years old, chest pain, high cholesterol, suspected to have diabetes
Review of Systems
General - loss of weight at a steady pace -- due to change in diet
Skin - Rashes ( 2 years ago)
Head - no hair loss
Eyes - 250,250
Ears - no pain, hearing loss , no discharge,
Nose, Sinuses - ubo (dry), 2 weeks - given ambroxal, amoxillin and citirizine but coughing is still
Commented [3]: move to throat?
occuring
Commented [4]: Respiratory yata
Throat, Mouth - uses dentures
Neck - mass at the back part of the neck
Breasts - no masses felt
Respiratory - no coughing of blood, asthma during younger years
Cardiovascular -
Gastrointestinal - bowel movements 2x a day, solid, no blood,
Peripheral vascular - no
Urinary - No pain, abnormal smell or blood. Wakes up to 2x a night to urinate
Genital - no itchiness or discomfort
Musculoskeletal - Back Pain attributed to coughing (not sure if muskuloskeletal)
Psychiatric
Neurological
Hematologic - doesnt bruise easily
Endocrines