MEDICAL HISTORY-QCGH

Historian: Capitle, Caraan, Cariaga

Proctor: Dr. R. Dela Cruz Date of History:01/27/2020
Informant: partner Date of Submission: 01/27/2020
Reliability: 75%

GENERAL DATA
Name: A.G.I.
Address: Desire, Sunville, Culiat, Quezon City Date of admission: 01/27/2020
Age: 50 Birth Place: Bato,Camarines Sur
Sex: F Religion: Roman Catholic
Marital Status: Single Birthdate: May 24, 1969
Occupation: former baker Nationality: Filipino

CHIEF COMPLAINT: Dizziness and blurring of vision

HISTORY OF PRESENT ILLNESS

2 days PTA, patient noted to have blurring of vision, dizziness and pale skin after eating
“kakanin” in the morning, applied “Katinko” ointment and rested which provided temporary
relief. No medications taken. BP measured by neighbor: 140/100. Went to a private clinic in
Tandang Sora, QC in the afternoon, BP: 190/100 and given BP lowering medication.

1-day PTA, patient still dizzy and with loss of balance when walking. Went to Ramos Hospital
because worsening of condition was referred to Quezon City General Hospital for further
management and treatment hence this admission.

PAST MEDICAL HISTORY

Patient claimed to have no childhood diseases of chicken pox, mumps, measles and had BCG
vaccine when she was young. She doesn’t have any known allergies except for some seafoods.
Recalled an episode of dengue fever in her home province Bicol in 2010. Neither did she had
major accidents, blood transfusions nor surgical operations.

FAMILY HISTORY
Both of the patient’s parents are still living. Her mother and a sister were diagnosed to have DM
and are currently taking medications as well. Her father was diagnosed with hypertension.
Patient stated that 6 out of her 10 siblings as ‘obese’.

PERSONAL & SOCIAL HISTORY

Patient’s civil status is single but she is in a partnership with a female. Attended college but
didn’t finished her degree. Set up a bakery business where she worked from 2009-2017. Stated
that she worked for 10-12 hours of work every day.
Due to her busy schedule she didn’t have time to prepare her meals hence she usually eats at a
fast food for convenience. She is fond of eating meat and foods rich in preservatives. Claimed to
have to no history of taking drugs, smoking and STDs. She is not fond of doing exercise as well.
Prior to confinement patient is living in an up-and-down building with her partner. The source of
their water supply is manila water and waste disposal is by the city’s scheduled garbage truck.

OBSTETRICAL HISTORY
Had her menarche at 13 years of age. Described her menstrual as regular with a scanty flow for 4
days. Her last menstrual period was on 01/27/2020. Patient claimed to have no pregnancy, G0P0

REVIEW OF SYSTEMS

GENERAL (+) weakness, (-) fatigue, (-) weight change, (-) fever, (-) chills, (-) sweats
SKIN (-) rash, (-) pruritus, (-) pigmentation, (-) lumps, (-) sores, (-) dryness, (-)
change in hair & nails
HEENT
HEAD (-) headache, (-) dizziness, (-) light headedness
EYES (-) vision, (-) glasses or contact lenses, (-) pain, (-) redness, (-) itching, (-)
excessive tearing,
(-) double vision, (-) blurred vision, (-) spots, (-) specks, (-) flashing lights,
(-) glaucoma, (-) cataracts
EARS (-) hearing, (-) tinnitus, (-) vertigo, (-) earaches, (-) discharge
NOSE & SINUSES (-) colds, (-) discharge, (-) itching, (-) dryness, (-) nosebleeds, (-) sinus
trouble, (-) pain, (-) obstruction,
(-) sense of smell, (-) sneezing
THROAT (OR MOUTH (-) pain, (-) dry mouth, (-) hoarseness, (-) sore throat, (-) bleeding gums, (-
& PHARYNX) ) dentures (if any & how they fit),
(-) sore tongue, (-) difficulty of swallowing
NECK (-) lumps, (-) swollen glands, (-) pain, (-) stiffness
BREASTS (-) Lumps, (-) pain, (-) discomfort, (-) nipple discharge, (-) bleeding , (-)
self-examination practices
RESPIRATORY (-) cough, (-) hemoptysis, (-) dyspnea, (-) pain, (-) wheezing, (-) sputum
CARDIOVASCULAR (-) heart trouble, (-) heart murmurs, (-) chest pain or discomfort, (-)
palpitations, (-) dyspnea, (-) orthopnea,
(-) paroxysmal nocturnal dyspnea, (-) edema
GASTROINTESTINAL (-) trouble swallowing, (-) heartburn, (-) appetite, (-) nausea, (-) vomiting ,
(-) bowel movements
(-) color, (-) size of stools, (-) change in bowel habits, (-) rectal bleeding, (-
) melena, (-) hemorrhoids,
(-) constipation, (-) diarrhea, (-) abdominal pain, (-) food intolerance, (-)
excessive belching or passing of gas.
URINARY frequency of urination: (-) polyuria, (-) nocturia, (-) urgency, (-) dysuria, (-
) hematuria, (-) incontinence, (-) stones
GENITAL
MALE (-) Hernias, (-) discharge from or sores on the penis, (-) testicular pain or
masses, (-) swelling, (-) ulcer,
 (-) itching, (-) sexual habits and problems, (-) exposure to HIV infection
FEMALE (-) dysmenorrhea, (-|) premenstrual tension, (-) vaginal discharge, (-)
bleeding, (-) itching, (-) sores,
(-) lumps, (-) sexual habits and problems, (-) exposure to HIV infection
PERIPHERAL (-) Claudication, (-) varicose veins, (-) past clots on veins
VASCULAR
MUSCULO- (-) muscle or joint pains, (-) cramps, (-) stiffness, (-) sweating, (-)
SKELETAL tenderness, (-) limitation of motion,
(-) trauma, (+) weakness
NEUROLOGIC (-) syncope, (-) blackouts, (-) seizures, (-) paralysis, (+) numbness, (-)
tingling or “pins or needles”,
(-) tremors and other involuntary movements, (-) pain, (-) sensory, (-)
memory
HEMATOLOGIC (-) anemia, (-) easy bruising, (-) bleeding
ENDOCRINE (-) cold intolerance, (-) excessive sweating, (-) excessive thirst or hunger, (-
) change in glove or shoe size
PSYCHIATRIC (-) nervousness, (-) tension, (-) mood, (-) depression, (-) memory change, (-
) suicide attempts (if relevant)