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Cagayan State University- Carig Campus

College of Medicine and Surgery

Medicine Ward 1
History Taking
Group 3 members:
AFALLA, JOYCE ANNE
ALFONSO, HANNAH FEBE RUTH
CONAG, RICH MARK
MARCUS, IDA PRISCILLA
MALLILLIN, CHRISTINE JOY
PARONG, MA. STEPHANIE

Date of Assessment: January 5, 2017(1:20pm)


Date and time of Admission: January 2, 2017 (2:00 pm)
Ward: AC
Name: Mr. CB
Age: 40
Sex: Male
Marital Status: Separated
Occupation: None (Former Fish Retailer)
Religion: Roman Catholic
Present Address: Baggao, Cagayan
Source of information: Patient
Reliability: The patient exhibits 90% reliability. The patient was conscious and was able to answer all
questions clearly.

Chief complaint: Difficulty of Breathing with Generalized Body Edema

PRESENT ILLNESS:

Last June 18, 2016, the patient noticed his leg started to feel heavy and he said that he often
experience ankle swelling in the afternoon. Then after five days, he noticed that his abdomen enlarged and there
were also swelling in both his lower extremities. According to him, he often suffered from shortness of breath
when working or upon exertion. Then on June 24, 2016, the patient experienced difficulty of breathing, with
generalized body edema and this prompted his brother to bring him to CVMC. He was confined for four days and
was given take home medications of Spinorolactone 25mg tablet BID, Carvedilol 25mg tabled BID, Captopril
25mg tablet TID, Lanoxin 0.25mg once a day and Atorvastatin 20mg tablet once a day. He could not remember
the name of the doctor during interview.
August 2016, the patient noticed that his sclera started to have yellowish discoloration but did not give
any medical attention, instead continued the prescribed maintenance drugs given to him. He also noticed that he
would often experience easy fatigability when working which entailed him to stop from working (fish retailing). He
said bed rest would resolve the aforementioned signs and symptoms.

November 2016, two months prior to admission, the patient has edema. He described it as having
edema on face, around eyes and on abdomen upon waking up then it will shift into his both lower extremities in
the afternoon. According to him, even when sitting for thirty minutes, the fluid will move to his lower back. He also
had productive cough with thick and whitish sputum discharge. Still with these symptoms, he did not seek for any
medical attention and continued his medications and recuperated by rest. Further, he said he was not complying
in taking his medications because of financial problem. At the time he stopped working he was supported by his
brother and aunt, thus making his finances and medications scarce and unmaintained.

December 31, two days prior to admission, the patient suffered from generalized body edema. The night
prior, when sleeping, he experienced difficulty of breathing which required him to sleep with two pillows.
Thereafter, his activities of daily living were also compromised and needed assistance ingoing to the bathroom,
walking, taking a bath which required his brother to assist him.

On January 2, one hour prior to admission, generalized edema was still present and the patient
experienced difficulty of breathing in which he can no longer tolerate. He rated it 9/10 as being difficult to tolerate.
This prompted his aunt and brother to bring him to CVMC, hence admitted.

PAST MEDICAL HISTORY

CHILDHOOD ILLNESS:

According to Mr. CB he suffered from chickenpox when he was Grade 5. He also suffered from common
occasional diseases such as colds, fever and cough which were managed by over the counter drugs such as
paracetamol, neozep, and solmux.

ADULT ILLNESS:

Last 2010, the patient was diagnosed of hypertension at CVMC and was given a maintenance drug of
Metoprolol. He was not admitted at that time hence sent home with therapeutic orders to lower blood pressure
like taking drugs, exercise and diet. According to him he was not 100% compliant with following the treatment
regimen mostly because of financial constraints. Last 2011, he was diagnosed of mild stroke and was admitted at
CVMC for four days.

FAMILY HISTORY:

His father died due to the complication of Hepatitis B Virus at the age of 50. His mother died due to
heart-related disease at the age of 55. His eldest brother died at the age of 26 due to hypertension. Other than
these, there was no history of kidney disease, cancer, anemia, or mental illness.

PERSONAL AND SOCIAL HISTORY:

Mr. CB was born and raised at Baggao, Cagayan, separated with his wife seven years ago, and has 2
children. He used to work as a fish retailer for ten years but due to his condition he stopped last 2015. He was a
chronic smoker for 25 years (started since he was 14 years old) with 1 pack of cigarette per day but he stopped it
last year. He is not an alcohol drinker. According to him, he is fond of eating salty foods like fish, garden
vegetables and chichirya, but since when he was hospitalized, he limited taking these. He does not have any
food allergies.

REVIEW OF SYSTEMS

HEENT:
Eyes: (-) poor vision
Ears: Optimum hearing function
Nose: No nasal stuffiness
RESPIRATORY:
(+) nonproductive cough
(+) orthopnea
CARDIAC:
(-) chest pain, (- ) palpitations
PERIPHERAL VASCULAR:
(+) bilateral leg edema
GASTROINTESTINAL:
Regular bowel movement, once a day
GENITOURINARY:
No difficulty in urination
MUSCULOSKELETAL:
(+) back pain
NEUROMUSCULAR:
(+) history of muscle weakness
PSYCHIATRIC:
No history of depression
HEMATOLOGICAL:
(-) Anemia

PHYSICAL EXAMINATION
Vital Signs:

Temperature: 36.7C
Pulse rate: 112 bpm, regular
Respiratory Rate: 23 cpm, Regular
Blood Pressure: 130/70 mmHg
SKIN:
-no lesions
EYES:
- yellow sclera
NECK:
-Distended jugular vein
ABDOMEN:
-protuberant
- increased abdominal girth
-umbilicus protrudes
-presence of shifting dullness

THORAX AND LUNGS:


- with crakles on both lung fields.
CARDIOVASCULAR:
-soft systolic murmur
EXTREMITIES:
-Bilateral pitting edema of lower extremities grade 3+ (there is a 6mm deep pit and goes back after 10-
12 seconds)

IMPRESSION: Dilated Cardiomyopathy