HISTORY

TAKING

Submitted By: KHATRI, Kailash

Level: MD-2
Block: 1
Group: 10
Preceptor: Dr. Ethel Mae Solon Malilong
Date: Sept 25, 2017
 Sept 21st, 2017

1:15pm

D.D, a 23 year old male, single, Roman Catholic, Filipino is a medical student currently
residing in Cebu City. Reliability is 95%.

Chief Complaint: Difficulty in breathing (dyspnea) since yesterday.

History of Present Illness

The patient has been experiencing itchiness in his throat 7 days prior to consult which presents
most of the time. He denies of having any kind of allergies and of taking any kind of medications
for it. He usually drinks warm water to alleviate it. Nothing specific that would aggravate the
condition.

Patient also has 5 days history of hard productive cough with phlegm which he describes as
yellow-green color. Throat itchiness is the triggering factor. He has been taking herbal
medication (lagundi capsules) for it.

3 days prior to consult, started having low grade fever.

Since 3 days ago he has had headaches particularly on top of the head. For which he has been
taking Paracetamol every 8 hours to alleviate the pain. He ranks the pain 6/10 in pain scale.

From yesterday, the patient is experiencing dyspnea which is triggered by exercise or

extraneous work and last usually 10-15 minutes with palpitation.

Occasional vomiting after having a meal especially after eating carbohydrates. Feels nauseous
most of the time.

Past Medical History

Childhood Illness: The patient has had Urinary Tract Infection (UTI) in 2006 and Dengue in 2008
in his childhood. Other than this he denies of having other childhood illness. The patient has
had complete vaccination in his childhood.

Adult Illness: The patient was diagnosed with non-fatty liver disease 4 months ago while having
a regular screening test. For which he has been taking phospholipids (Essentiale) from last 3
months.

The patient was an occasional drinker and is a non-smoker. Quitted drinking soft drinks, coffee
and eating rice from last 3 months, is now mostly taking fruits for his diet.
He had Hepatitis vaccination last month . But never had flu vaccination.

He has been taking Paracetamol every 8 hours for his headache.

Family History: Grandfather on his mothers side died due to lung cancer and grandmother
died due to typhoid. On his fathers side, grandmother passed away in 2013 while on coma,
she had kidney disease and diabetes mellitus. His grandfather is in good health. Both his
parents were diagnosed of hypertension in 2015. His father is a smoker and the patient agrees
on being a secondary smoker.

Personal & Social History: Was an occasional drinker, had quitted since last 3 months. Is a non-
smoker and is not an illicit drug user. From last 3 months he changed his diet replacing
carbohydrates (Soft drinks and rice) with fruits.

He currently has one sex partner, male and denies of having history of multiple sex partner.

Review of Systems:
General Survey: Lost 3 kgs in a month, from 76 to 73 kgs.

Skin: No rashes or other changes.

HEENT: Headache which is mainly on the top of the head. No hearing impairment. Itchiness in
the throat from last 7 days.

Neck: Denies any stiffness or problems.

Breast/Chest: Denies of having any tenderness or abnormal masses.

Respiratory: Cough with production of yellow-green phlegm. Dyspnea which lasts usually 10-15
mins. Denies of any blood in sputum.

Cardiovascular: Palpitations with dyspnea.

Gastrointestinal: Vomiting which occasionally happens after eating. Feels nauseous most of the
time. Denies of any other problem.

Urinary: Denies of having any pain and other problems during urination, with usual color of
urine being yellow.

Genital: Denies of any problems.

Peripheral Vascular: Not assessed.

Musculoskeletal: Denies of any muscular pain or joint pain.

Psychiatric: Appeared normal.

Neurologic: Not assessed.

Hematologic: Not assessed.

Endocrine: Denies of any thyroid masses. No history of cold intolerance.