I.

GENERAL DATA

Source of information/ Relationship to the patient: Daughter

Reliability: 90%
II. Chief Complaint
Dizziness

III. History of Present Illness

IV. Past Medical History

Patient was diagnosed and known to have hypertension and diabetes mellitus.
No previous hospitalizations and surgeries.
No allergies to food and medications

V. Family History
Both parents are still alive. Only the patient’s father has history of hypertension. No other hederofamilial
diseases such as DM, CVD, DM.

VI. Social History/Environmental

The patient is a known tobacco smoker. She consumes 1 “dubla” per day and has recently stopped before
being admitted.

The patient lives with her grandchildren most of the time but her daughters go visit her from time to time. She
sleeps at least 7-8 hours at night and also sleeps during the day. However, she still visits their pigs from time to time
as her hobby.

Food: vegetables and fruits

Drinking water: mineral water

Other findings:
(-) clubbing
<2 sec: capillary refill
FOOT: (+) Venous stasis