A.

BIODATA

Full name: Rivera, Aleia Cathrylle P.

Birthdate: April 12, 2002 Age: 19 years’ old

Address: Inabaan Norte, Rosario La Union

Contact number: 097765486780

Religion: Roman Catholic

Marital status: Single

Occupation: Student

Phil health number: None

Health care financing and usual source of medical care: Her Father and mother

B. CHIEF COMPLAINT

= coughing for about 2 weeks.

C. HISTORY OF PRESENT ILLNESS

o Do you cough all the time, or only during or after activity?

 cough got worst overtime especially at night.
o Do you cough after meals?
 Yes
o Do you have chest discomfort with your cough?

Yes, sometimes it is giving me a hard time to breathe
o Have you had a fever recently?
 No, I did not have any fever recently.
o When did it start/how long has it been going on?
 It started a week ago, and it’s been 2 weeks since I started coughing.
o Is this a new problem/ first time having this problem or illness ma’am?
 No, I’ve experienced this many times already.
o Intermittent or constant?
 Intermittent
o If intermittent, how long does it last, and how often do it occur?
 It lasts about 2-3 minutes; it occurs actively during night.
o What were you doing when this problem first started?

 I am just staying at our house then my relatives came home to visit.

o Do you have any other symptoms? Please describe them

 Sometime my chest hurts and my backs also. It is difficult for me to breathe.
o On the scale of 1-10. 10 being the worst and 1 being the least, how bad is your cough?
  8

D. PAST HEALTH HISTORY

o Do you have any allergies?

 Yes, I am allergic with shrimps, alamang, and crabs
o Have you ever been hospitalized? What was it? When was that?
 I’ve never been confine in a hospital. I just go there for checkups.
o Have you gone into surgeries?
 No, I haven’t
o Have you ever had an accident or injury?
 No, I haven’t
o What illnesses did you have as a child? Did you have the chicken pox? Measles?
 I experienced chicken pox and German measles.
o How old were you when you started your periods? Do you have any problems currently?
 I am 14 years’ old and there is no any problem about my menstruation.

E. FAMILY HISTORY

o Do you or did anyone in our family have any long-term health problems, like heart disease, diabetes, kidney disease,
bleeding disorder, or lung disease?

 Yes, my grandma she died in kidney disease.

o Do you or did anyone in our family have any health issues like high blood pressure, high cholesterol, or asthma?

 Yes, my grandma, mother, and my aunties they are experiencing high blood pressure and high cholesterols.

o Does anyone in our family have any other serious illnesses, such as cancer, stroke, Alzheimer's/dementia, genetic birth
disorder, or osteoporosis?

 No, we don’t have those illnesses.

o Are their illnesses under control? How are/were they treated ?

 Yes, they are taking their maintenance medicine.

F. ENVIRONMENTAL HISTORY

o Do you have any pets at home?

 Yes, we have dogs and cats.
o What are your hobbies?
 Watching, sometimes I read books, and I also bake
o Any recent trips?
 A month ago we traveled in Vigan, Ilocos Sur.

F. CURRENT HEALTH INFORMATION

o Do you smoke?
 No, I don’t smoke
 o Do you drink alcohols?
 Yes, occasionally only.
o Did you take any drugs or medicines for your illness?
 Yes, I am taking neozep and I also do this home remedy which is called suob.
o What do you do for physical activity or exercise?
 Sometimes I ride a bike and walk mt pets.
o Do you feel any allergies these days?
 No, I haven’t.

H. SOCIAL HISTORY

o Do you have any friends, how is your relationship with them?

 Yes, our relationship is nice.
o How is your relationship with your family?
 We had a strong and beautiful relationship?
o Do you feel safe in your relationships? Has anyone physically hurt you? Insulted you? Threatened you with bodily
harm?
 Yes, I do not have.

I. PSYCHOLOGIC HISTORY

o Have you had thoughts of hurting yourself?

 No

o Has there been a previous suicide attempt? When?

 I don’t have any.

o Do you have a plan to commit suicide?

 No and never.

o In the past year, have you been hit, kicked, or physically hurt by another person?

 No

o Are you in a relationship with someone who threatens or physically harms you?

 No

o Have you ever been abused? If yes, describe by whom, when, and how.

 I have not been abused.

J. REVIEW OF SYSTEMS

General

o What's your usual weight? Any recent weight changes?

 My usual weight is 52 and now my weight dropped into 49
o Any weakness, fatigue, or fever?
 Sometimes I feel a little dizzy.

Skin
 o Any rashes, lumps, or sores?
 I do not have any.
o Any itching, dryness, or changes in skin color?
 There no changes in my skin.
o HEENT

Head

o Any headache, dizziness, or lightheadedness?

 Dizziness occurs sometimes.
o Any recent head injury?
 Nothing

Eyes

o Any changes or problems in your vision?

 There is no change.
o Do you use glasses or contact lenses? When was your last eye exam?
 Yes, I wear glasses. My last eye checkup is last October.
o Any pain, redness, or excessive tearing?
 No, I do not have any.

Ears

o Any problems or changes in your hearing?

 There are no changes
o Any earaches, infections, or discharge?
 I do not have any.

Nose

o Any frequent colds or sinus trouble?

 Colds
o Any nasal stuffiness, discharge, or itching?
 Yes, itching.
o Any nosebleeds?
 None

Throat (mouth, pharynx)

o How are your teeth and gums?

 Sometimes my gums hurt
o Any bleeding gums?
 Yes
o When was your last dental examination?
 Last December after Christmas
o Has your tongue been sore?
 Yes
o Have you had frequent sore throats or hoarseness?
 Yes, sore throats.

Neck

o Any swollen glands?

 No, I do not have
o Any lumps, pain, or stiffness in the neck?
 No, I do not have any
Respiratory

o Any coughing? Anything coming upon the cough (sputum: color, quantity). Any blood in your cough(hemoptysis)?
 Coughing with phlegm
o Any shortness of breath(dyspnea), or wheezing (also pleurisy)?
 Shortness of breath
o When was your last chest X-ray?
 Last August
o Optional: Any history of lung disease (asthma, bronchitis, emphysema, pneumonia, or tuberculosis?)
 Asthma

Cardiovascular

o Any heart troubles?

 Sometimes it is difficult for me to breath
o Ever been told you have high blood pressure or heart murmurs?
 No, not any
o Any chest pain or discomfort?
 Chest pain
o Any palpations, shortness of breath(dyspnea)?
 Sometimes I suffered from shortness of breath

Gastrointestinal

o Any trouble swallowing, heartburn, or nausea?

 Difficult in swallowing solid foods
o Any changes in your appetite?
 Yes, my tastes changes

Bowel movements

o Any changes in your bowel habits or pain when defecating?

 There are no changes but there is a little pain when I defecate.
o Any constipation or diarrhea?
 Maybe it is just a tummy ache

Urinary

o Any changes or problems with how often you must urinate? Are you urinating? More than normal(polyuria) or at night
(nocturia)
 There are no changes.
o Any blood in your urine(hematuria)?
 There is no blood in my urine.
o Any urinary infections?
 I don’t have any
o Any pain in your kidneys or flanks?
 No, there is no pain.

Peripheral Vascular

o Any muscle pain (intermittent claudication), or leg cramps?

 Sometimes I experienced leg cramps
o Any changes in the color of your fingertips or toes during cold weather?
 No, there are no changes

Musculoskeletal

o Any muscle or joint pain?

  None
o Any back pain?
 Yes
o Any pain in your neck or lower back?
 None

Psychiatric

o How's your mood been?

 My mood has been good.
o Have you had any problems with your memory?
 No, I have not.
o Have you been feeling depressed / suicide attempts (if relevant)?
 No, but sometimes I feel stressed

Neurologic

o Any changes in mood, attention, or speech?

 No, there are no changes
o Any fainting, blackouts, or seizures?
 No, I haven’t

Hematologic

o Any history of anemia?

 Yes
o Do you bruise or bleed easily?
 I bruise easily