Complete Health History

Name: Patient X
Home Address: Brgy. Linao, Ormoc City
Age/Gender: 45
Status: Married
Nationality: Filipino
Occupation: Call-center Agent
Religion: Roman Catholic

Chief Complaint:
“Shortness of breath accompanied by productive cough with hemoptysis”

History of Present Illness:

Patient X is a 45 y/o, Male, Single, a Filipino and was born in Ormoc District Hospital, Ormoc City,
residing in Brgy. Linao, Ormoc City Leyte. He works as a Call Center Agent for 15 years in one of the known call
center company in Cebu. He travelled frequently from Cebu to Leyte to visit his wife and three children. The
symptoms such as cough began five days prior to admission. He believes that his symptoms will alleviate by
faith and by just using herbal remedies such as lagundi leaves. He was rushed to a Hospital Emergency
Department (ED) when cough has presence of hemoptysis, shortness of breath became severe, has low grade
fever, night diaphoresis, 25 pound weight loss, nausea, body malaise and left upper quadrant abdominal pain.
Two months ago he was hospitalized and treated for Acute Asthmatic Bronchitis. Upon assessing the patient,
he verbalized that he also experiencing chest pain. Pain is sharp, about 7/10 in severity, and worsens with
movement and cough. Pressing on the chest does not create the pain. He has never had chest pain in the past.
Recalls also shortness of breathing is severe most especially when performing his daily tasks but continued to
do household chores. He has no history of clotting disorder or cardiac history. He has allergies in dust and
sometimes it triggers his asthma.
His chest x-ray had extensive right upper lobe infiltrates and multiple cavitary lesions. Tuberculosis
was suspected and a TST was placed and read 25mm induration. Sputum specimens were collected and were
positive with numerous AFB infection.

Medical Diagnosis:
Pulmonary Tuberculosis.

Surgical History:
No previous record.

Medical History and Previous Hospitalization:

Admitted due to Acute Asthmatic Bronchitis.
Currently admitted due to Pulmonary Tuberculosis.

Immunization:
Complete EPI including BCG.

Social History:
Mr. X is married, residing in Brgy. Ormoc, City, Leyte. He is currently in Cebu for work and rented a small
apartment in Brgy. Apas, Lahug, Cebu City. Has three children aged 17, 14, and 8 yrs old and still studying. He
is a light smoker and drink occasionally with co-workers after work. Patient denies any recreational drug use.
Family History:
No family history of lung disease.
Mother died at 76 due to breast cancer.
Father died at 82 of “old age”.
Sister has been diagnosed with DM type 2 and HPTN.
Other 3 siblings are alive & well and healthy.

Allergies:
Dust: swelling in the face.
No known food and drug allergies.

Medication:
Asthma Bronchitis:
 Brochodilators: Salbutamol - used to dilate the bronchioles and allow better airflow.
 Steroids: Beclomethasone - to reduced swelling in the airways.
 Antibiotics
Allergies due to dust exposure: antihistamines such Ceterizine - helps to reduced stuffy nose, runny nose and
itching

Physical Examination:
Vital Signs:
Temp: 37.9 degrees celsius (low-grade fever)
O2 Sat: 93% (decreased O2 Saturation)
Pulse: 98 bpm
RR: 35 bpm (tachypnea)
BP: 140/90 mmHg (slightly elevated BP)
Weight: from 65 kls down to 54 kls.