Date and Time of Interview: August 20, 2010

2:00pm
Source of Information: Patient
Reliailit!: "0#
Referral: none
Identif!ing Data:
RS, is a 21 !ear old $ilipino male, single, Roman %at&olic and is residing at 'rg!( Pagsologon, Sta(
Rita Samar( )e is a displa!er in a grocer! store in t&eir place was admitted for t&e first time at *+R,% on
August 1-, 2010(
%&ief %omplaint: $ever
)PI:
10 da!s PTA, patient e.perienced productive coug&, amounting to &alf teaspoon of !ellowis& sputum
per e.pectorate( t&is usuall! e.acerates at nig&t, and was relieved ! rest(( &e too/ 'ioflu 000 mg 1 ta to e
ta/en 1. a da! w&ic& provided immediate relief( patient &as no &emopt!sis, no d!spnea, and aferile( no
consult was done
0 da!s PTA, patient still &ad productive coug&, wit& w&itis& sputum amounting to 1 teaspoon,
associated wit& an intermittent fever all t&roug&out t&e da! and is determined t&roug& touc&, &e also &ad
lig&t&eadedness w&ic& e.acerates w&en moving and is relieved ! rest( patient &ad no c&ills, no nausea, no
vomiting, no vertigo, no lurring of vision((&e too/ 1 talet of paracetamol 000 mg w&ic& provided &im
temporar! relief( still, no consult was done(
2 da!s PTA, still, wit& t&e aove s!mptoms mentioned, patient consulted t&e 2PD of *+R,% and &e
was advised to dail! monitor &is platelet count( no adominal pain noted, no epista.is, no emerging ras&es
seen(
&ours PTA, aferile, wit& dr! coug&, patient &ad &is platelet count ta/en and s&owed t&e result of 103
cuic per mm, and &e was advised for admission, &ence admission(
Past medical &istor!:
c&ild&ood illness4 immuni5ations 6patient cannot recall or &as no information aout &is immuni5ation7
no measles, no c&ic/en po., no polio, no primar! comple., no ast&ma, &as &ad common coug& and
colds
,edical4 patient &as een admitted on 2001 due to dengue at *+R,%( &e cannot recall e.act date of
admission nor t&e numer of da!s &ospitali5ed(
Surgical4 &as not undergone an! surgical procedures
Ps!c&iatric4 no &istor! of ps!c&ological prolems
$amil! &istor!:
Patient is t&e eldest among 10 c&ildren composed of 0 males and 0 females( t&e 3
t&
siling, a male,
died at t&e age of 3 !ears old due to 8da&ug9( all ot&er silings are alive and apparentl! well(
fat&er is :: !ears old and a farmer( &e &ad &istor! of renal prolemut is now recovered( t&e mot&er is
:0 !ears old, &ousewife, apparentl! well(
&e &as a famil! &istor! of &!pertension at &is paternal grand mo&er( no famil! &istor! of ast&ma, T',
D,, cancer, &epatic or cardiovascular disorders(
Ps!c&ological:
patient was orn and raised in Sta( Rita, samar( &is &ig&est educational attainment is 1
st
!ear &ig&
sc&ool( &e currentl! wor/s at a local grocer! store as a 8displa! o!9(
&e lives in a semi4 concrete &ouse wit& - ot&er people( &e descries t&is as ade;uatel! spaced for all of
t&em( t&e! &ave electricit! and t&e! get t&eir water from a well(
&is usual diet consists of rice aout 2 < cups per meal and viand mostl! of fis& and vegetales( &e &as
no preference for certain t!pe of food nor does &e &ave an! dietar! restrictions( &e does weig&t lifting aout 24
1 times a wee/ at &ome(
&e wa/es up around 0:10 am and goes to Tacloan for wor/ t&en goes ac/ &ome at = pm and usuall!
sleeps at 10 pm(
&e used to drin/ tua aout 1 gallon per drin/ing session once a awee/ wit& four ot&er friends, ut &as
stopped drin/ing a !ear ago( &e also smo/es 1 stic/s of cigarette per da! ut &as stopped a !ear ago(
&e is not involved in an! socio4 civic or religious groups
REVIEW OF SYSTEMS
General Survey: no weig&t loss, no wea/ness, no fatigue, aferile
Skin: wit& ras&es, no lumps, no sores, no itc&ing, no dr!ness, no color c&ange, no c&anges in &air or
nails
Head: no &eadac&e, no di55iness, no lig&t&eadedness
Eyes: no pain, no redness, no e.cessive tearing, no lurr! of vision, no diplopia
Ears: no tinnitus, no vertigo, no earac&e, no &earing impairment, no ear disc&arges
Nose: no colds, no nasal congestion, no runn! nose, no nasal stuffiness, no itc&ing, no epista.is,
Throat: complete set of teet&, no dentures, no leeding gums, no sore tongue, no dr! mout&, no sore
t&roat, no &oarseness of voice
Neck: no lumps, no pain, no stiffness, no limitation of movement
Breast: no lumps, no pain or discomfort,
Respiratory: wit& coug&, sputum w&itis& in color aout &alf teaspoon, no d!spnea, no ort&opnea, no
s&ortness of reat&, no w&ee5ing, no &emopt!sis, no ast&ma, no ronc&itis, no emp&!sema, no
pneumonia, and no tuerculosis
Cardiovascular: no &earturns, no c&est pain, no palpitations, no &!pertension, no /nown &eart
disease
Gastrointestinal: no loss of appetite, no d!sp&agia, no nausea, defecate ever! da!, no constipation,
no diarr&ea, no rectal leeding, no &ematemesis, no melena, no passing of gas, no >aundice, no liver or
gallladder prolem, no &epatitis
Urinary: no fre;uenc! of urination, no pol!uria, no nocturia, urine output aout &alf cup per episode,
no incontinence, no urning or pain on urination, no &ematuria, no urinar! tract infection
Genital: no &ernias, no disc&arge or sores in penis, no testicular pain or masses, no &istor! of se.uall!
transmitted disease
Peripheral Vascular: no leg cramps, no art&ralgia, no swelling wit& redness or tenderness
usculoskeletal: no art&ralgia, no m!algia, no stiffness, no art&ritis, no gout, no ac/ac&e, no
limitation of motion
Psychiatric: no memor! lapses, no tension, no nervousness
Neurolo!ic: no mood swing, no &eadac&e, no di55iness, no vertigo, no fainting, no lac/outs, no
tingling sensation, no tremors or ot&er involuntar! movements
He"atolo!ic: no eas! ruising, no leeding gums, no epista.is, no &emopt!sis, no &ematemesis, no
melena, no anemia, no past transfusion
Endocrine: no t&!roid troule, no pol!dipsia, no pol!p&agia, no pol!uria, no cold intolerance, no &eat
intolerance, no e.cessive t&irst, no diaetes
PHYSICAL EXAMINATION
General Survey
RS, a male patient,conscious,coherent, well-developed, afebrile, ambulatory with normal gait.
Wearing a clean light clothing and has no body odor. He has a relaxed and erect posture with well
coordinated movements. He is oriented to time, place, and person. Patients affect is appropriate to
situation with a cooperative attitude. He was responsive to !uestions and answered appropriately in a
clear, moderate pace and understandable speech. "here is no signs of distress noted. Height is #$%&.
Has an axillary temperature of '(.')*, blood pressure of ++,-.,mmHg on the left arm in sitting
position, respiratory rate of / bpm and pulse rate of (.bpm.
Skin
S0in has pallor and cold to touch. "here is mild s0in dryness and roughness. Rashes are
present in the hands and feet. "here is good s0in turgor and has no presence of edema. "here is no
1aundice and ecchymoses. 2ails are thic0 and has pallor but with a normal capillary refill of ' seconds
on blanch test. "here is no spooning or clubbing of fingers.
Head, Eyes, Ears, Nose, Throa !HEENT"
Head 3 blac0 hair and evenly distributed with average texture, no lice. Scalp without lesions and
nodules, no dandruff. 4acial s0in is uniform in color. 4acial movements are symmetric.
5yes 3 eyebrows are symmetrically aligned and e!ual in movement. 6ids close symmetrically and
there is bilateral blin0ing. *on1unctivae are moist and smooth but pale in color. Whitish sclera. *ornea
are transparent, shiny and smooth. Pupils are dar0 brown in color, e!ual in si7e, with a round and
smooth border. 8ris are flat and rounded. 9oth eyes coordinated, move in unison, with parallel
alignment. 5xtra occular muscle movement intact.
5ars 3 able to hear low and highn pitch sounds. Si7e are symmetrical and auricle are aligned with
the outer canthus of the eyes. 2o discharges, no lesion, no impacted cerumen.
2ose 3 are symmetrical and straight with the septum intact and at the midline. "here is no
discharges, no flaring, no tenderness, and no lesions. 2asal mucosa is pail and nasal sinuses are
non-tender.
"hroat 3 pale lips and oral mucosa. *omplete set of yellowish teeth with a pale moist gums. "ongue
in central position, moves freely, pin0 in color with thin whitish area at the center. Hard and soft palate
are light pin0 in color with uvula in the midline of the soft palate.
Ne#k
Head movement is coordinated, smooth, with no discomfort. "rachea located in the midline.
2ec0 is supple: thyroid isthmus palpable, lobes not felt.
Ly$%h nodes
6ymph nodes not enlarged. Small, soft, non-tender, and mobile tonsillar and posterior cervical
nodes bilaterally.
Thora& and lun's
*hest are symmetric. Spine is vertically aligned. Respiration is !uiet, and effortless without the
use of accessory muscles. *hest wall is intact with no tenderness and no masses. 4ull and symmetric
chest expansion. 9ilateral symmetry of vocal fremitus with a decreased fremitus noted at the right
basal lung area. 9reath sounds are vesicular with the presence of crac0les, but absence of rhonchi
and whee7es.