Patients Profile

A. Demographic
Name:
Address:
Age: 20 year old
Gender: Male
Civil Status: Single
Occupation:
Nationality:
Religion:
Admitting diagnosis:
Date of Admission:
Time of Admission:
B. Chief Complaint
Gynecomastia.
C. History of the Present Illness
The patient came in for a routine annual examination to establish adult
care and was evaluated because of gynecomastia.
D. History of the Past Illness
When patient was between 6 to 13 years old, patient had:
o Generalized nocturnal tonic-clonic seizures;
o Focal seizures involving the right leg, approximately twice a
o

year, for a total of 10-13 generalized seizure; and

Had taken carbamazepine until 14 years old after which the

seizure did not recur.

When patient was 7 years old, patient had:
o MRI of the head which revealed no abnormalities.
6 months PTA, patient had:
o Extracted his wisdome tooth;
o Constipation; and
o Chronic pilonidal cyst.
3 year history of:
o Bilateral chest enlargement with no nipple discharges;
o Occasional morning erections;
o Has never been sexually active, did not masturbate.
4 years before this evaluation, patient had:
o Increased thirst; (thirst was normal months before this
o
o

evaluation);
Fluid consumption;
Frequent urination, 4 to 5 times during the day and up to 3 times
each night; (months before evaluation frequency of urination
has decreased)

Patient had a several-year history of:

o Blurred vision which was correctedwith glasses; and
o Has occasional headaches after exertion
8 months PTA:
o Frequency of shaving decreased from weekly to every 2 weeks

E. Social History
Patient was a college student;
Lived with his parents;
Rarely drank alcohol; and
Had never smoked or used illicit drugs
F. Family History
His father had basal cell carcinoma;
maternal uncle had had colon cancer at 36 years of age;
his paternal grandfather died of colon cancer; and
his maternal grandfather had had renal cancer.
G. Allergies
No known allergies noted.
H. ASSESSMENT
Blood Pressure: 98/62 mm Hg, other vital signs were normal
Height= 179cm
Weight= 85kg
BMI= 26.5
1. Physical Assessment
1. General

The patient appeared young for his age

2. Chest

and had minimal facial hair.

Both breasts were enlarged, with no

3. Reproductive system

nipple retraction, masses, or discharge.

The testicles were small (approximately
2.5 cm in length; has small posterior
anal fissure and a small lump over the
coccyx with a central punctum and no
discharge.