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Name: Pt. K.C
Gender: Male
Age: 25 y/o
Address: 166-B Mandave St. Valenzuela
City
Religion: Born Again Christian
Occupation: Call Center Agent
Date of Admission: July 19, 2010
Attending Physician: Dr. Wake

Y   
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Difficulty of breathing for 5 days
       !
5 days prior to admission, the patient
started experiencing difficulty of breathing
which subsides whenever he uses a
nebulizer but recurred after few hours but
afterwards worsened which made him
sought a physician who recommended
admission.

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Past medical history reveals that the
patient has ad recurrent upper respiratory
infection and had bronchitis 2 yrs. ago. The
pt. has had no hospitalizations or
emergency department visits. Current
medications include diphenhydramine for
his intermittent runny nose and an
occasional puff of albuterol¶s inhaler which
only borrowed from his cousin.
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 The couple rent in a single storey
apartment which is near to a factory. The
patient is a heavy drinker consuming 4
bottles of beer a day and 12 bottles of beer
when there is an occasion. He also admits
that he is a chain smoker consuming 1 ½
packs per day for almost 7 yrs or 10.5
packyear. The patient also admits that he
takes marijuana occasionally.
6. 6AMILY HISTORY:
6amily history reveals that the
patient¶s father had a history of seasonal
hay fever as a child. Both parents are
indoor and outdoor smokers. The mother
reports that her husband has had some
difficulties with episodic cough and
shortness of breaths, but has not seen a
physician.
 On the other hand the mother said
that she also had asthma during childhood
but eventually fades and has not recurred
since then but the mother has a current
medical condition of hypertension. He has
2 siblings which his mother claimed never
had a serious medical condition aside from
fever and cough & colds.
 ÷  

‰General Appearance:
Seen lying on bed with 565 cc D5
NM + Aminophylline 250 mg regulated @
10-15gtts/min, intact and infusing well.
The patient was observed to be weak. Upon
interview the patient was conscious and
coherent.
‰Initial Vital Signs:
Temp: 36.3° C
PR: 76 bpm
RR: 24 cpm
BP: 110/70
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 + No lesions, scar Scalp has no

and nits.No scars or lesions
masses and without nits.
tenderness

 $ No presence of Hair is fine and

alopecia, well well distributed
deistributed,
shiny

 + Symmetrical, Symmetrically

no lesions and when showing
wrinkles face expression
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*%$3 y distributed eyelids and
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bean shaped aligned, soft,
and no and non tender
tenderness, pinna. Levels
lesions or scar. at the outer
canthus of the
eye.
 $ + No discharge, Ear canal has
present of some cerumen
small amount and no pus
of cerumen. discharged.
"

 ) Pink in color , Lips are

moist and pinkish in
symmetrical color, moist,
symmetrical
and smooth.

 (.) ' Pink in color , Gums and

(. moist buccal mucosa
are pinkish in
color, smooth
and moist. ±
Tongue moves
freely.
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and no lesions and Extremities
and scars. symmetrical in
Midline spine size.Spine is in
the midline.
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5 Skin is smooth, Patient skin

warm and no color is fair,
presence of smooth texture,
lesions, scars. dry
and warm to
touch.
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