History number: 2
Name of the patient: Rommel Francisco Preceptor: Dr. Ligon
Informant: Patient Date of Interview: July 25, 2011
Historian: Raymond Ceneta Date Submitted: August 1, 2011
Reliability: 100% Group number: 13
General Data:
Rommel Francisco married with 3 children, 52 years of age, a Filipino and Iglesia ni Cristo, pedicab driver. He is currently residing at Karuhatan Valenzuela City. He was born on January 12, 1957 in Manila near Fabella Hospital. He had his forth visit at Fatima Medical Center on July 25, 2011.
Chief Complaint:
Cough
History of Present Illness:
The complaint started last January 2011 when he used his bike to his work. He takes Tuseran Forte to relive the symptom. Four days prior to consultation, the patient experienced cough which persist when he is at work and relieved by taking Tuseran Forte 2x a day, it also persist when he sleep and this wake him up. Cough is accompanied by thick yellow sputum and patient is having half a tablespoon each cough. The patient characterized it as mild to moderate. It is associated with back pain. The symptoms persist for four days which leads the patient to seek medical attention.
Past Medical Illness:
The patient only had completed his vaccination in OPV; he doesn’t have immunization in BCG, DPT and Hepa B. He had mumps and measles. He does not have allergy on foods and drugs. He had his first surgical procedure in 1989 related to stab wound at right lower quadrant of abdomen, 2nd hospitalization was n November 2010 due to abdominal pain and 3rd hospitalization is related to his cough at Fatima Medical Center.
Family History:
Patient’s father died at 78 years old related to infection secondary to tooth extraction. Her mother died at 49 years of age because of Pulmonary Tuberculosis. No other heredofamilial and communicable disease noted such as Cancer, Diabetes Mellitus,