You are on page 1of 2

IDENTIFYING DATA:

J.C. is a 38-year old, male, married, a Mormon and of Filipino descent. He is a


resident of Brgy. Tapi, Kabankalan City. He works as a utility in a bus company. He
was admitted at CLMMRH for the first time on March 11, 2016 at 6:00 PM.
Source of history: Patient; patients son
Reliability: 70%; 70%
CHIEF COMPLAINT: Headache secondary to vehicular accident
HISTORY OF PRESENT ILLNESS:
Patient was apparently well until 2 days prior to admission when patient fell
from his motorcycle on his way to work. The patient states that he was driving
without helmet on at a moderate speed but slipped on a pile of sand on a curved
road which caused his motorcycle to glide. He fell right face first and lost his
consciousness for a few minutes. He sustained multiple abrasions, hematomas and
right clavicular fracture. He was rescued by his older brother who wanted to bring
him to the hospital, to which he refused. He asked to be brought home where he
rested and self-medicated with Mefenamic acid 500 mg 1 tablet twice a day which
provided temporary relief for right shoulder pain and headache which he rated 9/10
and 5/10 respectively. While at home, he experienced loss of appetite and was
increasingly drowsy.
9 hours prior to admission, patients wife noticed that his skin was cold and
clammy and his lips were cyanotic. Patient also complained worsening of headache;
this prompted his wife to bring him to the district hospital. He was requested chest
and cranial radiograph and CT-scan. Upon seeing the findings of the tests, the
attending physician immediately referred the patient to the regional hospital, hence
this admission.
PAST MEDICAL HISTORY:
Childhood illnesses: 1981- Measles
Adult illnesses:
Medical: No known medical history
Surgical: No known surgical history
Psychiatric: No known psychiatric history
Health maintenance:
Immunizations: Unrecalled
Screening tests: None
Maintenance medications: None
Allergies: No known food and drug allergies
Other hospitalizations: 1981 Measles
FAMILY HISTORY:
(-) Diabetes mellitus
(-) Heart diseases
(-) Hypertension
(+) Stroke
(-) Kidney diseases

(-) Arthritis
(-) Bronchial asthma
(-) Cancer
Death of immediate family members:
- 2014 older brother - CVA

(-) Epilepsy
- 4 siblings died at infancy unrecalled
causes and dates
PERSONAL AND SOCIAL HISTORY:
J.C. is the 5th of 9 siblings. He is an elementary graduate. He worked as a
mechanic for 3 years. He married at the age of 19 and has 5 children. He is
currently living with his wife and 5 children in a two-bedroom house. He presently
works an 8-hour shift as a utility at a bus company, with one day off per week. He
rides his motorcycle on his way to work everyday. He usually skips breakfast as he
wakes up at 12 noon to prepare for work and goes home at around 11 in the
evening. His regular diet consists of rice, fish and vegetables. He occasionally eats
pork and chicken. He does not follow any exercise regimen. He considers watching
television and going around the neighborhood as his form of leisure. He attends
mass every Sunday with his family. He was a 0.75 pack year smoker but he stopped
when his wife was pregnant with their first child 18 years ago. He claims to be a
social drinker. He denies the use of any alternative health care product.