DATE AND TIME OF HISTORY: September 22, 2015 at 2.

30 pm
SOURCE OF INFORMANT: PATIENT AND HER BROTHER
RELIABILITY: 100%
IDENTIFYING DATA:
Maria Sabio, a 35 year old, Female, Married, Filipino, Roman catholic, a housewife, blesses with
six children. Presently residing at Diit Tacloban City, was admitted at EVRMC on October 21,
2015 at around 3pm.
Chief complaint: Dyspnea
HISTORY OF PRESENT ILLNESS
Three days prior to admission, the patient developed dry cough. There was no fever and
restlesness reported. No medical consultation and intevention was done.
Two days prior to admission, patient still experienced dry cough with dyspnea and upper backpain
in a pain scale of 2 out of 10. No fever and restlesness was reported. Still no medical consultation
and intervention done.
A day prior to admission, the patient still experienced cough with transluscent phlegm about one
teaspoon per expectoration. Still with dyspnea that is alleviated when she lay down with two
pillows. Still with back pain and and already with chest pain in a scale of 4 out of 10. The patient
reported that she could only take small amout of food per meal. Patient used oil liniments to ease
the pain but it was ineffective. No medical medical consultation and intervetion done.
12 hours prior to admission, patient was awaken by her persistent cough, dyspnea, chest and
backpain that she characterized it as tightening with a pain scale of 10 out of 10. Patient went to
EVRMC for consultation. She was then advised for admission. Hence, confinement.
PAST MEDICAL HISTORY
CHILDHOOD ILLNESS:
(+) measles
(+) mumps
(+) chickenpox
(+) asthma
Immunization :
-Fully immunized
ADULT ILLNESSES:
MEDICAL: In 2012, the patient had an Xray exam and was diagnosed with bacterial pneumonia

secondary to a persistent asthma attacks with productive cough. She was given Co Amoxiclav
625mg tablets BID and anti-expectorant that was no longer recalled regarding to dosage.
PSYCHIATRIC : NONE
SURGERIES: NONE
OBSTETRICS: G6P6, All normal in ____ ? vaginal deliveries in EVRMC. She had her menarche
at the age 14. She has normal monthly menstruation that lastes for 3-4 days. And reported that she
doesnt use any birth control methods.

FAMILY HISTORY
- Patient is the 4th among her 6 siblings.
-Patient is married with 6 children, all boys
- With history of asthma, hypertension, stroke, diabetes mellitus and arthritis
- No cancer, epilepsy and other mental illness
PERSONAL AND SOCIAL HISTORY
Patient is married and with her husband in Diit, Tacloban City. She has 6 children and they are all
boys. She finished 3rd year high school in Bagacay. She is a fulltime housewife. Their house is
semiconcrete with a sim covered roof with 2 bedrooms and 1 comfort room. They dispose their
garbage everday picked up by the garbage truck. Their source of water is NAWASA and she
consumes 8-10 glasses of water daily. She normally urinates 5-7 times daily approximately 250ml
per urination. Her usual breakfast usually consists coffee and bread. For her lunch and dinner, she
usually eats fish, meat, vegetabkes and rice. She usually moves her bowel twice a day.
She spends her leisure time by watching aldub on tv, reading precious hearts romance novel, and
doing some household chores. She usually sleeps at 10pm and wakes up at around 5 am, she does
some light exercises like walking and stretching. She attends mass on sundays. She is non smoker
and drinks alcohol. She started drinking alcohol beverages at the age of 17. She usually drinks 2-3
glasses of red horse once a week.
She has an active sexual life.