FAMILY HISTORY

Father, deceased at 66, bronchial asthma

Mother, deceased at 65, unknown cause
Six siblings (patient is the eldest):
o Third sibling has asthma
o Youngest sibling deceased at 25, leukemia
o Other siblings apparently well
Four children (3 females, 1 male): all apparently well

PERSONAL AND SOCIAL HISTORY

Patient is happily married to his husband, owner and tailor of their tailoring shop
situated beside their house for 40 years. They also have a good relationship with
their children and as well as their grandchildren.
She is a graduate of two-year vocational course of Secretariat at De Guzman
Institute, Recto, Manila. She worked at a bookstore for less than a year. She usually
sleeps at 9pm until 5am. She is fond of drinking 1 cup of coca cola every meal and
every merienda thus drinks 5 cups/day and also drinks 4 cups of coffee daily. She
stopped drinking both coca cola and coffee last year upon diagnosis of Diabetes
Mellitus. She does not smoke nor drink alcohol. She eats vegetables and fish daily
and she isnt fond of taking salty foods. Patient does household chores daily as a
form of exercise.
She lives in a bungalow-type home with 2 bedrooms. It is well ventilated with 4
windows and well-lit. The drinking water source is mineral water and the
households garbage is being disposed 2x a day.
OBSTERTICAL AND MENSTRUAL HISTORY

Menarche at 13 years old

Menstrual cycle is irregular with interval of approximately 2 months, duration
of 2 days and uses 3 pads a day; usually accompanied by dysmenorrhea,
dizziness and sometimes loss of consciousness
Patient is multiparous G4P4 (4-0-0-4), all delivered spontaneously at a
hospital in Caloocan
Tubal ligation at 25 years old in Dr. Jose Fabella Memorial Hospital, Manila
Menopause at 50 years old with irritability as the most appreciated symptom

REVIEW OF SYSTEMS
Constitutional symptoms: (-) weight loss , (-) weakness, (-) loss of appetite, (-) fever

Head: (-) headache, (-) dizziness, (-) vertigo Eyes: (-) blurring of vision in both eyes,
(+) use of eyeglasses for 6 years (R: 175, L:200)

Ears: (-) earache, (-) deafness, (-) ear discharge, (-) tinnitus

Nose and sinuses: (-) change in smell, (-) nose bleeding, (-) nasal obstruction, (-)
nasal discharge

Mouth and Throat: (-) toothache, (-) gum bleeding, (-) sore throat, (-) hoarseness,
(+) use of upper teeth dentures

Neck: (-) pain, (-) limitation of movement, (-) mass

Breast: (-) lumps, (-) pain, (-) nipple discharge

Respiratory: (-) pleuritic chest pain, (-) hemoptysis

Cardiovascular: (-) substernal pain, (-) palpitations, (-) orthopnea, (-) syncope, (-)
easy fatigability

Gastrointestinal: (-) abdominal pain, (-) nausea, (-) vomiting, (-) dysphagia, (-)
diarrhea, (-) constipation,

(-) hematemesis, (-) melena, (-) hematochezia

Genitourinary: (-) dysuria, (-) urinary frequency, (-) hematuria, (-) incontinence, (-)
urethral discharge Extremities: (-) edema on back of right hand, (-) stiffness and (-)
limitation of movement of right upper and lower extremities, (-) swelling of joints

Nervous: (-) vertigo, (-) loss of consciousness, (-) paralysis, (-) speech disorder, (-)
loss of memory,

(-) confusion

Hematologic: (-) bleeding tendency, (-) easy bruising

Endocrine: (-) polyuria, (-) polydipsia, (-) heat and cold intolerance