PS: Jackie, here only in bulleted form.

LOC:

awake and alert

conscious and coherent
calm
clear
ambulatory
good posture
well groomed and appropriate to the event
Not in cardio-pulmonary distress.

VITAL SIGNS:

Temp- 36.3C
PR: 73bpm
RR-16
BP-110/70
Ht-161cm
Wt. 48kg

Remarks: All vitals are within normal limits

Lito Jacobe
Nov. 28,1957
26 tampoy Marulas, Valenzuela City
Married (2)
Filipino
Date data gathered: July 08,2015
Time gathered : 8:00 am

CC: Shortening of breath / Hinihingal

HPI:
Past Med Hx:

Completed childhood immunizations

Childhood illness: asthma
(-) adult immunizations
Adult illness: Tuberculosis, Asthma
Previous hospitalizations: Karuhatan Hospital- March 2014

Medications: Salbutamol tab 4mg, Vitamin C, 500mg, TB drugs (not sure

of the drug)

FAM Hx:

Mother-deceased- fell picking flowers from ilang-ilang tree, died 36 yrs old
Father-deceased- (+) Asthma; (+) Dementia died 76 yrs old

12 offspring
1st- no medical issues
2nd-had an epilepsy, fishermandrowned , (+) DM
3rd had a fight, and had his head blunted (+) TB
4th (+) DM
5th- excursion, drowned?
6th- Lito Jacobe- (+)TB, (+)Asthma
7th- (+)DM
8th- no medical issue
9th- (+) DM
10th- no medical issue
11th- (+) DM, (+)TB, (+) ASTHMA
12th no medical issue

1st family- 4 offspring , no medical issues

2nd family- 2 offspring, no medical issues

PERSONAL AND SOCIAL Hx:

Educational attainment: Highschool graduate

Occupation: Working in machine shop--- turnero
(-) smoker

(-) alcohol drinker

Food preferences: Vegetables
Housing conditions:
-Household size: 8
-Source of ventilation: one Window
-Regular garbage disposal at 10 pm
ROS:

Integumentary:

Brownish complexion
Dry skin and with no skin lesions manifested
Good skin turgor and elasticity
Nail beds- Pale-colored (+) clubbing
Capillary refill for 2 seconds