Past Medical History

The patient already had measles when he was 3, mumps when he was 7 and varicella when he was 11.
The patient had one episode of tonsillitis and he had taken antibiotics for it. According to his mother, aside
from seasonal cough and colds, he rarely had any disease or illness. The patient does not have any history
of convulsion. He was circumcised when he was 10 years old. However, due to bleeding, the patient
needed to receive blood transfusion in which two blood bags were given to him.

Family History

Gonzales Family
Informant: Melanie Gonzales
Address: Victoria, Currimao, Ilocos Norte
Date: 25 September 2017

The paternal grandfather has asthma. The maternal grandfather and grandmother both have
hypertension. The patient’s mother has a history of goiter. All his other first-degree relatives are
apparently healthy. No family history of cancer, diabetes, heart disease and mental illness.

Social and Environmental History

The patient lives with her father, mother and younger sibling in a bungalow house with 2 rooms and 1
communal comfort room in Victoria, Currimao, Ilocos Norte. According to the patient’s mother, they
practice proper hygiene. They all take a bath regularly and brush their teeth at least 2 times daily. Their
water source for bathing and washing comes from the deep well while they use mineral water for cooking
and drinking.

The patient’s mother is a high school graduate and does not have any occupation while his father is a
college undergraduate and works as a fisherman. According to the patient’s mother, their income is
adequate for their family. The patient’s family is a Roman Catholic.
A typical day of the patient begins with going to school. His classes start at 7 AM and ends until 3 PM.
After doing his school assignments, during his free time, the patient either plays with his friends or watch
the television.

PHYSICAL EXAMINATION

Lymph Nodes

Lymph nodes in the cervical, occipital, supraclavicular, axillary and epitrochlear area not palpable.

Breast

Symmetrical and has no masses.

Peripheral Vascular

No rashes, swelling, color change, or cyanosis in arms or legs. No clubbing in fingernails.

Pulses: Radial (2+), Brachial (2+), Popliteal (right 2+, left 2+)

Cardiovascular

No cardiac heaves. Symmetrical expansion with respiration, no other wall motions. No thrills appreciated.
Point of maximal impulse at midclavicular line, in fifth intercostal space. Normal S1 and S2, with regular
rate and rhythm. No splitting of heart sounds heard. No murmur. No S3 and S4. No friction rub. Capillary
refill is less than 2 seconds. Good skin turgor.

Thorax and Lungs

Normal contour without any deformities such as kyphoscoliosis. No rashes or other visible lesions. Thorax
is symmetric with good expansion. Chest wall movements are symmetrical, with no marked use of
accessory muscles. No retractions. Chest has no scars. No chest wall tenderness. Chest wall expansion is
adequate and symmetrical. Normal (minimal) tactile fremitus equal over all lung fields. Lung sounds
resonant over all fields. Vesicular breath sounds in all lung fields; no rales, wheezes or rhonchi.

REVIEW OF SYSTEMS

Breast

(-) lumps (-) pain (-) nipple discharge

Respiratory

(-) cough (-) hemoptysis (-) dyspnea

Cardiovascular

(-) chest pain (-) palpitations (-) dypnea (-) orthopnea (-) PND (-) edema