Medical History

I'd like to share one of the written medical histories that I've made. Just see how OC my preceptor could get. Hehe!


ABC, a 25-year old male, single, Filipino, Roman Catholic, pork meat vendor from Quezon City, was admitted for the first time in St. Luke’s Medical Center due to diarrhea. The informant was the patient himself and was given the reliability score of 60% due to his inability to recall some specific names, situations and dates.

Three days prior to admission, the patient experienced diarrhea which was described as profuse, acute, sporadic with a frequency of three to four times daily, and with no precipitating factors. The patient tried to alleviate his complaint by taking Loperamide HCl (Diatabs (Reformulated)) 2 mg two capsules every after episode of defecation. However he was not relieved. His stool was described as watery, yellowish, foul-smelling, and was estimated to be a cupful every excretion. The patient also complained of abdominal pain which involved the whole gastric region with no radiation. He also described the pain as vague, of moderate severity (5/10), sudden, usually lasting for one to three minutes and occasional. There were no precipitating factors but was sometimes alleviated upon fecal excretion. The patient denied any history of travel to endemic areas of diarrhea and intake of non-prescribed medications aside from the drug that was mentioned earlier. He also denied pain in defecation. He also denied significant weight change, muscle mass and subcutaneous fat loss, fever, sweats, anorexia, weakness, fatigue, insomnia, dysphagia, odynophagia, belching, heartburn, nausea, vomiting, retching, regurgitation, early satiety, hematemesis, hematochezia, melena, abdominal distention, flatulence, incontinence and constipation. Due to the persistence of symptoms, the patient sought consult at St. Luke’s Medical Center and was subsequently admitted.

The patient denied itchiness, moisture, turgor, change in texture and temperature, rashes and lesions, vasomotor changes, pigmentation and photosensitivity of the skin. He also denied changes in hair color and texture, brittleness, abnormal loss and distribution of hair. The patient also denied color changes, brittleness, ridging, pitting and abnormal curvatures of her fingernails. He denied visual dysfunctions, vertigo, redness, itchiness, pain of the eye, abnormal discharges and lacrimation, and scotomata. There were no claims of deafness, ear pain, tinnitus, and abnormal ear discharges. There were no claims of epistaxis, abnormal nasal discharges, nasal obstruction, itching, nasal stiffness and postnasal drip. There were also no claims of bleeding gums, sores, fissures, tongue abnormalities, and dental caries. She denied soreness, swollen tonsils, and hoarseness. He denied stiffness, limitation of motion, sensation of lump and masses of the neck. He also denied dyspnea, shortness of breath, cough, sputum production, hemoptysis, wheezing, and chest wall abnormalities. There were no claims of chest pain, chest discomfort, palpitations, shortness of breath, orthopnea, trepopnea, paroxysmal nocturnal dyspnea, dyspnea at rest and syncope. He denied phlebitis, varicosities, claudication, and edema. He also denied urethral discharge, testicular mass and pain, impotence, dysuria, incontinence, hematuria, genital lesions, hernia, perineal pain, pollakuria, flank pain, stones and dribbling of urine. He also denied joint stiffness, pain and swelling, muscle pain, cramps weakness, wasting and trauma, abnormal posture, deformities and tremors. He denied heat-cold intolerance, thyroid problems, diaphoresis, polyuria, polydypsia, and nocturia. He denied easy bruisability. He also denied seizure, dizziness, involuntary movements, mental changes, motor dysfunction, altered consciousness and paresthesia. He did not show signs of anxiety, depression, illusion, delusion, hallucination, interpersonal relationship difficulty and paranoia.

The patient denied having received the following immunizations: BCG, Hepatitis B, DPT, Pertussis Acellular, Poliomyelitis, H. Influenza b, Measles, MMR, Varicella, Hepatitis A, Typhoid fever, Pneumococcal and Meningococcal. He denied any childhood illnesses like Bronchial Asthma, Congenital Heart Disease, Convulsions, Diptheria, Dysentery, Hepatitis, Influenzae, Meningitis, Measles, Mumps, Nephritis, Otitis Media, Pertussis, Pneumonia, Primary Complex, Poliomyelitis, Rheumatic fever, Rubella, Rubeola, Tonsillitis, and Typhoid fever.

The patient claimed to have been diagnosed with Hepatitis in year 2000 through a specific blood test at Labor Hospital in Quezon City. He was admitted for confinement in the same hospital for seven days. He recalled being fed and administered with intravenous fluid. He, however, did not recall the medications given to him. The patient denied other illnesses such as Arthritides, Bronchial Asthma, Cancer, Cerebrovascular accidents, Cirrhosis, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, Endocrine disorders, Endometriosis, heart diseases, Hematopoeitic disorders, Hypertension, Gastrointestinal disorders, Kidney disorders, Malaria, Neurologic disorders, Pneumonia, Psychiatric illnesses, Rheumatic Fever, Rheumatic Heart Disease, Skin disorders, sexually transmitted diseases, Thyroid abnormalities, Tuberculosis, Typhoid Fever and Urinary Tract Infection.

The patient denied having previous surgical operations, and any type of accidents or injuries. He also denied usage of any herbal supplements, drugs, and solution. He denied having adverse drug reactions towards the drugs he took for his illnesses.

He claimed to have allergies with shrimps and eggs. Nevertheless, he denied having made blood transfusion, and intake of drugs which leads to substance abuse. He denied any forms of radiation or radiotherapies.

He claimed that his sexual life was very active. He is presently living with his common-law partner for six months already although he claimed to start having multiple partners since 2001. He denied problems in sexual preference, number of sexual partner, sexual interest, sexual function, and sexual satisfaction.

The patient lives in a small room in a very congested community with his common-law partner. They get water from a community deep well, and tap their electricity from their neighbor’s electric line.

The patient went to school but finished only until grade 6. From the province, he went to Manila to make a living in 1996. He had multiple odd jobs since and eventually found a more stable job, which is his present occupation, as a pork meat vendor in the market. He worked in the market from Monday to Friday since 2002. His live-in partner on the other hand buys their food for lunch and dinner in a carenderia in the neighborhood. His typical day involves him waking up early in the morning at 3 am, and by 4 am he goes to the market. He works all day and goes home by 4 pm. Upon getting home, he then proceeds to a beer drinking session with his friends, consuming around eight to ten bottles per session. He goes home for his meals including lunch and dinner.

The patient denied problems with any of her friends and members of the family.

The patient claimed to have been a smoker of five to ten sticks per day since 1998. He also claimed to have been a daily beer drinker since 2002 and consumes eight to bottles per drinking session. He denied other forms of substance abuse. He also denied having been on a special diet and any form of exercise.

He claimed that his mother was diagnosed with a heart disease. He also claimed that his auntie was diagnosed with Diabetes Mellitus and has had Cerebrovascular accident. He denied having family history of Allergy, Bronchial Asthma, Cancer, Congenital Heart Disease, Chronic Obstructive Pulmonary Disease, Gastrointestinal disorders, Hematopoeitic disease, Hypertension, Kidney disorders, Neurologic disorder, Psychiatric illnesses, Rheumatic fever and Rheumatic Heart Disease, Rheumatoid Arthritis, Skin disorders, Thyroid abnormalities and Tuberculosis.