The patient is a 69-year-old Filipino woman who was admitted to the hospital on August 21, 2023 with a chief complaint of intentional chlorine ingestion. Her medical history is otherwise unremarkable, with no known allergies, childhood illnesses, or significant family history. A review of systems found that she presented with a rash but was otherwise negative. She lives with her family in a rural area and works as a homemaker.
The patient is a 69-year-old Filipino woman who was admitted to the hospital on August 21, 2023 with a chief complaint of intentional chlorine ingestion. Her medical history is otherwise unremarkable, with no known allergies, childhood illnesses, or significant family history. A review of systems found that she presented with a rash but was otherwise negative. She lives with her family in a rural area and works as a homemaker.
The patient is a 69-year-old Filipino woman who was admitted to the hospital on August 21, 2023 with a chief complaint of intentional chlorine ingestion. Her medical history is otherwise unremarkable, with no known allergies, childhood illnesses, or significant family history. A review of systems found that she presented with a rash but was otherwise negative. She lives with her family in a rural area and works as a homemaker.
The patient is a 69-year-old Filipino woman who was admitted to the hospital on August 21, 2023 with a chief complaint of intentional chlorine ingestion. Her medical history is otherwise unremarkable, with no known allergies, childhood illnesses, or significant family history. A review of systems found that she presented with a rash but was otherwise negative. She lives with her family in a rural area and works as a homemaker.
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I.
HISTORY TAKING
General Data/Information:
Name: F. B. C. Age: 69 years old
Gender: Female Nationality: Filipino Religion: Roman Catholic Birthday: March 31, 1954 Educational Attainment: Status: Widowed Occupation: None Home Address: Caticugan, Santa Rita, Western Samar Source/s: Patient and her daughter Reliability: 95% Date admitted: August 21, 2023; 10:23 AM Date of Interview: August 21, 2023; 8AM
Chief Complaint/s: Intentional Chlorine Ingestion
History of Present Illness:
4 days prior to admission, patient ingested Allergies: No known allergies to food and medications.
Past Medical History
Childhood Illnesses. The patient had chicken pox when he was 16 years old and could not recall other illnesses he experienced as a child. Adult Illnesses. Medical: On January 2019, he was diagnosed with Pneumonia at the City Health Unit but was not hospitalized and had completed antibiotic treatment. This was his first hospital admission. Surgical: He did not undergo any surgical procedures. Health Maintenance: Fully immunized as a child. Completed one Medical screening check-up and physical assessment last January 2017 without abnormal findings.
Family History His father and mother are alive and has no any diagnosed illness. No known family history of diabetes, tuberculosis, heart or kidney disease, cancer, anemia, epilepsy or mental illness.
Personal/Social History: The patient is pure Filipino and working as a merchandiser with a minimum wage of 305php/day at a supermarket and works 6 days a week from 1pm to 11pm. He is married and lives with his wife and 2 children in a barangay near the highway. Their drinking water is from a water refilling station while domestic water supply is from a “Balon” nearby their home. Water for cooking is from a communal pump. On regular days, he eats three times a day. His diet is mostly sea foods and vegetables with rice. He also reported that he does not smoke, drinks alcoholic beverages occasionally and he is fond of drinking carbonated beverages.
