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Patient Profile and History

Patient Profile and History

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Published by rachael

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Published by: rachael on Jan 16, 2009
Copyright:Attribution Non-commercial

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05/26/2013

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PATIENT’S PROFILE
NAME: Mrs. VillegasAGE: 69y/oSEX: FemaleADDRESS: Fairlaine subdivision, Tarlac, CityBIRTHPLACE: TarlacNATIONALITY: FilipinoRELIGION: Roman CatholicCIVIL STATUS: MarriedBIRTHDAY: June 11,1939DATE AND TIME OF ADMISSION: July 14, 2008/9:01amFINAL DIAGNOSIS: Massive ascites 2º to portalhypertension 2 º to CLD
 
PATIENT’S HISTORY
Past History Medical history:
10 years ago, she developed Hypertension which was controlled bymedication and Diabetes Mellitus
Surgical history:
Hysterectomy 15 years ago, Cholecystectomy 17 years ago, Thyroidectomy 20 years, Apendectomy 25 years ago,
Medications:
plendil and avandia taken 10 years ago.
Allergies:
No known allergies
Injuries and accidents:
Ø
Special needs:
Ø
Blood transfusion:
450 cc of packed RBC; type AB; last July 14, 2008
Present history:
Last May year 2008 patient was admitted at JMC and was diagnosed of having liver cirrhosis.One week prior to admission she developed abdominal enlargement with accompanyingoccasional chest pain but she didn’t perceived the need to seek for medical help. Three daysprior the admission, her friend who was a registered nurse suggested her to be self examined bya physician. She was diagnosed of having massive ascites 2º to portal hypertension 2 º to chronicliver disease (CLD) and advised to be admitted at JMC.

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