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Case Study(Dm)

Case Study(Dm)

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Published by joanna

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Published by: joanna on Aug 27, 2009
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05/11/2014

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I. Health history A. Demographic profile Name:
R.G 
Gender:
Male 
Age:
41 years old 
Birth date:
September 23, 1967 
Birth place:
Pasig , Metro Manila 
Marital status:
Married 
Nationality:
Filipino 
Religion:
Born Again- Christian 
Address:
Brgy. Pantihan 3, Maragondon, Cavite 
Educational background:
High school graduate 
Occupation:
Factory worker in Monterey 
Usual source of medical care:
Doctor/Healthcare Professional
 B. Source and reliability of information 
The patient R.G is the primary source of information. He is conscious andcoherent, able to speak Tagalog fluently. His wife is also considered as source of information regarding patient status and condition. 
C. Reasons for seeking care or chief complaint (Top 3) 
1
st
– insufficient sleep at night2
nd
– loss of his weight3
rd
– scaly of skin 1
 
 
D. History of present illness 
Patient R.G was handled during our duty at Brgy. Pantihan 3, Maragondon,,Cavitewith the chief complaint of insufficient sleep at night, loss of his weight and scaly of skin. The laboratory test and special treatment for the patient are not applicable because this case is base on community setting.
E. PAST MEDICAL HISTORY OR PAST HEALTH
Pediatric/childhood
-Incomplete immunization- (-) serious illness on this stage
Injuries or accidents
-1992, right leg accident due to mishandling of machine
Serious or chronic illness
-December 2003, Diabetes Mellitus diagnosed clinically-2x FBS result 300mg/dl-2006 Pulmonary Tuberculosis, diagnosed clinically-Chest X-ray and sputum AFB examination-2007 Urinary Tract Infections-Urinalysis (pyuria)
Hospitalization
-1992, Water Rose General HospitalAdmitting diagnosis: Right leg machine accident2
 
-December 2003, Rizal Medical Center, Pasig City, Metro ManilaAdmitting diagnosis: Diabetes Mellitus Type 2
Operation
-not applicable
Obstetric History
-not applicable
Immunizations
-incomplete immunization (unrecalled)
Allergies
-No known allergies to food and medication
Medication
-Metformin 500mg/tab1 tab TID p.c.-Gliclezide 80mg/tab1 tab OD a.c.-Vitamin B Complex tablet1 tab OD-Alaxan 500mg/tab (Paracetamol + Ibuprofen)1 tab PRN for fever and pain
Last Examination Date
-July 2007 (OPD case), Philippine General Hospital, Taft Avenue, Manila3

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