PATIENTS PROFILE Name Age Date of Birth Gender Civil Status Occupation Address Nationality Religion : : : : : : : : : Mrs.

AD 62 years old December 7, 1946 Female Married None Brgy. Sambal Ilaya, Lemery, Batangas Filipino Roman Catholic November 16, 2009 7:00 am Bipedal Edema & Severe pain at lower extremities Dr. Datingaling & Dr. Landicho Diabetic Nephropathy November 20, 2009 2:00 pm Diabetic Nephropathy

Date of Admission : Time of Admission: Chief Complaint :

Attending Physician: Admitting Diagnosis: Date of Discharge : Time of Discharge : Final Diagnosis :

CLINICAL APPRAISAL A. PAST HEALTH HISTORY Mrs. AD barely remembered if she completed her immunization. During her childhood days, she only experienced episodes of fever, cough, common colds and diarrhea. She treated it by consulting to herbicharos or through herbal medicine such as Lagundi. She has no allergies to foods and drugs or experienced animal bites. Last 2004, Mrs. ADs daughter accompanied her in consulting in a small clinic near Brgy. Sambal Ilaya, that offered free check up. From there, she has found out that she has Diabetes Mellitus Type II through capillary blood glucose and also from urine sugar test. But still, Mrs. AD fails to comply on the diet advised to her. She also fails to comply on the prescribed medication because of their insufficient funds. According to her relatives, this is the second time that she was hospitalized. She was hospitalized for the first time and confined for two days at Batangas Provincial Hospital last August 2007 due to an increase in her blood pressure with the chief complaint of severe headache. According to Mrs. ADs daughter, her blood pressure has almost got 180/100. She has been taking over the counter drugs such as Flanax and Mefenamic acid for back pain which was according to her; the back pain was due to being overworked from doing the household chores. From her first hospitalization, Neoblock 50mg was prescribed and she has been taking Diamicron 30mg taken once a day for her diabetes before she was hospitalized for the second time. B. FAMILY HISTORY Mrs. AD is the eldest among the twelve children of her parents. She has 7 brothers and 4 sisters. Two of her siblings are also suffering from Diabetes Mellitus Type II. Her mother and father died due to heart disease. Both of her parents were hypertensive but no one from her parents had Diabetes. There is a history of Diabetes Mellitus Type II on her mother side. Her grandparents had Diabetes too. Mrs. AD got married to Mr. AD, 58, when she was 22. They have four children, two boys and two girls. Mrs. AD was 23 years old when she had her first son who is now 39 years old, followed by two girls who are 36 and 35 respectively. Her youngest child was a boy who died when he was 12 years old due to Typhoid fever and its complications. At present, Mr. and Mrs. ADs living children have their own families. Her second child together with her own family also resides at Barangay Sambal Ilaya, and their home is 10 minutes away from Mrs. ADs home. C. PERSONAL HISTORY Mrs. AD does not indulge herself into any vice. Mrs. AD has always spent her spare time in their place, Barangay Sambal, Ilaya which is near the seashore. She used to do the household chores before she has had bipedal edema and severe pain in her lower extremities. She is fond of eating salty and sweet foods. She is in the habit of eating fish such as dried fish, sardines and fish paste along with rice for her meal. According to Mrs. AD, no land is fertile enough to be planted on that is why their family has been accustomed to eating fish. She has been also accustomed to having coffee and softdrinks and also loves eating chicharon. She used to sleep every

10:00 in the evening after waiting for her husband from fishing and wakes up at 4:00 in the morning.

D. SOCIAL HISTORY Mrs. AD only finished grade school. She was not able to pursue her studies because of their familys financial status. Mrs. AD has a good relationship to her community particularly to her family. They are all Roman Catholics. Her husband is the one who makes a living for the family through fishing. Their monthly income ranges from P2,000-P4,000 monthly. The income which is coming from fishing isnt sufficient to meet their family needs although there are no more children to support. From time to time, their children try to support them financially. During their spare time, they stay in their home near the seashore so that they can get some fresh air. Their community is not that congested. The usual means of communication is through cellular phones. The primary means of transportation available in the barangay are jeepneys and tricycles. Community resources like Health Center and Barangay Hall are present but the people in their community do not utilize their resources very well. Mrs. AD hasnt ever tried to go to the Health Center in their barangay because of its inaccessibility; instead she will go to the clinic outside their place. Mrs. ADs family believes and sometimes relies on herbicharos or albularios. E. PYSCHOLOGICAL HISTORY Mrs. AD lives a simple life with her husband. Mrs. ADs quandaries are their financial instability and her illness. Their financial problem has been her major stressor that she usually needs to muddle through. She can communicate effectively and able to verbalize her feelings and her needs. She displays a good eye to eye contact. Staying near the seashore for relaxation is her way of coping with her stressor. F. HISTORY OF PRESENT ILLNESS As stated by her husband, he has been noticing that Mrs. AD has been gaining weight since September 2009. After a month, they both noticed that her lower extremities are becoming edematous. The pain on her lower extremities seemed to got worse as days passed by. And her weight gain is even noticeable. But last November 16, 2009, the pain experienced by Mrs. AD cannot be eased by simple NSAID drugs and herbicharos. So, on the same date, she was brought to Our Lady of Caysasay Medical Center which is the nearest hospital in their place with the chief complaint of bipedal edema and severe pain in her lower extremities. She was received via wheelchair since she finds it difficult to ambulate and her initial vital signs are Temperature: 37 C, BP: 150/100 mmHg, Pulse rate: 92 bpm, Respiratory rate: 35 breaths per minute. She was seen and examined by Dr. Datingaling and Dr. Landicho and they have discovered that Mrs. AD is oliguric. She was admitted with the diagnosis of Diabetic Nephropathy.