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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
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NAME: Mrs. Villegas AGE: 69y/o SEX: Female ADDRESS: Fairlaine subdivision, Tarlac, City BIRTHPLACE: Tarlac NATIONALITY: Filipino RELIGION: Roman Catholic CIVIL STATUS: Married BIRTHDAY: June 11,1939 DATE AND TIME OF ADMISSION: July 14, 2008/ 9:01am FINAL DIAGNOSIS: Massive ascites 2º to portal hypertension 2 º to CLD

Past History   Medical history: 10 years ago, she developed Hypertension which was controlled by medication 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 accompanying occasional chest pain but she didn’t perceived the need to seek for medical help. Three days prior the admission, her friend who was a registered nurse suggested her to be self examined by a physician. She was diagnosed of having massive ascites 2º to portal hypertension 2 º to chronic liver disease (CLD) and advised to be admitted at JMC.


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