Patient’s Profile

i. Biographic Data

Name : Jane
Age : 42 y/o
Gender : Female
Birthday : August 14, 1979
Civil Status : Married (to John)
Religion : Roman Catholic
Nationality : Filipino
Educational Attainment : High School Graduate
Occupation : Sales Lady at SM Mall
Socioeconomic Status : Low socioeconomic status

ii. Clinical Data

Chief Complaint : Increased Blood Pressure
Date of Admission : Feb. 15, 2021
Time of Admission : 9:00 AM
Manner of Admission : Ambulatory
Hospital : Davao Doctors Hospital
Ward/ Room No. : HRU
Attending Physician : Dr. Samaniego
Tentative Diagnosis : Pregnancy-Induced Hypertension
Final Diagnosis : Eclampsia

Vital Signs upon Admission:

VS upon Admission Results

Temperature 39.2 degrees Celsius
Pule Rate 90bpm
Respiratory Rate 20cpm
Blood Pressure 140/90mmHg
iii. Past Health History

The patient had no known case of hypertension, DM, asthma, and

thyroid disorder. She had a history of having measles, German measles,
mumps and rubella. Has a history of hospitalization and a surgery in 2017
for ectopic pregnancy @ 6 week AOG and D and C in 2019 for
Incomplete abortion @ 12 weeks AOG.

iv. Present Health History

The patient is a 42-year-old female, she is a multigravida and

currently on her 3rd pregnancy. She went to the hospital because of
increased blood pressure. Patient had a regular check-up during her first
and second trimester but failed on her third trimester until her last check
up and was found to have high blood pressure and suggestive of
Pregnancy-induced hypertension. She has a weight of 203 lbs with a
height of 5 feet and 3 inches. Her recent blood pressure is 140/90 mmHg.

v. Family History (with Genogram)

The patient’s name is Jane, a 42-year-old female and she works
SM Mall as sales lady. She’s married for almost 5 years with her husband
John. The couple reside in one of the relocation areas. Her family history
revealed no heredofamilial diseases.