PERSONAL INFORMATION

Name Jose Cruz

Age 62 years old
Birth Date March 12, 1959
Birth Place Santo Domingo, Bambang, Nueva Vizcaya
Address Santo Domingo, Bambang, Nueva Vizcaya
Gender Male
Blood Type O+
Nationality Filipino
Primary Languages Ilocano, Tagalog
Religion Born Again
Type of family Nuclear Family
Primary Source of Health Care Barangay Health Center
Services

Primary Source of Health related to Philhealth member

illness
Financial resources Welding Shop
Teaching Salary
Engineering
Significant Others Jennie Cruz
Age 55 years old
Address Santo Domingo, Bambang, Nueva Vizcaya Teacher
Occupation Wife
Relationship to Patient

Significant Others Roel Cruz

Age 27 years old
Address Santo Domingo, Bambang, Nueva Vizcaya
Occupation Engineer
Relationship to Patient Child

3P’s
PAST HEALTH HISTORY

During teenage years of Mr. Jose Cruz, he admitted that he had a bar life most especially
during his college years. He started drinking alcohol when he was 19 years old and up until now.
Moreover, he mentioned that he is dependent to cigarette smoking. Back then, he is okay with 2
to 3 sticks per day and now that he is an older adult he can have 12 sticks per day and his
maximum consumption is 20 sticks. He became this very dependent to cigarettes because he
does not want to experience the adverse effects of smoking.

About his daily routine, he wakes up at 5:00 in the morning and starts to take his 250ml
coffee. He starts opening his welding shop at 10:00 in the morning and he has his employees to
work with thim. He asserted that he is very productive at some days and most of the days, he is
very unproductive – just sitting on his chair and reading newspapers or watching movies while
staying in his shop. At night, he and his wife cooks their dinner and sleeps at 9:00 in the evening.
He mentioned that he never had an extreme exercise but he considered walking from his home to
his welding shop as an exercise. His shop is 15 meters away from his house and he said that he
walks for 25 minutes. On the other hand, he is hypertensive and their family has an automatic
blood pressure apparatus to monitor his blood pressure. Even though he has high blood pressure,
he did not visit any clinic for check-up and therefore, he is not taking any anti-hypertensive
drugs.

The reason why Mr. Jose cannot take extreme exercise is because he told us that he is
having chest pain whenever he is overdoing something and also. But even though he is obese, he
still have the initiative to take minor exercises. When he was asked about his food intake, he
mentioned that he is always tempted to eat burger and pizza which are rich in cholesterol since
McDonald establishment is beside his shop. Moreover, he also answered that they use animal-oil
base for cooking. He is very fond of eating processed foods, canton, canned goods, fried meats,
foods dipped in condiments such as bagoong, soy, salt and suka. But he also said that he eats
boiled fresh vegetables sometimes.

PRESENT HEALTH HISTORY

While having coffee in the morning, Mr. Jose experienced shortness of breath for 10
minutes but did not pay attention to it. He just have non-pharmacological treatment by
conducting the deep breathing technique and bent his torso forward. However, at 5:30 in the
morning, he is experiencing “squeezing” feeling in his chest. So, he called his wife and child and
request to admit him in the hospital.

Mr. Jose Cruz, 62 years old, 189 lbs, male was admitted to the Nueva Vizcaya Provincial
Hospital (NVPH) on March 12, 2021 at 6:00 AM. The client was received sitting, awake,
conscious, coherent and has chief complaints of sudden chest pain (8 out of 10), nauseous, has
difficulty breathing, shortness of breath. Vital signs were taken; blood pressure of 170/100
mmHg, temperarute of 37.9˚C, heart rate of 105 bpm, weak pulse and respiratory rate of 42 cpm.
Upon receiving the patient, he immediately received supplemental oxygen, aspirin, nitroglycerin
and morphine. After 30 minutes, he was given Metoprolol to decrease cardiac oxygen
consumption.

FAMILIAL HISTORY

Mr. Jose’s father died due to coronary artery disease. While her mother has Diabetes
Mellitus Type 1. Her sister who is living in Solano, Nueva Vizcaya is diagnosed having Stage 2
Hypertension. Other family members of Mr. Cruz have no history of illnesses.

SOCIO ECONOMIC STATUS

Currently, Mr. Cruz as a welder, gets a maximum of 2600 pesos a day. While his wife
has a monthly salary of 20,000. His only child works as an engineer and is giving money to his
family every after 2 months.
 COURSE IN THE WARD
March 12, 2021

 6:00 AM – Admission

Mr. Jose Cruz, 62 years old, 189 lbs, male was admitted to the Nueva Vizcaya Provincial
Hospital (NVPH). The client was received sitting, awake, conscious, coherent and has
chief complaints of sudden chest pain (8 out of 10), nauseous, has difficulty breathing,
shortness of breath. Vital signs were taken; blood pressure of 170/100 mmHg,
temperarute of 37.9˚C, heart rate of 105 bpm, weak pulse and respiratory rate of 42 cpm.
Upon receiving the patient, he immediately received supplemental oxygen, aspirin,
nitroglycerin and morphine. After 30 minutes, he was given Metoprolol to decrease
cardiac oxygen consumption.

 6:10 AM – ECG

From the emergency room, the patient was transferred to the ECG room.

 6:30 AM – ECG Result

The ECG result shows ST Segment Elevation and T waves inversion.

 6:35 AM - Laboratory Result

Results showed an increase level of troponin, elevated CK-MB and increase myoglobin
level.

 8:00 AM – Admit to Medical Ward for continuous monitoring

 11:30 AM - Discharge