DEMOGRAPHIC DATA

Name: Mr. EC

Age: 67 years old

Gender: Male

Nationality: Filipino

Date of admission: February 20, 2021

Time of admission:

Final diagnosis: Chronic Obstruction Pulmonary Disease

Admitting resident: Dr. JWE

NURSING HISTORY
History of Present Illness
One week prior to admission the patient presented with cough, productive, whitish
sputum associated with fever. He also reported body weakness, decrease oral intake and
dizziness. Mr. EC, 67 years old, male was admitted to the hospital on February 20, 2021. The
doctor ordered PNSS 1L x 16 hrs, 02 at 2 LPM for DOB with vital signs monitored every 4
hrs. He was ordered to have low salt, low fat diet. Diagnostic tests and medications were
ordered.
History of Past Illness
The patient was diagnosed with COPD since 2008. The patient has history of
hypertension. He does not have any history of diabetes mellitus , pulmonary tuberculosis and
there are no known allergies.