Patients Profile

o Name: Mrs. GLI

o Age: 59
o Gender: Female
o Birthday: June 17, 1963
o Address: P1 Ponggo, Nagtipunan, Quirino Province
o Occupation: Teacher
o Date of Admission: March 08, 2023
o Time of Admission: 5:40 pm
o Chief Complaint: RUQ pain and on and off Vomiting
o Admitting Diagnosis: Hypertensive Urgency CKD secondary to Diabetic
Nephropathy

Patient Medical History

Past Medical History

According to the SO the patient has diabetes for 30 years and she is taking insulin
whenever she has high sugar level. The patient undergone surgery which is
cholecystectomy which her bile removed in the year 1992 and was started to take
metoprolol and glycoside for her maintenance and to lower her blood sugar but if
was taken on and off. The patient was admitted last February 21, 2023 at Quirino
Provincial Medical Center because of Edema. The patient has completed her
immunization and had her shots for CoVid-19 Vaccine.

Present Medical History

The patient was brought to District Hospital of Nagtipunan Quirino for consultation
and referred to Devera Medical Center for admission. The patient was awake and
responsive upon admission last march 08, 2023 at 5: 40 pm. The patients chief
complaint was Right Upper Quadrant pain and on and off vomiting, her Vital Signs
follows:

Blood Pressure: 130/80 mmHg

Heart Rate: 79 bpm

Respiratory Rate: 18 cpm

Temperature: 36.5 ◦c

SPO2: 97 %

OB History

patient gave birth to two children through normal spontaneous delivery. The patient
gravida is 2, term 2, preterm 0, abortion 0, living 2 (G2, T2, P0, A0, L2). The patient
already reached her menopausal stage and her last menstrual period was on the
year 2001.

Social History

According to the SO the patient was working as a fulltime public primary teacher
since 1990 up to the present and now her family is working for her retirement papers.

Family History

Mother Father
HTN - -
Diabetes - -
CKD - -
Asthma - -
COPD - -
Cardiovascular disease - -
Overview