PATIENT’S DATA

GENERAL DATA:
Name:
Address:
Marital Status: Widowed
Age: 67 years old Gender: Male
Religion: Catholic
CHIEF COMPLAINT
“Pumunta ako sa baba sa OPD para mag pa check up , tapos nag pa laboratory
lumabas na mababa ang dugo ko kaya pina admit nila ako ” as verbalized by the
patient .
HISTORY OF PRESENT ILLNESS
An old Filipino male known as diabetic and with a history of hypertensive as
evidence by 160/90 mmhg blood pressure .
five months pta pt observed that his legs are swelling and having difficulty in walking
then went to east avenue medical center to have a check up . meds we’re given but
patient wants to transfer to QMMC due to (Di naman daw nawawala yung maga sa
east ave.) .
Four months pta (January 2018) patient was admitted in QMMC due to edema and
diagnosed as type 2 diabetes. the patient has no history of diabetes , pt stated that he
loves to eat sweet and salty foods a unhealthy meal planning choices . unhealthy
lifestyle that leads to diabetes and explains the excessive fluid volume in the lower
extremities .
Weeks pta patient was admitted and diagnosed CKD and was sent home after a
week of admission.
One day pta , during OPD check up patient was noted low levels of hemoglobin
was advised for admission . but refused due to no one will accompany him .
Pta pt came back (June 14 , 2014) and was immediately admitted .
PAST MEDICAL HISTORY
+Hypertensive
+Type 2 diabetes
FAMILY HISTORY
-Hypertensive

PERSONAL AND SOCIAL HISTORY

-Smoking 1 pack per day for 42 years (40 pack yr smoker)
-heavy alcoholic drinker since 15 years old
-denies drug use