PATIENT PROFILE

Name: Patient AL

Gender: Male

Religion: Roman Catholic

Hospital no.: 193322

Civil status: Married

Address: Zone III, Pinamalayan, Oriental Mindoro

Clinical diagnosis: ACUTE DECOMPENSATED HEART FAILURE DM TYPE II 

Admitting physician: xxxxxxxxxx

Chief complaint: Edema, DOB/SOB, Easy fatigability, Left side chest pain, Orthopnea

a)    PRESENT HEALTH HISTORY

The patient was a referee at a basketball event when he felt his shoes tightening and her heart rate slowly declining. It was on September 17, 2022 that he had difficulty sleeping. On that same month he had a wound on one of his finger that won’t heal properly due to his high blood sugar level.  His first admission at Oriental Mindoro Provincial Hospital was on September 25, 2022 and was discharged October 02,2022. A 2D Echo and Ultrasound was done showing that one of his valve wasn’t working properly. From that diagnosis, the cardiologist advised him to have a Heart Bypass Surgery, but due to financial constraint, they can’t afford to have it. Prior to his admission at OMPH, he first consulted at a hospital at Pinamalayan, Oriental Mindoro. Xray was done showing he has an abnormal buildup of fluid in the lungs.

b)    PAST HEALTH HISTORY

According to the patient, back in the year 1986 he was 3rd year high school when he first felt difficulty sleeping day and night that persevered throughout that month. The patient noticed that his illness shows up every after five (5) years. In the year 1994, he was confined at a hospital at Victoria, Oriental Mindoro. The doctor noticed there is an increase in his heart rate still even in Oxygen (O2) supply. Due to lack of proper equipment, his proper diagnosis was uncertain.

c)     FAMILY HEALTH HISTORY

Patient AL is the second born out of his six (6) siblings. His father died at the age of sixty-five due to diabetes his mother on the other hand died at the age of sixty-three (63) due to hypertension. His eldest sibling died of diabetes at the age of forty-six (46). Their third born is now showing signs and symptoms of diabetes.  The rest, however, are all healthy. The patient also stated that his grandmother from his father side also died of diabetes and his grandfather died of hypertension. His grandfather’s brothers are hypertensive as well.

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 PATIENT PROFILE

NAME: PATIENT RM

GENDER: FEMALE

BIRTHDAY: 03/12/46 (77 Y/O)

BIRTHPLACE: STA. MARIA PINAMALAYAN, ORIENTAL MINDORO

RELIGION: ROMAN CATHOLIC

HOSPITAL NUMBER: 1252733

CIVIL STATUS: MARRIED

ADDRESS: STA. MARIA PINAMALAYAN, ORIENTAL MINDORO

CLINICAL DIAGNOSIS: xxxxxxxxxxx

ADMITTING PHYSICIAN:

CHIEF COMPLAINT: DIZZINESS

A.    PRESENT HEALTH HISTORY

Currently, the patient resides at Sta. Maria, Pinamalayan, Mindoro Oriental. She formerly served as a barangay counselor and is currently an active participant in The Office for Senior Citizens Affairs OSCA. She attended Abada College, where she completed her first year before quitting.

Despite her age, she's still able to manage to work and buy groceries for herself. She goes to the office practically every day as an OSCA leader to file paperwork for her fellow seniors. However, because of her advanced age, she feels fatigued after walking kilometers from home to work, according to her relatives. Her relative also claim that it takes a long time for her wound to heal but they never suspected she has diabetes.

She was still able to snip the overgrown grass in their yard on the day of her stroke. Following that, she went into the city to buy some groceries for herself before returning home and continuing to weed. She took a break after gardening and sat in the rocking chair, complaining of dizziness, as one of her nieces observed.

They brought her to the hospital in Socorro right away, but she was later transferred to Oriental Mindoro Provincial Hospital. She had tests and lab work that proved she had a stroke. Additionally, it revealed she had diabetes and hypertension.

B.    PAST HEALTH HISTORY

She was previously hospitalized for a head injury sustained when she fell and struck her head on a wall. A CT Scan was done showing the bleeding was superficial. The doctor monitored her and was discharged shortly after that.  She has no documented childhood illnesses, according to her relatives. Her family also claimed that she might be getting prescriptions for drugs like losartan from doctors and taking them covertly. She drinks alcohol oftentimes. Especially when her friends come to visit her. She’s also a heavy coffee drinker taking more than three cups of coffee a day.

C.    FAMILY HISTORY

The patient is the youngest out of his eight (8) other living siblings. His mother has passed away and was diabetic, his father has a hernia and is now in need of optimum care due to old age. Two (2) out of his eight other siblings are experiencing the same yet a milder symptom of his illness.

1.     (M) None

2.     (M)Hypertensive

3.     (M) Asthma

4.     (M) Leg weakness

5.     (F) Diabetes

6.     (F) Diabetes

7.     (F) Asthma

8.     (M) Weakness on the waist area

9.     (M) Patient JBMJR

10.  (G) Deceased

The patient is married and with three (3) kids all are healthy.