Hepa B
Demographic Pages a) Demographic Profile: a. Name: Mr. R. A. b. Address: Ibaan, Batangas c. Age: 44 years old d. Status: Single e. Occupation: Farmer (previously) f. Educational Attainment: High-school graduate g. Chief Complaint: Hematemesis and melena h. Admitting Diagnosis: Hepatitis B infection i. Final Diagnosis: Esophageal varices s/t liver cirrhosis s/t chronic hepatitis B infection j. Date and Time of Admission: 3/3/13 07:00 am k. Attending Physician: Dr. Maralit
History
a. History of present illness
Patient RA is a 44 year old male with a know case of liver cirrhosis with esophageal varices secondary to chronic hepatitis B infection. He was apparently asymptomatic until one day prior to admission patient had several episodes of black tarry stool and vomiting but there’s no aggravated dizziness, dyspnea and bleeding from other site. The morning prior to admission patient had two episodes of vomiting of coffee-ground discharge. Patient was then rushed to the hospital for subsequent readmission. b. History of past illness
Patient RA noted that he no allergy to any food. He said that he doesn’t know if he was given the complete immunization when he was a child because her mom died in an early age and that immunizations are not really that famous that time. There are no prior admission to the hospital until he was diagnosed with the current illness last 2009. The year when he was diagnosed with Hepatitis B, the patient was given a maintenance of Zefix.
b) Genogram with Family History
There was no familial disease in the immediate family. Her mother died giving birth to his youngest sibling. His father has asthma but overall he is healthy. He has four sibling, all of them are health and have no vices.
LEGEND:
Offspring
Mother
Father
Deceased
Patient
d. Social Data
Our patient usually chats or bonds with
History
a. History of present illness
Patient RA is a 44 year old male with a know case of liver cirrhosis with esophageal varices secondary to chronic hepatitis B infection. He was apparently asymptomatic until one day prior to admission patient had several episodes of black tarry stool and vomiting but there’s no aggravated dizziness, dyspnea and bleeding from other site. The morning prior to admission patient had two episodes of vomiting of coffee-ground discharge. Patient was then rushed to the hospital for subsequent readmission. b. History of past illness
Patient RA noted that he no allergy to any food. He said that he doesn’t know if he was given the complete immunization when he was a child because her mom died in an early age and that immunizations are not really that famous that time. There are no prior admission to the hospital until he was diagnosed with the current illness last 2009. The year when he was diagnosed with Hepatitis B, the patient was given a maintenance of Zefix.
b) Genogram with Family History
There was no familial disease in the immediate family. Her mother died giving birth to his youngest sibling. His father has asthma but overall he is healthy. He has four sibling, all of them are health and have no vices.
LEGEND:
Offspring
Mother
Father
Deceased
Patient
d. Social Data
Our patient usually chats or bonds with