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
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:
d. Social Data
Our patient usually chats or bonds with his siblings and relatives around their compound. According to Macionis, socialization refers to lifelong learning, through social experience, that contributes to the development of the personality and allows full participation in society.(Macionis, et.al) In the case of our patient at his age (44y/o), he is still single so his life revolves around her family, relatives and friends only, there is no social growth as he is shy while talking to us. Full participation in the society will be difficult for him. Although quite shy, the patient is still approachable and accommodating as I talked to him.
1. Macionis, Gerber, John, Linda (2010). Sociology 7th Canadian Ed. Toronto, Ontario: Pearson Canada Inc.. pp. 103.
Following a healthy lifestyle means doing what you can to keep your body and mind in optimum shape. This involves making wise choices in your daily diet, performing the right amount of physical activity, coping well with stress and controlling your weight. In the case of our patient he has this routine of waking up at 5:00 in the morning to prepare for farming. The patient loves eating vegetables and fruits. He seldom eats junk foods but loves soft drinks so much. The patient does not exercise daily but considered his work as his exercise. He usually sleeps at around 10pm. According to him, he has no vices but does drink occasionally. Leading a healthy lifestyle can do more than prevent disease. It can also help you have more energy and stamina, stay slim, be more alert, fight stress and live a longer life.
Read more: http://www.livestrong.com/article/373286-what-does-a-healthy-lifestyle-mean/#ixzz2N1rKwYbN
f. Psychological Data
The patient is conscious, coherent and answers the questions accordingly. The patient uses appropriate words and replies with understanding. There was no flight of ideas or lack of apprehension. When I asked on how they cope with their problems as a family, the patient said that he and his siblings...
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