A. DEMOGRAPHIC DATA, CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS Name: Patient DM. QAge: 46 y/old
Address: Batia Bocaue, BulacanBirthday: March 28, 1966 Occupation: CookMarital Status: Married
Gender: MaleRace: Asian
Religious Orientation: Roman CatholicEducational Attainment: High School Graduate (4th Year) Healthcare Financing: NoneTime of Admission: 9:31 am
Date of Admission: Sept. 26, 2012Time of Discharge:
Date of discharge:Sept. 26, 2012
Initial Diagnosis: t/c Congestive Heart Failure
REASON FOR VISIT/CHIEFCOMPLAINT
“Sumasakit ang dibdib ko pati tiyan ko, saka nahihirapan ako huminga”as verbalized by the client.
B. HISTORY OF PAST ILLNESS
Patient stated that he has complete immunization but he can recall what specific vaccine he has received. He stated that he doesn’t have allergies to medications, food and environment. He didn’t experience any injury in the past, except for minor injuries like skin abrasions or cuts in his hand and feet by playing basketball. He never experience to be hospitalized and he takes over-the-counter drugs like paracetamol (Biogesic tablet) when he suffers from fever.
HISTORY OF PRESENT ILLNESS
Prior to admission, patient DM.Q has been experiencing mild chest pain with difficulty of breathing, abdominal pain and edema on his lower extremities. He was admitted in the Emergency Room of Bulacan Medical Center and given Furosemide 20mg TIVq15x3dose with blood pressure <100 systolic for management. On the same day, he was discharged and advised to come back if he experience again the same symptoms, and he was given a take home medicines such as Aldactone 25mg tablet P.O.
C. FAMILY GENOGRAM
(?) (?) (?) (?)
65 63 6068 65 HpnA/W Smoker Hpn/CA A/W
46 43 39
CHF A/W A/W
Male Male Client Deceased Male A/W- Alive and Well CA-Cancer
Female Female Client Deceased Female V/A-Vehicular Accident CHF-Congestive Heart Failure
FUNCTIONAL HEALTH PATTERN
FUNCTIONAL HEALTH PATTERN| Prior to Hospitalization| During Hospitalization| 1. Health Perception/Health Management Pattern 2. Nutritional &Metabolic Pattern| “Mga 8/10 siguro ako” as verbalized by the client when asked to described his health on a scale of 1-10, 1 being the lowest and 10 being the highest prior to hospitalization; “Wala akong nararamdaman nuon na kahit anu at kumportable ako na nakakagawa ng mga trabaho ko”, as verbalized by the client.He is non alcoholic and non smoker and never taken an illegal drugs. Client believes that proper diet, exercises, and adequate financial support are the things needed to maintain proper health diet and no vices are factors of having a healthy body. | September 23, 2012| September 24, 2012| Semptember 25, 2012| Breakfast...