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Patient Profile and History

Mrs. Villegas is a 69-year-old Filipino woman admitted to the hospital on July 14, 2008 with a final diagnosis of massive ascites secondary to portal hypertension secondary to chronic liver disease. She has a history of hypertension, diabetes, and prior surgeries including hysterectomy, cholecystectomy, thyroidectomy, appendectomy. Last year she was diagnosed with liver cirrhosis. Three days before current admission, a nurse friend noticed her abdominal enlargement and chest pain and she was found to have massive ascites.

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Erwin John Aquino
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472 views3 pages

Patient Profile and History

Mrs. Villegas is a 69-year-old Filipino woman admitted to the hospital on July 14, 2008 with a final diagnosis of massive ascites secondary to portal hypertension secondary to chronic liver disease. She has a history of hypertension, diabetes, and prior surgeries including hysterectomy, cholecystectomy, thyroidectomy, appendectomy. Last year she was diagnosed with liver cirrhosis. Three days before current admission, a nurse friend noticed her abdominal enlargement and chest pain and she was found to have massive ascites.

Uploaded by

Erwin John Aquino
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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PATIENT’S PROFILE

 NAME: Mrs. Villegas


 AGE: 69y/o
 SEX: Female
 ADDRESS: Fairlaine subdivision, Tarlac, City
 BIRTHPLACE: Tarlac
 NATIONALITY: Filipino
 RELIGION: Roman Catholic
 CIVIL STATUS: Married
 BIRTHDAY: June 11,1939
 DATE AND TIME OF ADMISSION: July 14, 2008/ 9:01am
 FINAL DIAGNOSIS: Massive ascites 2º to portal
hypertension 2 º to CLD
PATIENT’S HISTORY
 Past History
  
 Medical history: 10 years ago, she developed Hypertension which was controlled by medication and Diabetes
Mellitus
 Surgical history: Hysterectomy 15 years ago, Cholecystectomy 17 years ago, Thyroidectomy 20 years,
Apendectomy 25 years ago,
 Medications: plendil and avandia taken 10 years ago.
 Allergies: No known allergies
 Injuries and accidents: Ø
 Special needs: Ø
 Blood transfusion: 450 cc of packed RBC; type AB; last July 14, 2008

 Present history:

 Last May year 2008 patient was admitted at JMC and was diagnosed of having liver cirrhosis.

 One week prior to admission she developed abdominal enlargement with accompanying occasional chest pain
but she didn’t perceived the need to seek for medical help. Three days prior the admission, her friend who was a
registered nurse suggested her to be self examined by a physician. She was diagnosed of having massive ascites 2º
to portal hypertension 2 º to chronic liver disease (CLD) and advised to be admitted at JMC.
GENOGRAM

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