HISTORY/PROFILE OF THE PATIENT

Demographic Data
Name : Mrs. E.L.
Service : Female Medical Ward
Attending Physician : Dr. Cidro
Room/Bed No. : Bed 19
Address : B3 L27 Laurel St. Villa Elisa,
Anabu 2E Imus, Cavite
Age : 65 years old
Civil Status : Married
Nationality : Filipino
Religion : Roman Catholic
Occupation : None
Date of Admission : August 23, 2010

Chief Complaint: Abdominal pain in epigastric area

History of Present Illness:

One week prior to admission, patient had loose bowel movement of 3-4 episodes/days for
4 days about 2-3 tablespoon/bout, greenish in color, accomplish with abdominal pain. Patient
took Gatorade affording relief of LBM. No consult was done. Two days prior to admission
patient noted abdominal pain in epigastric area accompanied with pallor and body weakness.
Persistence of symptoms prompted consult hence admitted.

Past Medical History:

She got hospitalized last year because of Chronic Renal Failure. She had chickenpox was
she was eight years old. Her usual ailments includes cough, colds and fever however, she takes
herbal medications.
 
Social History:

Patient is the 2nd among the four siblings and is a high school graduate. She is not very
active in community projects.

Environmental History

Patient resides in Imus, Cavite. Her house is made of wood and cement. She lives near
wet market place. She lives away from the creek and away from the highway.
 Lifestyle

Patient is a non-smoker and occasional drinker. Her typical lifestyle is staying at home
and other recreational activities such as bingo and playing cards. Her usual diet includes meat,
high carbohydrates and vegetables. She is fun of eating salty and sweet foods.

FAMILY HISTORY

Family Member Age (years) Sex Marital status Health Condition Deceased
Father E. 72 M Married Respiratory problem 
(Emphysema)
Mother I. 85 F Married Stroke 
Melchor 32 M Single Vehicular accident 
Patient E. 65 F Married ESRD
Claire 63 F Married Hypertension
Francisco 59 M Widow N/A