I.

Vital Information

Name: Mr. M.C. P.

Age: 85 years old

Sex: Male

Height/Weight: 74kg/57

Civil Status: Widow

Religion: Roman Catholic

Nationality: Filipino

Birthdate: July 24, 1932

Birth place: Iloilo city

Current Address: Simeon Aguilar St., Passi City, Iloilo

Educational Attainment:

Occupation: None

Chief Complaints: Fever & Cough

Date: 09/10/17.

Mode of transportation: Stretcher

Accompanied by: Granddaughter (Ms. P. K. P.)

Mental/Emotional status upon admission: Unconscious

Admission Vital Signs: Temperature

Respiratory Rate

Cardiac Rate

Blood Pressure

Medical Diagnosis: ARF IV pob. Cardiogenic Shock 2

Cardiac Arrhythmia (V-tach); T/C ACS

N-STEMI; S/P Arrest; T/C Urosepsis;

HAP-resolving; HCVD; DM II-NIR

Attending Physician: Dr. Palmes,P. (Cardiologist/IM)

 Dr. Sotomil, M. H. (Gastroenterologist)

Dr. Momville, C. (Pulmonologist)

Dr. Jurao, L. (IM/Infectious Diseases)

Dr. Cabrera, M. (Rehab)

Dr. Suresca, S. (IM/Pulmonologist)

Number and Dates of Previous Hospital Admission: unrecalled

Ward and Bed Number: MICU, 4th, Bed 12

Food/Drug Allergies: No Known Allergies

Source of Information: Secondary Mother and Clients Chart

Person to be contacted in case of emergency: Mr. P. K. P. (Granddaughter),

Contact Number:

Insurance:

II. History of Present Illness

Two weeks prior to admission client complain of occurrence productive cough;

whitish sputum, with fever, easy fatigability. Sought consultation with Physician and was

given antibiotics. As claimed Physician noticed him to be pale and was requested with

CBC. CBC results showed decreased RBC and Hemoglobin. (Labs results unavailable).

Seven days prior to admission still with persistence of symptoms and with

Hemoglobin level of 5.80 mg/dL and Hematocrit level of 16.50 vol%. Patient was advised

for admission at Our Lady of Pilar Medical Center and was transfused with 2 units of

PRBC. He was then discharged after 3 days and was advised referral to a nephrologist

and dialysis.

On the day of admission March 4, 2017; 7:12 am at SPH Iloilo patient came in to

the ER, sought consultation to a nephrologist and was ordered laboratories, where results
revealed Creatinine level of 2114 umol/L; and was then admitted under the service of Dr.

Caro-Pastolera and Dr. Barrameda. Hemodialysis was then done.

On the same day, March 4, 2017 5:15 pm, patient was then endorsed to MAMA

ward via wheelchair, status post hemodialysis. Was then transferred to SJ bed 3.

Last march 6, 2017, labs were retaken and revealed a results of alleviating the

creatinine level up with 1332.90 umol/L.

On March 8, 2017, student nurse received this 29-year-old, male, alert, oriented to

person, place, time and event, cooperative, maintains eye contact; clear speech and

modulated voice; responds appropriately; with Intra-jugular catheter; on a left arm

precaution; Parents by bedside.

III. Past Medical History

Mr. M.D. that he experiences easy fatigability prior to the onset of the problem. Patient

verbalized that he completed childhood immunizations. Patient verbalized to have

experienced measles, chicken pox, and fever, as childhood illness with dates unrecalled.

Client was also admitted on the year 2002 for appendicitis with number of days admitted

unrecalled and on 2009 with reason of hospitalization and number of days admitted

unrecalled. His last hospital admission was last February 25, 2017 in Our Lady of Pilar

Medical center due to Low Hgb level. Client has maintenance of Losartan 50 mg OD for

he is hypertensive since 2014. No history of allergic reaction, rashes. No history of

psychiatric illnesses as claimed.

IV. Lifestyle or Current Health Status

Client does not smoke, occasionally drinks alcoholic beverages of 1-3 bottles. Patient

buys foods at fast food chains, consuming 100% of his meal. Patient eats about three

meals a day with an intake of snacks in between meal times. Patient has no dentures.
Patient claimed to eat Dingdong usually when hes busy with his office works. Patient

drinks about 8-10 glasses of water a day. Patient urinates with no burning sensation for

4-6 times a day; defecates to brown well-formed stool, once a day. Client is independent

in handling his finances as source of income comes from his work. Patient used 1-2

pillows with one under his head and one pillow on his left side; sleeps in a supine position.

Patient would sleep at 8 pm and then would later wake up at 5 am; stated no difficulty

sleeping. Patients daily exercise is walking around his neighborhood and biking from time

to time.

Patient is currently on maintenance of Losartan 50mg OD for high blood pressure.

V. Family History

Patients mother is healthy while hes father is living with hypertension. The both sides

of her family dont have diabetes mellitus. No occurrence of rare genetic conditions. He

has two siblings; the youngest is in his 5th year college taking up architecture, claimed to

be healthy; while the other one is working as a seaman, status post cholecystectomy.

VI. Personal and Social History

Mr. M. D is a BSMT graduate. Patient lives in an urban community setting in a house

made of concrete materials. While in Imus, Cavite City he lives independently alone while

his family were here in Iloilo city. Mr. M.D. makes the overall decisions for himself. Patient

financial was supported by his salary. Hobbies include biking, resting and watching TV.

Patient is a Roman Catholics, attend mass every Sunday.

 VII. Stressors

Physical

Patient claimed to feel discomfort due to his IJ cannula as it makes his movement

limited and discomfort; copes with limiting his movement.

Psychological

Patient verbalized Isa lang ko nga gatudlo sa opisina namon, ti amo na bastante

ang office subong.; copes by father called the office and informed them about the current

health situation of his son. The office permitted and was given him a leave.