Вы находитесь на странице: 1из 2

Clinical history

General Data: liquete, Milagros, 62 years old, female widowed, retired


bank officer, Roman Catholic, Filipino, born on August 11, 1948 in Manila,
presently residing at 50 Mozart corner Chopin St. Ideal Subdivision, Quezon
City, admitted for the 1st time on our institution on August 22, 2010.

Chief complaint: diabetic foot

History of Present illness:


6months prior to admission, patient had a right anterior tibial wound
associated with trauma by bumping on the wall. No fever, chills and bleeding
was noted.
3months prior to admission, patient noticed that the wound was not
healing now associated with signs of inflammation, she then consulted in a
private clinic where she was given unrecalled antibiotic for 2 weeks and was
taught wound dressing. She was then referred to an endocrinologist who
then advised her for admission.
Few hours prior to consult, patient sought consult with her private
physician where she was advised admission, hence admitted at the
constitution.

Past Medical History


Patient had a chicken pox, mumps, measles during childhood. Patient
is a Diabetic for 10 years maintained on Diamicron BID for 10 years and
Metformin 1tab OD for 5 years, she is also hypertensive for 10 years
maintained on Metoprolol 50mg/tab 1tab BID, losartan 50mg/tab OD,
clopidogrel 75mg/tab 1tab OD, highest BP was 160/110mmHg and usual BP
of 160/80-90mmHg.
Diagnosed with GERD January 2010 maintained on Omeprazole 20mg/tab OD
1991- underwent hysterectomy at St. Lukes Medical Center due to myoma.
1980's- underwent polpypectomy at St. Lukes Hospital.
Denies any history of malignancy, pulmonary tuberculosis and kidney
diseases. No history of accidents.
Patient is allergic to squid and has no allergy to drugs.

Family History:

Father- 43 years old decease due to throat cancer


Mother- 95 years old decease unknown cause
3siblings- 1st and 3rd sibling has hypertension
Maternal and Paternal side has a history of hypertension, Diabetes Miletus,
Bronchial Asthma, Liver Cirrhosis and Heart Disease.
Personal and Social History:
Patient has a masters degree on business administration and has worked as
a bank officer for 35 years now. She has been wodowed for 5 years and has
2 kids who are apparently well. She is non smoker, and Non alcohol beverage
drinker. She lives in a bungalow house that is well lit and ventilated with
4rooms and 3 bathrooms.
OB-Gyn History:
Patient had her menarche at the age of 10 that lasted for 3 days moderate
on flow, consuming 2-3 pasadors per day, moderately soaked. Subsequently
menses were regular that lasted 3-4 days moderate in flow, consuming 3
pads per day.