Professional Documents
Culture Documents
Sample Patient History
Sample Patient History
abdominal pain. A few months after, the patient experienced lumbosacral pain, and latter
diagnosed to have Benign prostate hyperplasia through biopsy. Surgery was suggested but the
patient refused and decided to take medications as primary therapeutic regimen. On the year
2013, the patient was diagnosed to have an inguinal hernia. On the same year, the patient was
also diagnosed to have Diabetes Mellitus type 2. Last February 2016, the patient was again
hospitalized due to Pneumonia. There are no other significant medical histories since then.
SOCIAL-ENVIRONMENTAL HISTORY
The patient claimed to have started smoking at the age of 15 years old with average pack
1 and a half pack of cigarette per day. The patient is also an occasional alcoholic beverages
drinker. The patient lives in a two storey house in a non-congested neighbourhood with his wife
and children. Water for drinking purposes come from a water refilling station near their
residence and water for domestic use come from the Baguio Water District. The patient is
married, with 4 children and is a retired crewman in a ship.
FAMILY HISTORY
The patients mother was known to have diabetes mellitus that had a trajectory problem
of nephropathy, and died at the age of 86 years old. His father was diagnosed to have bone
cancer and died at the age of 64 years old. His grandmother on the maternal side was diagnosed
with HPN and died at the age of 100 years old. There are no other significant heredofamilial
diseases in the family.