D.

PATIENT’S PROFILE

i. Biographic Data

Name: Patient X

Age: 82 years old

Sex: Male

Civil status: Married

Birthday: November 19, 1936

Religion: Catholic

Nationality: Filipino

Admitting Physician: Dr. Pacioles, Orlino A.M.D.

Date of admission: 12/18/2018

Time of admission: 2:17 AM

Room #: 2102

ii. Past Health History

The patient is a known diabetic and hypertensive for more than 10 years with
maintenance medications of Gliclazide (Diamicron) for DM and Losartan (Amodipine)
for hypertension. Way back on year 2013, the patient was diagnosed with Pulmonary
Tuberculosis (PTB) and treated for 1 year. Other than that, there no other previous
surgeries and hospitalization.
iii. Present Health History

2 days prior to admission, patient noted uncoordinated movements while walking

so patient took a rest. Hours later patient noticed slurring of speech so they sought
consult on a traditional & oriental medicine center with temporary relief. 1 day PTA,
patient noted dizziness and right sided weakness while standing. No medicines taken.
Sought consult on a nearby hospital and was referred to this instituition for admission.

i. Family History (with Genogram)

Patient’s family history was traced with hypertension on both maternal and paternal
sides. His maternal side was also traced with Diabetes Mellitus while on the paternal
side, liver cancer was traced. The patient has 3 siblings, 2 are male while 2 are female.

vi. Developmental History

When the patient was born Makes reflex movements like sucking and startling,
has jerky, uncontrolled arm and leg movements. Starts learning to be comforted by
caregivers, Begins getting attached to caregivers. At the age of 3 months she can able to
holds her head up unsupported for a short time, she develops different cries for different
needs (hungry, tired, wet). At the age of 5 moths she moves things from hand to hand,
recognizes and responds to own name. At the age of 7 months she sits without support.
At the age of 9 months she starts to understand no, follows a falling object with eyes. At
the age of 12 months she walks holding on to hands or furniture, may stand alone, and
may take a few steps alone. At the age of 18 months she likes to hand things to others
as play, may have temper tantrums, and may be afraid of strangers. At age of 2 years old
she shows more and more independence, shows defiant behavior (doing what he has
been told not to). According to Eric Erickson’s stage of psychological development she
was undergone to, our patient belongs in 3rd stage which is Initiative vs. guilt ages 3-6
years old. In this stage she initiate in limitation and suddenly feels guilt when child
developing a conscience feel in competition with the parent (i.e., oedipal feelings).

vii. Nutritional History

The patient doesn’t practice any diet in regards to his condition. He prefers to eat salty
and fatty foods all the time. He is also a heavy smoker since he verbalized that he can
finish a pack of cigarretes in a day. He is also a heavy drinker of alcoholic beverages.

viii. Immunization

Patient’s mother stated that she was fully immunized with BCG, DPT1, DPT2, DPT3,
Measles, OPV1, OPV2, OPV3, MMR1, Hepa B1, Hepa B2, Hepa B3, Chickenpox, Hib
1, Hib 2 and Hib 3 according to their age and intervals.