University of San Carlos

College of Nursing
Cebu City

CASE STUDY FORMAT

I. PATIENT DEMOGRAPHIC PROFILE

Name:Ayda Bagayao Age: 54 Status: Divorced

Religion: Catholic Occupation: N-O-N-E

Nationality: Filipino Gender: Female

Home Address: Sto. Rosario, Jagobiao, Mandaue City

II. HEALTH HISTORY PROFILE

A. Past Medical History (include dates, severity, complications if any)

1. Pediatric and Adult Illness

Date Illness Medication Remarks

Can’t recall Hypertension
Pre-diabetes Meformine

2. Immunization

Immunization Doses Dates Remarks

BCG 1 Can’t remember
DPT 3
OPV 3

3. Hospitalization

Date/Year Hospital Diagnosis Duration

Year 2000 Vicente Sotto Menopausal 3 days
MemoRial Medical
Hospital

4. Injuries and Accidents

 Nay Ayda has no past injuries and accidents.

5. Transfusions
No past transfusions.

6. Allergies (specify)
No allergies.

B. Family History (support with a Genogram and limit to two (2) generation if
patient can recall).

Lola Anding (D,L) Lolo Basik (D)

Jonathan Roger Ayda (HTN, DM) Liza (L)

Jennifer (M) Sheena (M) Jun2x (S)

Legend: D– Deceased
M- Married
HTN - Hypertension
DM - Diabetes Mellitus
S– Single
L- Leprosy
* Only the side of Ayda. She is divorced!

C. Social and Personal History

Nay Ayda has no job. She stays at home. Cook for her grandchildren and
nieces and also for her brother who stays in her and who supports them in their daily
needs. Nay Ayda has (3) three children. Jennifer, as her eldest and is married.
Sheena, her middle, also married and is pregnant. And her youngest who stays with
her named jun2x, still studying and single. Nay Ayda has no experience in military or
foreign travel. She has no habits at all. Her diet, before she likes sweets and loved
to drink soft drinks. But she was advised by the doctor to minimize it because her
glucose level is high. And so she did. Nay Ayda has an extended type of family. This
composed of a brother, niece, grandchildren, and son. Her beliefs in cultural was,
Leprosy is not a communicable disease but it is in the blood.

Nay Ayda’s daily average day is, in the morning, she was clothes, cook, take
care of her grandchildren, do household chores. She takes a nap during day time if
she is done with her activities.
D. Review of System (for the past 6 months). Physical Assessment

General Weight Loss Fatigue Anorexia Night Sweats

Chills Fever Weakness
- overwork because of activities in the house.

Skin Itch Rash Lesions Bruising Bleeding Color Change

Eyes Pain Discharges Itch Vision Loss Diplopia

Excessive Tearing Glasses/Contact Lens Date of Last Exam:
- when she stands up suddenly, she sometimes lose her vision.

Ears Earaches Discharges Tinnitus Hearing Loss

Nose Obstruction Discharges Epistaxis

Throat and Mouth Sore Throats Bleeding Gums Toothache Dentures

Neck and Head Swelling Dysphagia Hoarseness

Chest Cough Sputum: Amount and Character Hemoptysis

Wheeze Pain on Respiration Dyspnea

Cardiovascular Precordial Pain Palpitation Dyspnea on Exertion

Paroxysmal Nocturnal Dyspena Orthopnea
Edema Heart murmur Thrombophlebitis Claudication

Gastrointestinal Heartburn Nausea Vomitting Diarrhea Food Intolerance

Excessive gas or indication Constipation Change n Bowel
Movement
Jaundice Bloating Melena Hemorrhoids Hernia
Genitourinary Heartburn Nausea Vomiting Diarrhea
Food Intolerance Excessive Gas or Indication Constipation
Change in Bowel Movement Jaundice Bloating
Melena Hemorrhoids Hernia

Extremities Joint Pains Varicose Veins Claudication Back Pain

Edema Stiffness Deformities

Endocrine Hot Flashes Hair Loss Temperature Intolerance

Polydipsia Goiter

Neurology Numbness Tingling Tremor Fainting Headaches

Muscle Weakness Ataxia Unconsciousness Paralysis/paresis
Memory Loss Dizziness Seizure
-bacause of overwork or over fatigue.

Psych Anxiety Depression Sexual Problems Insomia

Nightmares

Others
Pathophysiology of Diabetes Mellitus
 CASE STUDY

Diabetes Mellitus

By:
DAN CAPAPAS
JOHN KENNY CAMPOS
HOPE BERNADAS

Group 56
3L