PATIENT’S PROFILE
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NAME: Mrs. Villegas
AGE: 69y/o
SEX: Female
ADDRESS: Fairlaine subdivision, Tarlac, City
BIRTHPLACE: Tarlac
NATIONALITY: Filipino
RELIGION: Roman Catholic
CIVIL STATUS: Married
BIRTHDAY: June 11,1939
DATE AND TIME OF ADMISSION: July 14, 2008/ 9:01am
FINAL DIAGNOSIS: Massive ascites 2º to portal
hypertension 2 º to CLD
PATIENT’S HISTORY
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Past History
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Medical history: 10 years ago, she developed Hypertension which was controlled by medication and Diabetes
Mellitus
Surgical history: Hysterectomy 15 years ago, Cholecystectomy 17 years ago, Thyroidectomy 20 years,
Apendectomy 25 years ago,
Medications:
plendil and avandia taken 10 years ago.
Allergies:
No known allergies
Injuries and accidents: Ø
Special needs:
Ø
Blood transfusion: 450 cc of packed RBC; type AB; last July 14, 2008
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Present history:
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Last May year 2008 patient was admitted at JMC and was diagnosed of having liver cirrhosis.
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One week prior to admission she developed abdominal enlargement with accompanying occasional chest pain but
she didn’t perceived the need to seek for medical help. Three days prior the admission, her friend who was a
registered nurse suggested her to be self examined by a physician. She was diagnosed of having massive ascites 2º
to portal hypertension 2 º to chronic liver disease (CLD) and advised to be admitted at JMC.
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GENOGRAM