PATIENT’S PROFILE

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
Past History
 
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

Present history:

Last May year 2008 patient was admitted at JMC and was diagnosed of having liver cirrhosis.

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.
GENOGRAM