Luna
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IV. Pat ient ’s Profi le
Name: Mr. AU Address: Brgy. II-C San Pablo Laguna City Birthday: Birth place: Laguna City Age: 49 yrs. old Sex: M Civil Status: Married Nationality: Filipino Religion: Inglesia Ni Cristo Occupation: Technician Chief Complaint: Date of Admission: 08/20/09 Admitting Physician: Dr. Andres Admitting Diagnosis: Fx class complete tibial plateau (L1, C3)
Nursing History
Chief Complaint: Pain in left lumbar
A. Past Medical History
Mr. AU significant childhood illnesses are measles, chickenpox, mumps, sore eyes and fever. According to his relatives, he was able to complete all the immunizations required in his childhood life such as BCG, Hepa B, measles, DPT and OPV vaccines. According to his relatives, being admitted to San Juan Medical Center was the first time that Mr. F.D.G’s was being hospitalized. They also noted that Mr. F.D.G had not yet encountered any form of surgery but do practice self medicating whenever he feels something wrong in his health. His relative as well mentioned that Mr. F.D.G does not practice taking up any vitamins in spite of the job he have as a street sweeper.
B. History of Present Illness
Two minutes prior to admission, the patient was sweeping the streets when he suddenly noted right chest pain aggreviated by deep breathing. The patient then went to the Emergency Room of San Juan Medical Center for a consultation then being admitted on the same day.
C. Family Health History
According to his relatives, they live as an extended family in the same house in the vicinity of San Juan. Mr. F.D.G was a smoker a year ago and admitted that he was a alcoholic drinker. They admitted that his job as a street sweeper was not enough to sustain all the needs of their family financially. His father was a carpenter before and was diagnosed with Diabetes while his mother was a simple housewife and no medical illness noted
Name: Mr. AU Address: Brgy. II-C San Pablo Laguna City Birthday: Birth place: Laguna City Age: 49 yrs. old Sex: M Civil Status: Married Nationality: Filipino Religion: Inglesia Ni Cristo Occupation: Technician Chief Complaint: Date of Admission: 08/20/09 Admitting Physician: Dr. Andres Admitting Diagnosis: Fx class complete tibial plateau (L1, C3)
Nursing History
Chief Complaint: Pain in left lumbar
A. Past Medical History
Mr. AU significant childhood illnesses are measles, chickenpox, mumps, sore eyes and fever. According to his relatives, he was able to complete all the immunizations required in his childhood life such as BCG, Hepa B, measles, DPT and OPV vaccines. According to his relatives, being admitted to San Juan Medical Center was the first time that Mr. F.D.G’s was being hospitalized. They also noted that Mr. F.D.G had not yet encountered any form of surgery but do practice self medicating whenever he feels something wrong in his health. His relative as well mentioned that Mr. F.D.G does not practice taking up any vitamins in spite of the job he have as a street sweeper.
B. History of Present Illness
Two minutes prior to admission, the patient was sweeping the streets when he suddenly noted right chest pain aggreviated by deep breathing. The patient then went to the Emergency Room of San Juan Medical Center for a consultation then being admitted on the same day.
C. Family Health History
According to his relatives, they live as an extended family in the same house in the vicinity of San Juan. Mr. F.D.G was a smoker a year ago and admitted that he was a alcoholic drinker. They admitted that his job as a street sweeper was not enough to sustain all the needs of their family financially. His father was a carpenter before and was diagnosed with Diabetes while his mother was a simple housewife and no medical illness noted
