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Guiriba, Jon Jerico M.

3-D

July 21, 2015


Dra. Asuncion Tan

Identifying data: M.A.,62 years old, Born on April 17, 1953, Manila, Religion is Iglesia
ni Cristo, Married, Filipino nationality, currently resides in Bagong silang, Caloocan,
admitted on July 9, 2015 in NRMF-medical hospital.
Chief complaint: follow up
Interval History:
30 years prior to admission, patient presented with back pain, incontinence,
and fever. Patient frequently delays voiding because of her work. She was
diagnosed with Pyelonephritis with UTI, physician prescribed antibiotics which
relieved the signs and symptoms.
1 year prior to admission the patient presented with above symptoms and
was prescribed unrecalled antibiotics. Same signs and symptoms recurred 3 more
times. Also diagnosed with Diabetes Mellitus type 2, Metformin 500mg/tab BID was
prescribed as maintenance. Diagnosed with Hypertension, Losartan 50mg/tab OD
was prescribed as maintenance.
16 days prior to admission, patient presented with fever, 42C, had syncope.
Admitted in FEU NRMF medical hospital for 7 days, was diagnosed with
Pyelonephritis, Pneumonia, and Liver cirrhosis. Omeprazole 40mg/capsule, 1capsule
OD, Nitrofurantoin 100mg/tablet OD.
1 day prior to admission patient presented with fever and loss of appetite,
38.4C, self-medicated with Paracetamol every four hours, four times, which relieved
the fever.
On the day of admission patient went for a follow-u checkup. Urine culture
was conducted, results showed the urine was positive with blood. Patient was
advised for admission by the physician, resulting to subsequent admission to FEU
NRMF medical hospital

Past Health history:

Had measles, chickenpox, mumps


1985: Diagnosed with Pyelonephritis
2014: Diagnosed with Diabetes, Hypertension and Pyelonephritis
No history of accidents, mental illness, allergies, operations, blood transfusion
March 2015: admitted to Jose rodriguez hospital due to diarrhea
No accidents, no surgeries, no blood transfusions

Family History:

Father: Died 65 years old because of asthma

Mother: Died 66 years old unrecalled cause of death


Siblings: 7 siblings, youngest sibling died of Leukemia, other siblings
apparently well
Children: 4 children, 3 female 2 male, 2 nd child, female, has UTI, other
children apparently well
No history of diabetes, kidney disease, hypertension
No history of mental illness

Personal and Social History:


Married, Husband 67 years old and 4 children all apparently well, works as a
tailor. Highschool graduate. Sleeps for 5 hours regularly. No regular exercise, does
not drink alcohol, does not smoke. Fond of eating vegetables, avoids salty foods.
One story house near the highway, lives with husband and 3 rd child. Source of water
is Maynilad and mineral water. Garbage is collected 2x a week.
Gynecologic history:

Mencarche: 14 years old


Irregular menses (longest interval: 1year)
G4P4, all delivered normal spontaneous delivery by an obstetrician with no
fetomaternal complications

Review of Systems: