PATIENT PROFILE

NAME: Patient Dare

AGE: 70 y/o
SEX: Male
ADDRESS: Bangsoy Subdivision Ambiong road, Aurora Hill Baguio City
OCCUPATION: Retired Crewman
RELIGION: Roman Catholic
CIVIL STATUS: Married
BIRTHDATE: September 20, 1945
CHIEF COMPLAINT: Dizziness, Shortness of breath
DATE OF ADMISSION: 03-30-16
ADMITTING PHYSICIAN: Dr. Ang
ATTENDING PHYSICIAN: Dr. Sofia Black
DIAGNOSIS/S: DM II, CAD, HPN, BPH, COPD
PATIENT HISTORY
HISTORY OF PRESENT ILLNESS
A few hours before admission, the patient experienced dizziness, shortness of breath,
chest pains, the patient then resorted to taking the due maintenance medications that were
previously prescribed by his physician. Few hours after taking the medications, the said sign
and symptoms persisted prompting the patient to seek consult at SLU-HSH. There he was
subjected to different diagnostic test and was found out to have atherosclerotic aortic knob and
pleural thickening, hence admission.
PAST MEDICAL HISTORY
The patient had his first heart attack back in 1992 with associated symptoms of left
hemiparesis, dizziness, and shortness of breath. Work up and diagnostics at Saint Lukes
Medical Center revealing a mild ischemic heart due to fat and nicotine deposition in the
coronary artery. On the year 1997, he had his second episode of heart attack with associated
symptoms of left hemi paresis with tingling sensations described as Nanlalamig at parang
nakukuryente yung kalahati ng katawan ko. Left tongue deviation was also noted. Work up and
diagnosis again revealed another artery in the heart to be obstructed. On the year 1999, the
patient decided to move to Baguio City, and his doctor from St. Lukes Medical Center referred
him to Dr. Black of SLU-HSH. On the year 2001, the patient was diagnosed to have emphysema
and chronic bronchitis, he was then advised to quit smoking, but as the significant others
claimed Tumatakas takas pa din siya nun, naninigarilyo ng paisa-isa. On the same year,
another blood vessel was diagnosed to be obstructed due to nicotine and fat deposition. On the
year 2007, the patient was confined due to gastritis with associated bleeding of the GIT and

abdominal pain. A few months after, the patient experienced lumbosacral pain, and latter
diagnosed to have Benign prostate hyperplasia through biopsy. Surgery was suggested but the
patient refused and decided to take medications as primary therapeutic regimen. On the year
2013, the patient was diagnosed to have an inguinal hernia. On the same year, the patient was
also diagnosed to have Diabetes Mellitus type 2. Last February 2016, the patient was again
hospitalized due to Pneumonia. There are no other significant medical histories since then.
SOCIAL-ENVIRONMENTAL HISTORY
The patient claimed to have started smoking at the age of 15 years old with average pack
1 and a half pack of cigarette per day. The patient is also an occasional alcoholic beverages
drinker. The patient lives in a two storey house in a non-congested neighbourhood with his wife
and children. Water for drinking purposes come from a water refilling station near their
residence and water for domestic use come from the Baguio Water District. The patient is
married, with 4 children and is a retired crewman in a ship.
FAMILY HISTORY
The patients mother was known to have diabetes mellitus that had a trajectory problem
of nephropathy, and died at the age of 86 years old. His father was diagnosed to have bone
cancer and died at the age of 64 years old. His grandmother on the maternal side was diagnosed
with HPN and died at the age of 100 years old. There are no other significant heredofamilial
diseases in the family.