I.

Vital Information

Client’s Name: Mr. M.G.

Age: 45 yrs. Old
Sex: Male
Weight: 78 kgs
Height: 5’7
Civil Status: Married
Religion: LDS
Nationality: Filipino
Birthplace: Busan, South Korea
Birthday: 05/06/1964
Current Address: Molo, I.C. Iloilo city
Educational attainment: BSME CPU
Occupation: Drilling Engineer
Chief complaints: Right Flank pain
Date and time of admission to ER: January 10, 2010, 7:29am
Manner of admission to the ER: Ambulatory
Accompanied by whom: Mrs. C.G (wife)
Mental/Emotional status upon admission: conscious, alert, oriented, cooperative and
understanding
Admission Vital Signs:
Temperature: 36.8degree celsius
Pulse rate: 89beats/min
Respiratory rate: 22breaths/min
Blood pressure: 140/90 mmHg
Impression/Medical Diagnosis:
T/C Urolithiasis Right. DM2, Deplipidemia
S/P ARF stage 2 to pre-renal azotenia stage 2 to severe DHN (2005)
S/P HDx4 (2005)
Attending Physicians: Dr. C and Dr. M
Number of previous hospitalizations: 1 – year 2005 because of renal failure
Food/drug allergy: Aspirin
Source of information: Patient – Primary
Person to be contacted incase of emergency: Mrs. C.G.
Contact number: 09194486282

II. History of present Illness

Last January 8, 2010 at around 4pm in the afternoon patient felt slight gnawing pain in
his right flank area rated as 3 base on the pain rating scale, the pain was tolerable and was felt by
the client in their house at Molo, I.C. Ilo-ilo city. Patient verbalize that he doesn’t know of any
aggravating or alleviating factors that could contribute to his pain. As said by the patient there
were no remedies, medications or treatment being utilize to relief the pain he just endure it and
hoping that it will be gone by the next day with some rest and sleep. On the last January 10, 2010
at around 3am in the morning client felt severe gnawing pain in his right flank area rated as 9.
Clients then decided to be admitted and upon arrival to the ER the following laboratory were
ordered as follows: Chest X-ray PA view, IS-APL Xray, FPS, UA, iP and Ultrasound of KUB.
Treatments were CBG-TID and Buscopan 1amp 26H for flank pain. Medications were as
follows: Metforfin – Glucophage, Forte 850mg 1tab (Breakfast and dinner), Acarbose –
Glucobay 100mg 1tab TID, Droglitazone – Prialta 15mg 1tab OD before dinner, Atorvastatin –
Lipitor 20mg 1tab OD, and Fenofiltrate – Tipantyl 200mg 1tab OD. An IV was attached to the
client’s right radial vein PNSS 1Lx100cc/hr and was then transferred to Sacred Heart Unit via
wheel chair accompanied by Mrs. C.G and received by staff nurse and assigned to room 234 as
the client’s room of choice.

III. Past Medical History

 The patient claimed that he was in good state of health prior to illness. The immunization
that the client can remember is BCG and polio that was taken but the patient claimed that he had
completed his immunizations. There was one previous hospitalization last year 2005 because of
renal failure and there were no history of accidents/falls or any injuries and no psychiatric illness

IV. Current Health Status

As verbalize by the patient he does not smoke, or take any illegal drugs and occasionally
drinks with only 1 beer and started drinking during his high school days. Client has good appetite
and can consume 100% of his meal; client usually eats vegetables, meat, fish, and rice and also
drinks 2-3 glasses of water per day. Has no bladder/bowel incontinence or difficulty during
bowel movement/urination. Patient’s goes to gym or cycling 3 times a month as form of exercise
and sleeps in supine position with two pillows one on his head and one that he is holding while
sleeping. Usually sleeps 10pm in the evening and wakes up 7am in the morning. The medication
that the client is currently taking is the maintenance medication for his Diabetes Mellitus.

V. Family History

The family of the patient is compose with Him Mr. M.G – 45 yrs. Old, Mrs. C.G – 44 yrs.
Old, Ms. S.G – 20 yrs. Old, Ms. Z.G – 18 yrs. Old, Ms. M.G – 3 yrs. Old. The rest of the family
member is in good health condition. The father of the client died at the age of 69 because of heart
attack and his mother died at the age of 44 because of breast cancer and his brother Mr. R.G died
at the age of 24 because of heart attack. As said by the client his grandmother had Diabetes
mellitus and there were no existence of rare genetic conditions.

VI. Personal History

As claimed by the patient he lived in an urban area and there were no environmental
hazards in their home that could contribute to his present illness or can trigger an illness
response. The patient has no problem in performing activities of daily living such as bathing,
dressing, cooking and eating. The patient has a good relationship with his family and he is the
one who makes the final decision in terms of decision making. The family is independent in
terms of support system in times of needs and also in financial situation as verbalized by the
patient. The monthly income of the patient is 200,000php and according to the patient it is
enough to support the basic needs of the family. The patient claimed has a good relationship
toward his wife.