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Patient's Profile

Name: A.R.
Address: Bulacan, Talisay City, Cebu
Age: 55 years old
Gender: Male
Birth Date: 12-12-1945
Marital Status: Married
Religion: Roman Catholic
Nationality: Filipino
Educational Attainment: College Undergraduate
Occupation: Retired Sales Agent
Chief complaint: Poor Wound Healing at right lower extremities and left
foot
Date of Admission: 03-05-2017
Date of Discharge: 03-10-2017
Attending Physician: Dr. E. Tiempo/ Dr. K. Cimafranca

Final Diagnosis:
- Diabetic Foot, 2nd digit of Left foot
- Non-healing wound, right anterior leg area
- Coronary Artery Disease
- Hypertensive Cardiovascular Disease
- Diabetes Mellitus Type 2, poorly controlled
- s/p wound debridement (3-08-17)
NURSING HEALTH HISTORY

History of Present Illness:

Patient was diagnosed with Diabetes Mellitus in the year 2000. He


was then prescribed to take Metformin 500 mg tablet once a day as
his maintenance medication for diabetes. Two weeks prior to
admission, patient noted swelling and tenderness on his left leg
particularly the second digit of left foot.

A week prior to admission, patient was bitten by a mosquito at the


right anterior leg area, which he described as pruritic thus the
patient kept on scratching until he accidentally excoriated the
lesion. The lesion was noted to be erythematous with a central
ulceration measuring 2cmx3cm. It was also associated with swelling
and serous discharge. The patient self-medicated by placing
grounded amoxicillin tab directly to the wound with no relief of
symptoms noted. Condition was tolerated and so he didn't go for
consultation.

However, 3 days PTA, patient noted persistence of non-healing


wound at right leg, and the swelling and tenderness of the left foot
accompanied with dark discoloration of the 2nd digit of the foot.
Hence, patient decided to seek consultation and was then advised
for admission.

Past Health History:

As a child, when he was five years old, he experienced having


chickenpox and mumps.
He doesn't remember if he had received immunizations in his
childhood years.
No other childhood illnesses were remembered by the client aside
from the occasional cough and colds and diarrhea.

In the same year he was diagnosed with DM type 2, he was also


diagnosed with hypertension and he takes a prescribed medicine as
maintenance, which is Losartan 100mg tab to be taken once a day.
In 2004, patient had undergone nasal polypectomy at Perpetual
Succour Hospital, Cebu City. In 2015, he was once again admitted
at Perpetual Succour Hospital due to easy fatigability and work up
showed that he has Coronary Artery Disease. He was advised to
undergo CABG, but he refused because of financial concerns and
opted for pharmacologic management.

Family History:

According to the patient, his family had a history of Diabetes


Mellitus and Hypertension on both his paternal and maternal sides.

Social History:

Patient was a smoker, he consumed about 2-3 packs/day for a total


of 30 pack years According to the patient, he had stopped smoking
last 2015. The patient was also a heavy alcohol drinker consuming
about 6 Beer grande per session 3-4x a week, he also stopped
drinking last 2015 but he still drinks little amount of red wine and
brandy occasionally.