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Case study Health history

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I. Health history
A. Demographic profile
Name: J.C.
Gender: Female
Age: 37 years old
Birth date: November 8, 1973
Birth place: Brgy. Katilingban Molo, Iloilo City
Marital status: Married
Nationality: Filipino
Religion: Roman Catholic
Address: Brgy. Katilingban Molo, Iloilo City
Educational background: High school graduate
Occupation: Housewife
Usual source of medical care: Doctor/Healthcare Professional
B. Source and reliability of information
The patient J.C. is the primary source of information. He is conscious and coherent,
able to speak Ilongo fluently. His husband is also considered as source of information
regarding patient status and condition.
C. Reasons for seeking care or chief complaint (Top 3)
1st PUC (Premature Uterine Contraction)
2nd Insufficient sleep at night
3rd Scaly of skin
D. History of present illness
Patient J.C. was handled during our duty at Iloilo Doctor’s Hospital
with the chief complaint of insufficient sleep at night, loss of his weight and scaly of
skin. The laboratory tests are CBC, Urinalysis and CST.
E. PAST MEDICAL HISTORY OR PAST HEALTH
Pediatric/childhood
-Complete immunization- (-) serious illness on this stage

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Serious or chronic illness
- July 2004, Diabetes Mellitus diagnosed clinically
-2x FBS result 300mg/dl
1.
-December 2003, Iloilo Doctor’s Hospital, West Avenue Molo, Iloilo City
Admitting diagnosis: Diabetes Mellitus Type 2
Operation
-not applicable
Obstetric History
-not applicable
Immunizations
-Complete immunization
Allergies
-No known allergies to food and medication
Medication
-Cefuroxime (zoltax) 500 mg/tab
1 tab BID
8 - 6
-Fluconazole (Diflucan) 180mg/tab
1 tab PO
as single dose
-Salbutamol (Ventolin)
2tsp TID
8 - 1 6
-Isoxsuprine (Isoxilan) 1oz
1 tab q4H
12 - 6 - 12 - 6

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I. Health history A. Demographic profile Name: J.C. Gender: Female Age: 37 years old Birth date: November 8, 1973 Birth place: Brgy. Katilingban Molo, Iloilo City Marital status: Married Nationality: Filipino Religion: Roman Catholic Address: Brgy. Katilingban Molo, Iloilo City Educational background: High school graduate Occupation: Housewife Usual source of medical care: Doctor/Healthcare Professional B. Source and reliability of information The patient J.C. is the primary source of information. He is conscious and coherent, able to speak Ilongo fluently. His husband is also considered as source of information regarding patient status and condition. C. Reasons for seeking care or chief complaint (Top 3) 1st – PUC (Premature Uterine Contraction) 2nd – Insufficient sleep at night 3rd – Scaly of skin I. Health history A. Demographic profile Name:R.G Gender:Male Age: 41 years old Birth date: September 23, 1967 Birth place: Pasig , Metro Manila Marital status:Married Nationality:Fil ipino Religion: Born Again- Christian Address: Brgy. Pantihan 3, Maragondon, Cavite Educational background: High school graduate Occupation: Factory worker in Monterey Usual source of medical care: Doctor/Healthcare Professional B. Source and reliability of information The patient R.G is the primary source of information. He is conscious and coherent, able to speak Tagalog fluently. His wife is also considered as source of information regarding patient status and condition. C. ...
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