Scribd
Upload
28 views2 pages

Case Data and Information Patient's Biographical Data

This document contains biographical and clinical information about patient J.P.B., an 82-year-old man admitted to the hospital on February 17, 2017 for being unable to talk, walk or eat. His past medical history includes hypertension but no other illnesses. A physical examination found him conscious and coherent with normal vital signs and no other abnormalities noted.

Uploaded by

Sydelle Gravador
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
28 views2 pages

Case Data and Information Patient's Biographical Data

This document contains biographical and clinical information about patient J.P.B., an 82-year-old man admitted to the hospital on February 17, 2017 for being unable to talk, walk or eat. His past medical history includes hypertension but no other illnesses. A physical examination found him conscious and coherent with normal vital signs and no other abnormalities noted.

Uploaded by

Sydelle Gravador
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 2

CHAPTER II

CASE DATA AND INFORMATION

Patients Biographical Data

Patients Name: J.P.B

Date of Birth: January 11, 1935

Age: 82 years old

Address: Barangay Linantayan, Basay Negros Oriental

Case Number: 10344745

Physician: Dr. HMJ

Date admitted: February 17,2017

Time of admission: 04:07 pm

Health Insurance: Philhealth

Source: Patient 10 %

S.O - 80 %

Chart - 10%

S.O - 20%

100%

Chief of Complaint: Unable to talk, walk and eat

History of Past Illness:


Past History:

(-) DM
(+) HPN
(-) Arthritis
(-) Heart disease
(-) Kidney disease
(-)Bronchial Asthma

Physical Examination:

Conscious and coherent


(-) pallor (-) Jaundice; Jenile skin turgor and mobility
Normocephalic anicteric sclerae
Pink palpebral conjunctivae
Supple neck
A dynamic precordium, distinct S1 and S2
No deformities or swellings noted

You might also like