A.

Patients Profile
1. Demographic data:

Name:
Gender: Male
Age: 74
Civil Status: Single
Birthday 04/8/1940
Birthplace: Bauko Mountain Province
Address: Crystal Cave Baguio city
Nationality: Filipino
Religion: Roman Catholic
Date of admission: 03 24 2015
Admitting Physician:
Diagnosis: Pneumonia,PTB suspect
Final Diagnosis: Post TB Bronchiectasis

2.Health History
1.Chief Complaint

Nahihirapan akong huminga at matagal na itong ubo ko

2. History of Present Illness: The patient was apparently well until 2 days prior to admission
he experienced difficulty of breathing with associated productive cough characterized as thick
greenish sputum felt throughout the day, with noted chest pains and 2 pillows orthopnea but no
fever,no body weakness and joint pains.No medication and no consultation was done.
The condition persisted until few hours Prior to admission,patient was still coughing and with
noted chest discomfort. Patient also complained of on and off knee pains, precipitated by
movement and relieved by rest .These prompted patient for consultation,hence admission.

3. History of Past Illness

A.Past History : The patient has a diagnosed history of PTB in 2007 with medications
taken(unrecalled) and has Hepatitis B. The patient has no history of hypertension, Diabetes
Mellitus ,bronchial asthma ,heart disease and stroke.
.The patient has no known food and drug allergies and no previous surgical interventions done.

B.Family History The patient has a family history of hypertension and COPD on his fathers
side:Grandfather and pneumonia on his father. No known family history of d iabetes mellitus
,heart disease ,stroke ,bronchial asthma ,PTB and cancer

C.Social and Environmental History the patient previously works as a private miner for 35
years.The patient is a smoker for 50 pack years , an occasional alcoholic beverage drinker and
loves to eat salty foods .He is living in a well ventilated and non congested environment with his
family.He has a good interpersonal relationship with his family ,friends and within the
community..Water is obtained from a nearest water refilling station.The water for domestic use
is from water district.The patient has pets (dog) and stayed out the house.Toilet is flushed type.

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LIST OF PRIORITIZED PROBLEMS
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PRIORITIZATION OF PROBLEMS:
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