CLINICAL INFORMATION

C. Past medical history: According to our client, this is his 4th time to be admitted in the Cotabato Regional and Medical center. The first was in June 2009 due to stroke and he experienced right sided paralysis. Prior to that, he was fond of eating fatty foods with coconut milk, goat meat, beef and salty foods and he also smoking. But after his stroke, he changed his diet and had therapies but he didnt stop smoking(1 pack/day). He also stopped working. The second was September 2010 due to persistent cough. And the third was caused by hypertension which occurred last May 2013. General data: Patient X, 69years old, married, residing at Dalican Gang, Sultan Kudarat and was admitted at the Pay ward room 5 of Cotabato Regional and Medical Center due to emergency hypertension.

Personal/Social History:

OCCUPATION: None WEIGHT: 56 kg HEIGHT: 52 BMI: 22

EDUCATION: Elementary undergrad STATUS: Married NO. OF CHILDREN: 6 NO. OF PARTNERS: 1 DRUG USE: (-) SMOKING: (+) ALCOHOL INTAKE: (-) ADMITTING DIAGNOSIS: Hypertensive urgency

History of present illness:

According to Patient X, 1 week prior to his admission he experienced difficulty of breathing associated with chest pain usually at night, dizziness, easy fatigability, nape pain, palpitations, weakness and headache. But he tried to manage it at home by sitting and by taking Captopril SL. On the 7th day, he consulted Dr. Maliga and his BP was 220/110 mmHg and was advised to be admitted to his room of choice under his service for monitoring and proper nursing and medical management on November 21, 2013.

PAST MEDICAL HISTORY: (+) history of previous surgery (-) others (+) Hypertension (+) persistent cough (-) DM

FAMILY HISTORY (+) HPN(paternal side) (-) DM (-) others