DEMOGRAPHIC DATA

Name: Patient L
Age: 62 years old
Gender: Female
Birthday: February 28, 1960
Birthplace: San Vicente, Urdaneta, Pangasinan, Philippines
Marital Status: Married
Religion: Roman Catholic
Address: Purok 2, Rang-ayan, Roxas, Isabela
Occupation: Housewife
Race: Filipino
Ethnic Origin Ilocano
Educational Attainment: High school graduate
Primary Language Spoken: Ybanag, Ilocano
Attending Physician:  Dr. Charito Dayos- Dayos- Pascual Medical
Center
 Dr. Victor Jesus Villaroman of Dr. Ester R.
Garcia Medical Center – Main AP
 Dr. Christine Untalan (Pulmonologist)
Significant Other or support person: Husband
Date of Admission May 2, 2022
Time of Admission 06:28 am
Hospital  Dayos- Pascual Medical Center
 Dr. Ester R. Garcia Medical Center
 Isabela United Doctors Medical Center
Chief complaint Difficulty of breathing
Body weakness
Admitting Diagnosis Heart failure secondary to Ischemic heart disease
Final Diagnosis Cardiopulmonary arrest secondary to Acute
Respiratory Failure Community acquired pneumonia
high risk with hypoxia; Coronary Heart Failure
Source of Data 80%- Patient L
20%- Husband

FAMILY BACKGROUND
 Patient L is a married woman, who belongs to a nuclear type of family. They are
currently residing at Purok 2, Rang-ayan, Roxas, Isabela. Patient L together with her husband
and youngest son, are currently living in their 7x9 concrete house with a galvanized roof
estimated by her husband. The house is occupied by the whole family which has 3 bedrooms, a
kitchen and a receiving area. The first room is occupied by Patient L and her husband. While the
second room is occupied by his youngest son alone. The third bedroom is reserved only for her
eldest son when he will come home together with his wife and son. The distance of their house to
the city is approximately 6 kilometers away and the time of travel is about 15-20 minutes when
using public transportation. Their kitchen is located outside the house which is approximately 4
meters away. The distance of their kitchen from the comfort room is about 4 meters. In their
kitchen, they are using wood for cooking which is used daily by the family. The appliances
available in their home are, television, electric fan, speaker, washing machine and rice cooker.
The type of their comfort room is a water-sealed in which they own it. Their water source is from
a pump well used for washing clothes, cleaning, dishwashing, etc. In terms of their potable
drinking water, it is from free flow water and sometimes they will buy mineral water if her
grandson is at their home. On the other hand, with regards to their home and environment
condition, they are secured from any health threats and any accidents inside their house.
Patient L is a high school graduate and now a full time housewife since they got married.
The source of income of the family is from farming because they have their own 1 hectare which
is planted with Palay twice a year and their net income each cropping is about 20,000. Another is
from their ½ hectares of fruit bearing trees, specifically mango and banana trees. The husband
said that they can receive 2,500 from it. They also have livestock like goats, ducks, and native
chicken to sell for additional income. They also have a sari-sari store which can generate income
of approximately 2,000-3,000 per month. Patient L stated that their income is enough for them to
survive since they are only 3 living permanently in their home. Her husband also said that they
can save money from it for future use and they are also giving money to their first born son
especially when they need it.
 In terms of nutrition, she ate 4 meals and 2 snacks in a day. For breakfast, she usually
has coffee (½ tbsp of sugar,2 tbsp. of cream, 1 tbsp of black premium coffee), 2 cups of fried
rice, fried egg, and fried smoked fish with tomatoes. She would love to dip in a spicy bagooong
sauce and fish sauce but it depends on the dish prepared. The usual snack of Patient L at 10 am
was 4 pcs of white loaf bread with mayonnaise spread, donut, mamon and ½ liters of coke. For
lunch, she would have meat like papaitan or adobo with 2 cups of rice and she would take
another serving of rice if she desired. At 2pm she usually has ice cream or a slice of cake if there
is. At 4pm, Patient L consumed 1-2 cups of rice with leftover dishes from lunch. While for
dinner, she would usually have tinola, chopsuey, dinengdeng or pakbet with 1 cup of rice. At 7
pm while watching television, she would eat nuts, crackers or chips. When it comes to her
potable drinking water, she can drink 2 liters of water a day. She does not have any vices like
drinking alcohol or smoking and doesn’t have a regular check-up because she only seeks for
medical attention when she cannot tolerate anymore.
When it comes to her habits in life, she considers cleaning the house like pulling grass,
sweeping, washing clothes as her hobby. She tends to walk 300-400 meter every day for her
exercise. In terms of hygiene, she takes a bath two times for morning and noon while she takes a
shower at 7pm. While for her sleeping pattern, she usually sleeps at 9pm and wakes up at 5am.
In waste disposal, they separate the plastic (non-biodegradable) from the leaves (biodegradable).
The leaves serve as their fertilizer because they also have flowers and vegetables planted in the
backyard. While the plastics waste is placed in a sack because there is a dump truck that collects
their waste every Saturday.

FAMILY HEALTH HISTORY

Patient L’s family is in the middle class of society. On her paternal side, she was not able
to identify her grandfather and grandmother because they died before she was born. The father of
Patient L was the fourth born child. He is a carpenter and died in their home at the age of 68 due
to ulcer as stated by her. Whereas on her maternal side, she was not able to identify any
information of her grandfather and grandmother because they died before she was born. The
mother of Patient L was the third born child and died in their home at the age of 65 due to
hypertension.
Patient L’s mother and father were bestowed with 9 children. Her mother gave birth to
her 9 children through normal spontaneous delivery inside their house in San Vicente, Urdaneta,
Pangasinan which was assisted by a traditional midwife. All of them were breastfed by their
mother. The first born child was a 73 years old woman, who died at their home due to
hypertension. While the second child is a 80 years old woman who doesn’t have any
illness/disease. The third child is a healthy woman with 78 years of age. The fourth child is a 69
years old woman who doesn’t have any illness/disease. Another is the fifth born child with the
age of 65, a healthy woman. Next is the sixth born child which is a 64 years old woman without
any illness/disease. While the seventh child was 60 years old when he died at the hospital due to
enlargement of the sinus as stated by the patient. She was not able to identify the hospital where
her sibling died, who was the attending physician as well as the date and time of confinement.
The eight born child is Patient L who is a 62 years old woman. She was diagnosed by Dr.
Charito Dayos with diabetes mellitus and enlargement of the heart in December 2021 at Dayos-
Rizal Medical Hospital. Unfortunately, she died at Isabela United Doctors Medical Center on
May 5, 2021 due to complications. The ninth born child is a healthy 60 years old man without
any illness/disease.
Patient L’s husband is 60 years old now. They were bestowed with 2 children and both of
them are still alive and don't have any illness/disease. The first born child is a 25 years old man
and he works as a bagger for Puregold-Roxas. The second born child is a 21 years old male who
doesn’t have any illness/disease. He is currently studying as an information technology student.
 

GENOGRAM

PAST HEALTH HISTORY

At the age of 12, she experienced breast development and also her first menstruation. She
experienced a normal menstrual cycle and it lasted for about 5 days. Patient L can use 3- 4
napkins fully soaked and she does not experience any menstrual discomfort like dysmenorrhea.
Her axillary and pubic hair started when she was at the age of 14. Patient L and her husband
were married on May 4, 1995. Patient L delivered a cesarean section to her 2 born son. The first
born child is a 25 years old male now and delivered via cesarean section at Dumlao Hospital in
Roxas, Isabela. She was 35 years old during her first pregnancy. According to the patient, the
weight of her first son was 4.5 kg. Her physician which was Dr Neonema told that due to the
weight of her baby and already reached the due date of her delivery but still not able to deliver
on scheduled date, she needed to be delivered via cesarean section. While their second son is a
21 years old male   now. She was 37 years old back then. Patient L delivered her second son at
Dumlao Hospital in Roxas, Isabela but was unable to identify the doctor because she cannot
recall the name. The second son weighed 4.2kg and that indicated her to deliver their second son
via cesarean section. They are both breastfed by Patient L and are term babies. In terms of
immunization as stated by Patient L, they received immunization such as BCG, Hepa B, DPT,
OPV and AMV-1. Patient L, during her second month of pregnancy she experienced nausea and
vomiting when she woke up in the morning. According to her she relieves it by eating crackers,
fatigue was also experienced and relieved it by sleeping.
With regards to immunization, Patient L stated that she did not complete her vaccination
such as Hepa B, DPT, OPV, AMV-1 aside from BCG because she only knew that she has a mark
in the right deltoid.  Patient L was breastfed and delivered via NSD at their home. Patient L
believes in quack doctors and traditional healers. Hence, she only seeks medical attention when
she is sick. Patient L received Covid-19 vaccine with the brand of Johnson and Johnson on July,
30, 2022 at RHU- Roxas.
She also experienced common illnesses such as colds, fever, cough, headache and LBM.
Patient L managed this using over the counter drugs such as Neosep and water therapy for colds,
Paracetamol for fever associated with cough and colds, Mefenamic for toothache and
Loperamide for Lbm. She had suffered from mumps when she was in elementary school. In
treating her mumps, he used “akot-akot” and mixed it with vinegar. Patient L also had a boil
when she was an elementary student. She said that her father popped the boil with the use of a
bottle and covered the site with pounded petals of Gumamela flower. She does not have any
allergies to foods, drugs, and objects like latex or rubber.
 

PRESENT HEALTH HISTORY

Before hospitalization, Patient L felt headache and pain in the nape but relief it with rest
and sleep. She was 72 kg and started to lose weight. In December 2021, Patient L was rushed by
her husband to Dayos- Pascual Medical Center emergency room because of difficulty of
breathing and body weakness. She was examined by Dr. Charito Dayos, who was her attending
physician. She was diagnosed with type 2 Diabetes Mellitus and an enlargement of heart. She
was instructed to limit her food intake specifically on carbohydrate foods like rice and fatty
foods like meats. Limit water intake of 1 liter to consume for the whole day and low sodium diet.
But the husband told us that Patient L will hide another 1 liter of water and drinks secretly when
there is no one watching. She is non-compliant to the advised of her attending physician because
she wanted to satisfy her thirst.
         On April 28, 2022, she was rushed again by her husband to Dayos- Pascual Medical
Center because of difficulty breathing and body weakness. It had the same signs and symptoms
and problems from December 2021. On the third day, Patient L vomited blood once. She was
confined for about 3 days and transferred to Dr. Ester R. Garcia Medical Center because there
was no Intensive Care Unit inside the facility.
         On May 2, 2022, she was transferred and admitted at 06:28 am to Dr. Ester R. Garcia
Medical Center and her attending physician was Dr. Victor Jesus Villaroman and Dr. Christine
Untalan. Her vital signs are: Blood pressure of 140/80, heart rate of 86, respiratory rate 28,
temperature of 36. There is a positive difficulty of breathing, fever, bilateral crackles and
productive cough. Dr. Villaroman ordered a diagnostic exam; CBC, NA/K, Creatinine, Troponin
1, ABG, 12 Lead ECG and chest x-ray. Patient diet was LSLF and DM diet:Limit OFI <1L/day.
Medication of Piperacillin Tazobactam 2.25g TIB q6, Hydrocortisone 100mg TIB q8 and
Furosemide 40mg TIB q8. They suspected her to have pulmonary tuberculosis. And so, she was
placed in an isolation room.
On May 3, 2022, Patient was diagnosed with pneumonia high risk, congestive heart failure,
diabeter mellitus type 2. Dr. Untalan ordered SARS Dov 2 RT PCR, Sputum genexpert and
drugs such as enoxaparin 0.4ml subq OD, levofloxacin 750mg IV OD and dexamethasone 6mg
IV OD. There is a negative difficulty of breathing and fever. Positive rales on both lung fields,
productive cough, hyperglycemia and bipedal edema. We interviewed the patient at 10 in the
morning in her room. She was with her husband and second son. She responded and answered
questions but she felt tired easily. She lost from 72 kg to 51 kg.
         On May 4, 2022 at 1:20pm, Patient L had cardiac arrest and had a GCS score of 3
(E1V1M1), RBS of 258. They intubated Patient L, performed cpr with ambu bagging and
administered 1 mg of epinephrine. Around 1:50pm, the patient was revived. Due to
unavailability of mechanical ventilator, Patient L was transferred to Isabela United Doctors
Medical Center. At 5pm, the patient was admitted to IUDMC under Dr. Villaroman. With blood
pressure of 150/80, pulse rate of 40, temperature of 36 with GCS of 9 (E1V4M4). At 10:15 pm,
Patient L GCS score is 3 with dilated pupils. There was no pulse that’s why CPR started. After 5
minutes, there is a pulse after administering 1mg epinephrine.
         On May 5, 2022 at 12:30 in the midnight, a weak pulse with heart rate of 76, blood
pressure of 130/80, respiratory rate of 20, temperature of 36 and oxygen saturation of 95. The
family of Patient L family signed a waiver of DNR status.
         When 3:32 in the morning came, Patient L pronounced dead. They gave post mortem
care and were transferred to the morgue.