Wednesday, September 15, 2010

History of Present Illness

The patient was diagnosed as having hypertension in the year 1990. He was able to control his high blood pressure by taking the prescribed anti-hypertensive drug for 8 months which he could not remember the name. However, the patient wasn’t able to comply with his medication regimen and didn’t have follow up consultation because of financial problem.

Few days prior to patient’s admission, the patient experienced headache, nausea and vomiting from unknown reasons, increase in his blood pressure, muscle weakness and drowsiness. He was rushed in a local hospital in Sta. Mesa and experienced seizures during his stay. They were advised for transfer to another hospital for further management.

On September 01, 2009 at 3:05 pm, the patient was admitted to the emergency department of Sampaloc District hospital with chief complaints of increased in blood pressure and decrease sensorium. The attending physician asked the patient’s relative regarding the symptoms experienced by the patient and ordered a series of diagnostic exams which include SGPT, H. pylori test, HCT, BUN, serum creatinine, serum Na, serum K, Complete blood count, FBS, Chest X-ray, cranial CT-scan, and RBS


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