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HEALTH HISTORY A. DEMOGRAPHIC (BIOGRAPHICAL) DATA o Clients Initials: M.E o Gender: Male o Age: 40 y/o o Birth Date: Oct. 6, 1972 o Birthplace: Makati o Civil Status: Single o Nationality: Filipino o Religion: Christian o Address: Bangkal, Makati City o Educational Background: High School Undergraduate o Occupation: Tricycle Driver, Taxi Driver, Vendor o Usual Source of Medical Care: Phil. Health B. SOURCE AND RELIABILITY OF INFORMATION o The source of information is from the Client himself and his mother, who both seem reliable. C. REASON FOR SEEKING CARE o Pain on the lower back due to a lower back abscess. D. HISTORY OF PRESENT ILLNESS o Five months, PTC. o Patient noted single furuncle on his lower back. o No medications taken. o Good appetite but still loses weight. o Furuncle grew, erupted and was infected. o No fever, coughs, cold, or other symptoms. E. PAST MEDICAL HISTORY o (+) Tuberculosis o ( - ) Diabetes Mellitus o ( - ) Asthma o ( - ) Hypertension o ( - ) Allergies to food and medication o ( - ) Previous operations


The client is currently engaged but already has three children, the eldest is a six year old boy, followed by a four year old boy, and the youngest child is a two year old girl. In the family, there is no history of having hypertension, diabetes, asthma or pulmonary tuberculosis. Madalang lang kami magpa-ospital, hindi kami sakitin, as verbalized by the client.

G. SOCIO-ECONOMIC o (+) Previous Smoker consumes 1-2 sticks every day. o (+) Occasional alcoholic beverage drinker o Works as a taxi driver, tricycle driver, and a vendor.

H. DEVELOPMENTAL HISTORY STAGES Infancy (birth to 18 months) Early Childhood (2 to 3 years) BASIC CONFLICT Trust vs. Mistrust IMPORTANT EVENTS Feeding OUTCOME Children develop a sense of trust when caregivers provide reliability, care, and affection. A lack of this will lead to mistrust. Children need to develop a sense of personal control over physical skills and a sense of independence. Success leads to feelings of autonomy, failure results in feelings of shame and doubt. Children need to begin asserting control and power over the environment. Success in this stage leads to a sense of purpose. Children who try to exert too much power experience disapproval, resulting in a sense of guilt. Children need to cope with new social and academic demands. Success leads to a sense of competence, while failure results in feelings of inferiority. Teens need to develop a sense of self and personal identity. Success leads to an ability to stay true to yourself, while failure leads to role confusion and a weak sense of self. Young adults need to form intimate, loving relationships with other people. Success leads to strong relationships, while failure results in loneliness and isolation. Adults need to create or nurture things that will outlast them, often by having children or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world. Older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads to feelings of wisdom, while failure results in regret, bitterness, and despair.

Autonomy vs. Shame and Doubt

Toilet Training

Preschool (3 to 5 years)

Initiative vs. Guilt


School Age (6 to 11 years)

Industry vs. Inferiority


Adolescence (12 to 18 years)

Identity vs. Role Confusion

Social Relationships

Young Adulthood (19 to 40 years)

Intimacy vs. Isolation


Middle Adulthood (40 to 65 years)

Generativity vs. Stagnation

Work and Parenthood

Maturity(65 to death)

Ego Integrity vs. Despair

Reflection on Life


REVIEW OF SYSTEMS o General: (+) Weight loss (-) Weakness / Malaise (-) Fever (-) Chills (-) Sweats / Night Sweats o Integumentary: Skin no history of skin diseases, (-)jaundice, cyanosis, flushed, (+) multiple wounds in different stages of healing on left lower extremity Hair no recent hair loss or changes in texture Nails no changes in shape, color or brittleness Head: (-) Headaches (-) Head injuries (-) Dizziness / Vertigo Eyes: (-) Difficulty w/ vision (-) Eye pain (-) Redness, swelling, watering, discharge Ears: (-) History of infections, hearing loss Mouth & Throat: (+) Throat pain during coughing, expulsion of mucus. Neck: (-) Pain (-) Limitation of movement (-) Lumps / enlargements Chest & Axillae: (-) Pain (-) Lumps / enlargements (-) Discharge Respiratory: (+) Tuberculosis (+) Sputum (-) Crackles, rales, wheezes Clear breath sounds Symmetrical chest expansion

Cardiovascular: Regular rhythm (-) Murmurs Good S1 and S2

Gastrointestinal: Good appetite (-) Allergies to food and medications (-) History of Abdominal Diseases / Surgery Urinary: (-) Pain (-) Difficulty in urination Genitalia: (-) Pain (-) Sores (-) Lesions (-) Discharge (-) Lumps / Enlargements (-) Hernia Musculoskeletal: Joints (-) Pain, Stiffness, Swelling, Limitation of Motion, Noise w/ Joint Motion Muscles (-) Pain, Cramps, Weakness, Plegia, Coordination Problems Back (+) Pain at the left lower portion of the back Neurologic: Motor Function (-) Paresis, Plegia, Coordination Problems Sensory Function (-) Memory Disorders, Disorientation Mental Status (-) Nervousness, Mood Change, Depression, Hallucination, Dysfunction Hematologic: (-) Bleeding of Skin, Mucous membrane (-) Excessive Bruising (-) Transfusions (-) Lymph Node Swelling Endocrine: (-) Diabetes (-) Thyroid disease (-) Intolerance to heat or cold (-) Diaphoresis


FUNCTIONAL ASSESSMENT The general health of the patient has been good in terms of feeling nothing out of the ordinary, no sickness, illness or disease that aggravates or becomes a hindrance to the clients daily activities. (-) Episodes of coughs and colds, no fever or body weakness. The client feels good about himself and admits that he confidently speaks his mind; he also finds it easy to socialize with the people around him and interact naturally. The patient is able to fully perform self care and needs no assistance. Sleeps an average of five to eight hours, gets plenty of exercise through tricycle/taxi driving, as well as vending. The client is not allergic to any food or medications, has a healthy appetite, he claims that he consumes a lot of food, mostly rice and meat with vegetables, shows a preference of fish over some meats. Does not have a hard time with urination or bowel movement, if ever he does have problems, he claims it is usually solved through increasing fluid intake and eating foods high in fiber. No changes in sexual or reproductive patterns.

K. PERSONAL / SOCIAL HISTORY The client admits to being a smoker in the past and is able to consume a minimum of two sticks per day, he also admits to drinking occasionally. He is the head of the family who works and enjoys working with the people around him and those that avail his services as a tricycle and taxi driver. The client rarely travels far, usually goes on trips with his family in the form of walks and going to the mall. L. ENVIRONMENT HISTORY The family lives in a two bedroom house in Makati, within a closely packed community of houses and other families. The waste management / plumbing work efficiently. Various amenities are available to the family. M. PATHOPHYSIOLOGY Tuberculosis is an infectious disease that primarily affects the lung parenchyma. It also may be transmitted to other parts of the body, including the meninges, kidneys, bones, and lymph nodes. The primary infectious agent Mycobacterium Tuberculosis is an acid-fast aerobic rod that grows slowly and is sensitive to heat and ultraviolet light. Tuberculosis is a worldwide public health problem associated with poverty, malnutrition, overcrowding, and inadequate health care. TB spreads from person to person by airborne transmission. An infected person releases droplet nuclei through talking, coughing, sneezing, laughing or singing.

TB begins when a susceptible person inhales mycobacteria and becomes infected. The bacteria are transmitted through the airways and into the alveoli where they are deposited and begin to multiply. The bacilli are transported via the lymph system and the bloodstream and are carried to the other parts of the body and the lungs. The immune systems responds by an inflammatory reaction, phagocytes come and engulf many bacteria; the tissue reaction to the elimination of bacteria accumulates as exudates which results in bronchopneumonia. Granulomas, new tissues of dead and live bacilli are surrounded by macrophages which are transformed into fibrous tissue mass; the material becomes necrotic and turns into a cheesy mass. At this point the bacteria becomes dormant, active diseases develops because of inadequate immune response or re-infection which causes the Granulomas to ulcerate, releasing the cheesy mass into the bronchi. The release of the cheesy material into the bronchi causes the immune system to react via an inflammatory response, which causes the lungs to become inflamed and further develop bronchopneumonia and tubercle formation.