Date of assessment: November 23, 2009

Nursing Health History

Name: Aireen Pama
Sex::Female
Age: 30 years old
Address: 1440 Felix huesta st, Sta cruz, Manila
Date of birth: October 08, 1979
Place of birth: Iloilo city
Religion: Catholic
Nationality: Filipino
Marital status: Single
Chief Complaint: Fever, headache and sudden neck mass
AMD: Juanita Lu Lim
Diagnosis: Lymphoma

Next kin of data:

Name: Lily Pama

Age: 35 years old
Relationship: sister

Present Health History

November 1, 2009, the patient experienced fever and severe headache for five days. She
drinks Flanax as prescribed by her doctor to relieve the pain. After taking her medicine she
experienced sweating and fever started to subside. Every morning her temperature started to
increase and decreases after lunch where she takes her Flanax. She noticed that there was a mass
growing on her neck. There were also rashes on her face and arms. Edema was also seen on her
face. The patient also experienced drying of the mouth, sticky saliva, muscle weakness and joint
pain. She is suffering for five days because she is waiting for her doctor on vacation. On the fifth
day, Ms. Pama consulted on her physician for check up. She was confined at the Metropolitan
Hospital Medical Center on November 19, 2009 for more observations and laboratories. In the
hospital, she experienced insomnia for two days, vomiting, abdominal pain and frequent
urination. The doctor’s primary finding was systemic viral lupus but still looking for a more
objective diagnosis.

Past Health History

 Ms. Pama experienced chicken pox, measles and mumps since she was
3 years old. There are no allergies noted in terms of food or things that
surround her. Her childhood immunization is complete. The patient was
hospitalized two times in Metropolitan Hospital Medical Center. During her
first hospitalization, she undergo to splenectomy because of her immune
system was weak. Her platelet started to decrease in number. After the
procedure she did not go for her next check up. She taught that her disease
was completely healed. Presently, it is her second hospitalization in metro
with a diagnosis of lymphoma. Vitamins such as ascorbic acid and caltrate
were taken regularly.

Family Health History

The Family has a history of hypertension and asthma. Ms. Pama does
not inherited one of the disease from her parents. Her sister inherited her
asthma to her mother.

Social History
The patient is living with her family and livin partner. She stops schooling when she was
in her 1st year of college. She has difficulty in understanding the lessons because she stops too
long. When in times of decision making, she can handle herself according to the situation. If she
cannot handle the problem, she tries asking advice to her family and friends. When stress came,
she likes to watch t.v alone. She likes to talk with their neighbors near them. The members of the
family are open to share when there is a problem within the family or personal problems. They
are very close to each other.

Lifestyle
The patient is responsible for their household choirs. She frequently
watch t.v when her households where done. On weekends, she chooses to
walk going to the mall or with her friends which is near to their house. She
avoids sweet foods because she is afraid to have diabetes. She eats lots of
vegetables, less rice and much more on meat. Their family uncommonly eats
fish. She stops her vices when she was 25 years old because it was advised
by her doctor.

Psychological data

The patient participates well in the assessment. She is open in our

conversation and gathering of all the data that I needed to her. She tries to
ask me of what I am doing. She appreciates my work by saying thank you. If
misunderstanding happens she tries to clarify what she doesn’t understand.
She told me that she feels sad after knowing that she cannot have her own
children because of her condition.

Patterns of Health Care

The family seeks only for medical check up when the pain is unmanageable. She buys
over the counter drugs if she experience common colds and pain. She knows who and where to
run for emergency situations about the health of the family.

Review of the Systems

Integumentary system:
“wala naman akong allergies kahit saan” as verbalized by the client.
“parang hindi nawawala ang rashes ko sa mukha at braso. Ano kaya pwede kong gawin? braso”
as verbalized by the client.

Respiratory system:
“hindi naman ako nahihirapang huminga” as verbalized by the client.

Cardiovascular system:
“hindi naman naninikip ang dibdib ko ” as verbalized by the client.

Musculoskeletal system:
“masakit yung tiyan” as verbalized by the client.

Urinary system:
”madalas akong umihi, yon lang ang napansin ko lang” as verbalized by the client.

Nervous system:
“makakalimutin nga ako minsan” as verbalized by the client.
“ para saan ba yang gamot? Ang dami naman kasi. Kanina alas 7 nakainom na ako ulit. Mamaya
ko na inumin yung gamut” as verbalized by the client.

Digestive system:
“parang masusuka ako pagkatapos ko uminom ng gamut. Sumakit din ang tiyan ko” as
verbalized by the client.

genitourinary system:
“hindi na ako magkakaanak sabi sakin ng doctor bawal daw ako mag buntis dahil sa kalagayan
ko” as verbalized by the client.

Immune system
“sabi sakin ng doctor mahina daw ang resistensya ng katawan ko” as verbalized by the client.