Nursing History

Biographical Data:

Name: Mrs. Victoria

Age: 63 years old

Gender: Female

Birthday: August 04, 1953

Birthplace: Laguna

Address: Unit 1035 Bldg10 Phase II, Guadalupe Bliss, Cembo, Makati City

Nationality: Filipino

Religion: Roman Catholic

Occupation: Secondary Teacher (Retired)

Source of Admission: Emergency Room

Date of Admission: July 01, 2017

Hospital: VRP Medical Center

Diagnosis: Pulmonary Congestion secondary to parapneumonic process to

consider CHF

Diet: Low Fat

Informant: Mrs. Victoria and Significant other

Chief Complaint:

Nahihirapan ako huminga at masakit ang aking dibdib.

As verbalized by the patient.

History of Present Illness:

3 days prior to consultation Mrs. Victoria experienced shortness of breath especially when doing
activities, However, Mrs. Victoria can still do minimal household chores.

2 day prior to consultation, Mrs. Victoria is no longer capable to travel, she experienced increased
shortness of breath while doing his activities.

1 day prior to consultation, Mrs. Victoria can no longer performed household chores and needs rest to
relieved shortness of breath.
 On the day of admission, Mrs. Victoria was rushed to emergency room accompanied by her daughter
because she cant breathe properly and she experience chest pain with a pain scale of 6/10.

Past Medical History:

Last 2011, Mrs. Victoria went as an out-patient in Ospital ng Makati and was diagnosed with stage 2
hypertension, she was then advised to took maintenance drug which is amlodipine 10mg once a day per
orem regularly. However, she doesnt took her maintenance drug regularly according to her significant
other. Also, she lost to follow up.

Personal & Social History:

Mrs. Victoria is widowed and has 3 daughters. She was a secondary teacher at Cembo Highschool and
retired last 2015. She doesnt smoke nor drink alcoholic beverages.