Health History

I. Personal data

Name: Mrs. X
Birthdate: 06/25/1985
Age: 32 y/o
Educational attainment: first year college
Civil status: married
Religion: Iglesia ni Cristo
Date of admission: 01/24/18
Chief complaint: back pain, in labor
Diagnosis: C/S
Date of interview: 01/25/18

II. Reactions & Expectations to illness Hospitalization, Diagnosis study & Personnel

A. History of Present Illness

The patient was admitted at BMC (Bulacan Medical Center) last Jan. 24, 2018
At 12pm. She said that she already scheduled for her delivery that’s why she actually
expected for that. According to her on that day she felt backache, cramps like having a
severe period, and also vaginal discharges of pinkish fluid. She delivered healthy baby
boy weighing 2.7 kg at 9pm.
Upon admission she had a following assessment: AOG of 35 weeks & 5 days,
FHT of 153 beats/min, BP of 110/80 mmHg. And upon examination of OB ROD she
diagnosed of G3P1 she was given an IVF of D5LR iL @ 8 hours.
Upon interview the client said she felt discomfort because of her suture on her
hypogastric area. She had IVF of D5LR iL @ full level regulated @ 10 gtts/min (KVO)
Infusing well on her left metacarpal vein. She still monitored by the OB ROD and other
health team. She was given oral medicines such as celecoxib 200 mg BID, FeSO4 1tab
OD, Ascorbic acid 1tab OD and Cefuroxime 750 mg TID.

B. Past health history

According to the client she experienced usual illness during childhood years as
Cough and colds, fever and boil. She said that she had complete immunization and
doesn’t have any drug nor food allergies. She added that she doesn’t experience any
accident.

C. Family History

According to the client on her mother side they had a history of hypertension,
while on her father side she added that they have a history of diabetes.
D. Obstetric History
Coitarche – 15 y/o AOG – 35 weeks and 5 days (8months)
Menarche – 12 y/o EDC – February 24, 2018
LMP – 05/20/2017 G3P1 (due to her 2x of miscarriage)

III. Activity of Daily Living

A. Circulation

Her vitals sign was as follows: temperature of 36.7 °C/axilla, pulse rate of 72
beats/min, regular in rhythm and blood pressure of 110/80 mmHg, capillary refill took 1-
2 secs.

B. Respiration

Her respiratory rate was 22 breaths/min , and it was an effortless breathing.

C. Food and Fluid

Prior to hospitalization she said that she eats 3 times a day, breakfast at 8am,
lunch at 12pm and dinner at 7pm. She added that she consumes 2 cups of rice and a
serving of viand like fried chicken, sinigang and pakbet. And for her snacks at 3pm it is
usually bread and coffee. Also she said for her fluid intake, she drinks 10-11 glasses of
water every day.

D. Elimination

Prior to admission she said, she usually voids 8 times a day, aromatic in odor
and its color yellow. She added that she defecates 2 times a day once in morning and
once in evening. It is formed and brown in color.
During hospitalization she had catheter connected to urine bag at 190cc level
color yellow urine.

E. Rest and Sleep

Prior to hospitalization, according to her she usually sleep at 8pm and wakes
up at 6am, she doesn’t experience any difficulty of sleeping. She sleep at noontime.
Her forms of rest are watching tv and listening to music.
During hospitalization, she spends her time lying on the bed. She experienced
difficulty of sleeping due to the hospital environment.

F. Personal Hygiene

Prior to hospitalization, according to her she takes a bath once day, she
brushed her teeth twice a day every after meal. She changes her clothes 2 times a day
 During hospitalization, she said that, she hasn’t taken a bath because oh her
condition and IVF connected to her. Her fingernails and toenails are untrimmed and
untidy.

G. Exercise
According to her when she was still pregnant, she just do walking along their
street.

IV. Competencies

A. Physical

She is physically dependent, unable to walk and stand alone. She needs
assistance in doing things like she need to sit on the bed. She prefer to stay on her bed
and not capable of performing her usual routine. The ivf connected to her serves as a
hindrance limiting her movements.

B. Emotional

According to her, she had many friends at their place in the community. Also she
said she is very close to her family and neighborhood. She added that whenever they
encountered problems in life with her husband they face it together with strong based
personality.

C. Mental

Upon interview the client able to answer some of my questions directly without
hesitate or doubt but if the questions is too deep she quickly ask it again to repeat the
question. She had presence of mind. She maintain an eye to eye contact. Regards to
decision making she said that they really take the responsibilities together with the help
of their parents.

D. Social

According to her, she had good relationship with her family, treating her
neighbors and relatives in a good way. She doesn’t have any problem in their place. And
also on their community organization she added.

E. Spiritual

She said her religion is Iglesia ni Cristo, she goes to church every Wednesday
and Saturday with her family. Also she said that she always pray to god and doesn’t
have any religious organization.
 F. Environmental

According to the client she lived in a concrete type of house with a bedroom and
the space of the house is appropriate for their family size. There are some cockroaches and
mosquitoes. They are near the barangay hall approximately 5mins of walk.And for market it is
about 20 minutes ride in jeepney. She said that their water spply is deep well for drinking water
and also for other use. They have garbage collection every monday

PHYSICAL ASSESSMENT

I. General Appearance:
She is tan in complexion. She is neat in appearance yet she has trimmed and tidy
fingernails and toenails and her hair is neat without any foul odor. She is wearing a hospital
gown. She just be on the bed all throughout the examination. She had an IVF of D5LR 1L at
regulated @ 30 gtts per minute infusing well on her left metacarpal vein.

II. Vital Signs

Temperature: 36.4 degree Celsius
Pulse Rate: 90 beats per minute
Respiratory Rate: 21 breaths per minute
Blood Pressure: 120/80 mmHg

III. Physical Assessment

A. Head ( Hair, Scalp, and Skull)

The Head is round, symmetrical and proportional to the body. The hair evenly
distributed. It is fixed and combed. There is no dandruff and no sign of infestation seen.
No nodules, lesions or masses noted.

B. Face
The Face of the client is symmetric. There is no pimples. No presence of
nodules or mass

C. Eyes
The eyes are Symmetrically aligned. There is no presence of discharges,lesions or
inflammation and no discoloration. The both pupil are equal and reactive to bright
ight and she does wear any eyeglasses and can read clearly by reading her text
messages.

D. Ears
 The auricles are symmetrical and evenly aligned with one another. There is no
presence of cerumenr. There is no discharges and inflammation. She can hear evenly by
responding whenever her name was called.

E. Nose
The nose has no presence of bleeding, discharges or nasal flaring. She can smell
evenly by stating that the bathroom has a foul odor.

F. Mouth
The lips of the client is free from lesions and masses. The teeth is 28 in total
the gums is pinkish color. Tongue is freely movable, with dry lips. She can’t taste
because her diet is NPO.

G. Neck
She can move her neck freely. Upon palpation and observation there is no lymph
nodes felt, masses or any scars noted.

H. Chest Shoulder and Back

There is no presence of mass. The shoulder is symmetrical and no presence of

pain, discomfort and retractions. The back is free from any lesions and mass.

I. Abdomen

She had a stretch mark. And there is a peristaltic movement

J. Genitalia

On her peripadthere is a presence of lochia rubra.

K. Upper Extremities

There is no abrasions,scars or lesions.Blood capillary refill test took 1-2 seconds.

L. Lower Extremities

She can flexed her both knee joint. The client was sble to walk without
assistance because. It has no edema and inflammation. She can perform range of motion.
 Emergency Case

ADMISSION:
 A 4 year old boy from Sta.Barbara, Baliuag Bulacan with chief complaint of
Vomiting 3x
 Diarrhea 6x
 Fever
 Seen and examined by Dr.Braga with order made:
Consent signed and secured
 NPO for 4 hours
 D5 0.3% NaCl hooked as venoclysis 100cc fast drip and the regulate to 50cc/hr.
 Request for CBC, PC, urinalysis and fecalysis
 Medications through IV
Metronidazole 500mg/ml
 Paracetamol 1ml if with fever 38
Transferred to Pedia ward

DISCHARGE:
 A case of a 43 year old woman from Piel Baliwag, Bulacan with a chief complaint of
Severe pain at RLQ radiating to LLQ when palpating since 7:00 in the Evening (07-18-2019)
 Headache
 Nausea
 With facial grimace noted.
 VS of: BP 140/80 mmHg; Temp: 37.1 degree Celcius; PR: 78bpm; RR: 23bpm
and Oxygen Saturation 99%
 Seen and examined by ROD with order made:
 STAT AP
 Request for CBC, UA, Chest X-Ray and Ultrasound given
 Refusal for admission signed.

DISCHARGE:
 A case of a 16 year old boy from San Rafael, Bulacan with a chief complaint of
 Back pain and Muscle Pain
 Weakness on both extremities x3 days
 Pain on Lower Extremities when standing
 VS of: BP 120/90mmHg; Temp: 36.4 degree Celcius; PR: 75bpm; RR: 22bpm
and Oxygen Saturation 98%
 Seen and examined by Dr. Ruth Reyes with order made:
 Request for CBC, UA, Serum and Electrolytes given
 For Admission (for referral to BMC letter given)
 Refusal for admission signed by the mother.

-Mara Gomez-
-Gladys Francisco-