reveals the occurrence of Peptic Ulcer Disease twice.

The client stated that Unang peptic ulcer

ko noong early 4th year HS days and yung 2nd noong late 2nd semester ng 1st year college.
The client has no history of hospitalization, has complete immunization and ongoing
Anti-Hepatitis B vaccination and had undergone laboratory exams such as CBC, urinalysis and
stool exam. The results of the stated examinations are normal. The client has no known cause of
allergy. The client has no records of laboratory examinations related to GERD.
The client currently takes 40 mg of Esomeprazole (Nexium), once a day, for 14 days and
10 mg of Domperidone (Motilium), three times a day, for 7 days, as prescribed by the physician.
The client verbalized Sumusunod naman ako s utos ng doctor regarding sa pag-inom ng gamot
ko.
The client defecates every morning upon waking up or after meals. The stool is solid in
consistency but upon medication, stool became watery. The menarche is at 10 years old, with a
regular menstrual period and duration of 7 days. The client uses 2-4 pads a day with a moderate
amount of menses. The client has no gynaecological history.
The client has a family history of breast cancer which was experienced by the
grandmother, hypertension which was experienced by the grandmother and grandfathers, and
peptic ulcer disease which was experienced by the sister. All the mentioned family members are
alive at present.
The client has a middle self esteem, close relationship with family members and practices
eating together with family members. The client can feed herself and is independent in terms of
hygienic practices, has full ROM, active in exercise, can sleep without difficulty, and has a
regular pattern of elimination. Defecating is done every morning upon waking up or after meals.

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She eats 3-4 meals a day and drinks 2-4 glasses of water. The client prefers to eat meat
and does not like vegetables. She verbalized, Di ako masyado kumakain ng gulay, mas gusto
ko karne. Kahit pinagbawalan ako, umiinom pa rin ako ng softdrinks pero paminsan na lang
eversince nagkaroon ako ng Ulcer. Mga 1 to 3 times(8oz) a week na lang. Same goes with
chocolate. She stated, Heavy meals naman ako lagi since breakfast up to dinner. Late na kami
magdinner. She added Nagkakanin na ako every breakfast since nung nagka-ulcer ako. Pero
recently, nawawalan na ako ng gana ubusin ung pagkain ko kapag nararamdaman kong
nasusuka ako, as verbalized by the client. She also verbalized that , Since nagstart yung
college late na kaming mag- dinner, hinihintay pa kasi namin lagi yung ate ko bago kumain,
tapos mga 9pm na siya nakakauwi galing sa trabaho. She has difficulty swallowing and makes
use of her accessory muscles.
The clients hobbies and interests include drawing and playing computer games. She can
speak English and Tagalog. She participates in a civic organization specifically the Philippine
Red Cross.
The client lives in an owned concrete house with two bedrooms, one comfort room
which is buhos type, and electricity. Their water is supplied by MWSS. Garbage is collected.
Her means of transportation is public. Community resources include a church, health center,
mall, sports facilities and a hospital.
The client has positive weight loss from 110 lbs to 100 lbs within 2 months. Height is
51, stands erect and has a symmetrical body structure. Her visual acuity is 20/20. Her tongue
and buccal mucosa is pinkish. Lymph nodes are non-palpable except for the tonsilar lymph
node.

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The breasts are symmetrical and is free of lesions and masses. The areola is brownish and
the nipples are flat.
The clients lungs are symmetrical, with full expansion, and Tactile Fremitus is equal
bilaterally. Thoraxs percussion sounds are resonant.
Pulsation is present in the heart with point of maximum impulse is located at the fifth
intercoastal space, mid clavicular line. The hearts rhythm is regular and murmurs are absent.
The abdomen is symmetrical and flat. There is no presence of surgical scars and obvious
pulsation. Abdominal sounds are tympanitic, bowel sounds are normoactive (9). The client is
negative for rebound tenderness. The size of the liver is 8.5 cm.
The client has full range of motion. The reflexes are normal (+2) in the brachial, biceps,
triceps and abdominal patellar and is absent (0) for Babinski reflex.

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