HISTORY

NURSING HISTORY

PAST HEALTH HISTORY

Patient G.P. was fully immunized. She had her BCG vaccine as evidenced of the BCG
scar in her right deltoid muscle. She didnt experience any childhood illnesses such as chicken
pox, measles, and mumps but she experienced symptoms such as cough, colds, and fever. Her
initial management was by taking OTC drugs such as Neozep 500 mg 3x a day and Biogesic 500
mg 4x a day, also she take herbal medicine like lagundi leaves for cough. She has no allergic to
any food and drugs.

PRESENT HEALTH HISTORY

August 14, 2016, patient G.P. was admitted and was diagnosed with Rectosigmoid, she
undergone Diagnostic procedures such as CT scan, X-ray, laparoscopy lower anterior resection.
She was given pharmacological management such as vitamin k 10 mg IV every 8 hours,
Cefoxitin1g IV every 8 hours, Metronidazole 500 mg IV every 8 hours and Omeprazole 40 mg
once a day. Upon discharge pt. was instructed to return on September 19 for follow up check-up.

September 19, 2016 patient G.P. undergone hematology, clinical chemistry and had her
chemotherapy. She was given pharmacological management such as Dexamethasone 4 mg ,
Oxaliplatin 100mg + D5W 500 ml, Onsia 8mg/IV, Oxaliplatin 110mg + D5W 500ml x 2 hours

October 4, 2016 patient G.P did not come back for her chemotherapy because she refused it do
have chemotherapy.

October 17, 2016 patient G.P decided to continue her medication by the convincing power of her
children to continue her medication.

One month prior to the admission patient complained of epigastric pain radiating to the back
associated with hematochezia. No fever, no nausea/vomiting, no diarrhea. Patient consulted LHC
and was prescribed unrecalled medications which afforded temporary relief.

Two days prior to admission condition persisted, now with decrease caliber in stool and weight
loss, and was advised for admission.

SOCIAL HEALT H ISTORY

Patient G.P is living in a extended family. In their house she has her long time partner
together with their her (single) daughter and her (married) son with his family. She is resident of
Taribubu, Tuao East, Cagayan. She is the second daughter among five siblings. She is working as
a market vendor. But she never smokes nor drinks alcohol. She said that despite of

FAMILY HEALTH HISTORY

No noted family history of hypertension, diabetes mellitus, cancer, asthma, tuberculosis, heart
disease, stroke and kidney failure on both paternal and maternal sides.