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NURSING HEALTH HISTORY

Vital Information
Code Name: Secret
Age: 79 years old
Gender: Female
Civil Status: Widow
Date of Birth: 04/18/1939
Place of Birth: Iligan City
Race: Filipino
Cultural or Ethnic Background/Group: Bisaya
Primary Language (Spoken and Read): Bisaya
Secondary Language (Spoken and Read): Tagalog
Religion: Roman Catholic
Highest Educational Attainment (Client): College Graduate
Occupation (Client): Retired Librarian
Usual Health Care Provider/s: Doctor
Date and time of Admission: Febuary 9, 2019; 12:25 PM
Date of Discharge: Febuary 27, 2019
Source/s of History: Patient: 35%
SO: 25%
Chart: 20%
Doctor: 20%

Reason/s for Seeking Health Care: Pricking to crampy epigastric pain radiating to the
back & both flanks and nausea
Primary Attending Physician: Dr. Timonera
Consultants/Specialists: Dr. Debalucos, Daroy, Marquez, Sumndad
Initial Impression/Diagnosis: Acute gastritis
Final Diagnosis: 1. Obstructive jaundice secondary to
choledocholelithiasis
Entrero-Gallbladder fistula
2. Incision & Drainage of subcutaneous abscess
3. Acute Pancreatitis
4. Hypertensive stage 2
5. Ischemic Heart Disease
6. Aortic Stenosis
7. Bronchial asthma with acute exacerbation
8. Diabetes Mellitus Type 2
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Description of the patient:
Patient is conscious, coherent, oriented and conversant but
is sometimes irritated. No in respiratory distress and was
afebrile during our shift. With Jackson Pratt drainage at
right upper quadrant, surgical wound was tender, reddish
and with minimal pus upon inspection. Urinary catheter
was attached and patient wears diaper. IVF of PNSS @
20gtts/min is inserted at right dorsum hand. Good hygiene
was observed.

NURSING HISTORY

A. Chief Complaints/Reason for visit

Around 12:25 PM on Febuary 9, 2019, the client arrived at the emergency department for
a chief complaint of pricking to crampy epigastric pain radiating to the back & both flanks and
nausea. The client had a 180/100 BP and was given Amlodipine (Besilate) 5mg. That prompted
her to seek help now.
B. History of Present Illness
On Febuary 8 around 7PM in the evening, secret manifested abdominal pain specifically
in the epigastrium area with a PS of 6/10, burning in character and is radiating to the back and both
flanks, she had been having a clay-colored stool and a yellowish urine. Patient took pantoprazole
40mg and had a rest which offered temporary relief.
Morning PTA, abdominal pain increased in severity after eating “fish paksiw” and pepino
salad and is now associated with nausea, hence client sought for help at Adventist Medical Center-
Iligan (AMC-I) and was admitted. These are the following vital signs upon admission; BP: 180/100
mmHg, T: 36 degree Celsius, PR: 58 bpm, RR: 21 bpm and O2sat of 99 %. She was given
Pantoprazole (Pantocin) 40mg IVTT, Tramadol 50 mg IVTT and Metoclopramide 1 ampule IVTT
for nausea and vomiting.
Upon initial rounds, patient is conscious, coherent, oriented and conversant but is
sometimes irritated. No in respiratory distress and was afebrile. With Jackson Pratt drainage at
right upper quadrant, surgical wound was tender, reddish and with minimal pus upon inspection.
Urinary catheter was attached and patient wears diaper. IVF of PNSS @ 20gtts/min is inserted at
right dorsum hand. Good hygiene was observed. Patient have reported tenderness at right upper
quadrant with a PS of 5-6/10
C. Past Health History
Patient secret was born in AMC-I hospital via normal spontaneous vaginal delivery
(NSVD), term. Accordingly, the client was able to complete the needed and required vaccinations.
She had experienced chickenpox, diarrhea, fever, cough and flu but was not hospitalized for this
conditions. She takes over-the-counter medications such as paracetamol, diatab, bioflu and
mefenamic acid to provide relief for minor illnesses.
As reported by the patient, she was admitted at Mercy hospital when she was 25 years old
due to amoebiasis, she manifested severe abdominal pain and diarrhoea. She was admitted twice
at AMC-I. First was on the year 2007, secret was admitted for 4 days due to loss of consciousness
and had a diagnosis of syncope. Second was on the year 2017, 11th of November where she
experienced sharp, stabbing chest pain radiating to the neck unrelieved by rest as verbalized. She
took Candesartan and Metformin during that time but was not relieved by it, hence was admitted
for 2 days and had a final diagnosis of acute coronary syndrome with unstable angina, hypertension
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stage 2, community acquired pneumonia-lower risk and urinary tract infection. Last month, she
had an operation for cataract at left eye.
Patient secret is hypertensive since 2 years ago, having a blood pressure ranging between
of 170/100 - 140/100 and is a known diabetic for 3 years.
Secret is compliant to her maintenance medications which are Aspirin 80mg, metformin
500mg, linagliptin 5mg, Kremil-S, Amlodipine 5mg, Atorvastatin 40mg, Pantoprazole 40mg,
Trimetazidine 35mg and Candesartan 8mg. she takes montelukast 10mg if she is manifesting
difficulty of breathing and Kremil-S to provide relief for flatulence and gas pain.
She has no known allergy to medications, food and as well as latex.