Interview and Assessment Date:
March 29, 2010
Setting: Female Ward Abuyog Hospital Name: Salanap, FlorianaAge: 50Date of Birth: December 17, 1959Birthplace: Abuyog, LeyteSex: FemaleCivil Status: MarriedOccupation: HousewifeSpouse: Salanap, NoelOccupation:Carpenter Address: Buntay, Abuyog, LeyteReligion: CatholicRace/Nationality: Asian/FilipinoAttending Physician: Dr. BautistaSource of Information: Client, and her daughter
“Highblood ako, maiha na inin mga lima ka.tuig na. Tigda nla naglipong an ak uloasya guinpaadmit ak ky dere na ngane ak nakakatukdaw.
HISTORY OF PRESENT ILLNESS
The client was admitted last March 26, 2010 at around 8:30 in the morning. Admittedto the female ward per wheelchair – dizziness noted.Admission Diagnosis: HCVDFinal Diagnosis: Hypertensive cardiovascular Disease, Diabetes Mellitus, type 2
Symptoms started: 45 years oldOnset of symptoms: GradualOften the problem occurs: During afternoonExact Location of distress: HeadCharacter of the complaint: intensity of pain (8 in the scale of 1-10 as the highest is 10)Activity in which the client was involved when the problem occurred:Doing household chores and walkingPhenomena or symptoms associated with the chief complaint: dizzinessFactors that aggravate the problem: foods with ginataan and oily foodsFactors that alleviate the problem: leaves of yabana, tanglad, daily exercise