Patient Information

Patient VOLTES FIVE Age: 37 years old

Name:
Gender: Health Insurance (Phil Health ): Marital status:
male ___ Single
___ active ___ Married
female ___ Widowed
___ not active ___ separated

Allergies

Drugs: Pen G Reaction: Rashes and Shortness of

breath
Food: Egg Reaction: Rashes

Medical Information
Chief Complaint/Reason for encounter today:

Blurry of vision and headache

History of present illness:

2 weeks ptc, the patient had sudden onset of blurred vision with no associated
headache, dizziness, nausea, vomiting, seizures or decrease sensorium

Past medical Family history:

history

The patient has no history of hypertension, heart The patient claims that they do not have familial
disease, allergies, goiter, and cancer. However, history of hypertension and pre eclampsia. No
she have experienced preeclampsia in her two present illness is currently experienced by any of
Admission Diagnosis: Pre-eclampsia with severe features
previous pregnancies. The patient have the member of the family.
undergone LSCS
Date andatTime
BGHMC in her two previous
of Admission: January 12, 2019 at 2:00 am
pregnancy, for arrest of cervical dilatation and for
previousFinal Diagnosis:
uterine scar. Pre-eclampsia with severe features

Place of admission: Baguio General Hospital and Medical Center

Date of rotation: January 14-16( 11-7 shift)

13 AREAS OF ASSESMENT
PSYCHOLOGICAL STATUS
Age ___ Address _________________
Religion__________ Ethnic Background __________________
Marital status ______________ Language ___________

MENTAL AND EMOTIONAL STATUS

Conscious unconscious

Alert Not Alert

Responsive Not Responsive

Cooperative Not Cooperative

Time oriented Not Time oriented

High Anxiety Low Anxiety

Stress Not Stress

ENVIRONMENTAL STATUS
Adequate Lighting Inadequate Lighting

Noisy Peaceful

Comfortable temp. Not comfortable temp.

Clean (linen) Unclean (linen)

SENSOR STATUS
eyeglasses contactless

Visual far sighted near sighted

lesion scar discoloration cataract

symmetrical asymmetrical

with hearing aid

Auditory
lesions

discharges color______ dry moist

symmetrical asymmetrical

nasal flaring

Olfactory lesions

distinguish scent

discharges color______
distinguish taste

Gustatory lesion

ulcerations
Identify textures rough smooth cold warm
Tactile
tremors
MOTOR STATUS
prosthetics location_________
 limited movement location________

needs assistance what physical activity_________

THERMOREGULATORY STATUS
febrile afebrile

Temp. _____(degree centigrade)

RESPIRATORY STATUS
regular irregular
Respiration
RR _____(per min)
clear wheezes crackles bronchi
Lung sounds
Lung: symmetrical asymmetrical
Oxygen Spo2_____(/min)
CIRCULATORY STATUS
BP ______mm/hg
PR ______bpm
Capillary refill _____sec
NUTRITIONAL STATUS
Diet _________ solid liquid semi
self-feed need assistance

Food restrictions_________
ELIMINATION STATUS
PO/tube feeding intake _______ IV intake _______
Input/Output
Urine output _______
Catheter type_______
Urine Color _____
clear cloudy
SLEEP, REST AND COMFORT STATUS
Hours of sleep _______
What interferes the sleeping pattern ________
comfortable uncomfortable
FLUID AND ELECTROLYE STATUS
PO/tube feeding fluid intake _______(ml)
INTEGUMENTARY STATUS
intact color ________

pallor rash lesion scar

Appearance
Location ______________
Turgor ____(sec) Site_____

Skin warm hot dry moist cold

Dressing : dry intact
Wound dressing
Drainage: very soiled minimal soiled not soiled