II.

Biographic Data

Name: A.J.R
Gender: Female
Age: 17 y/o
Occupation: None
Civil Status: Single
Birthdate: October 01, 2002
Birthplace: Abucay, Bataan
Religious Affiliation: Roman Catholic
Ethnic Group/Race: Filipino
Address: Calaylayan, Abucay Bataan

Reason for Seeking Care:

“Matindi kasi yung sakit ng tagiliran ko kaya nasugod ako dito (Bataan General
Hospital and Medical Center) as verbalized by the patient.

II. Nursing History

a. History of Present Illness

Ectopic Pregnancy
Onset - Is this a new problem / first time having this problem? “ngayon lang po talaga sakin
nangyari to”
Location - “Dito sa kanang tagiliran ko” as verbalized by the pt.
Duration - “Pawala wala ang sakit, madalas umaabot ng ilang minuto yung sakit”
Characteristic - Quality (particularly important if pain)
“Parang sinasaksak yung tagiliran ko sa sobrang sakit” as verbalized by the pt.

Associated manifestations (Any other symptoms that you have?)

+ Presence of varicose veins

Relieving/aggravating factors:
o What helps it, What makes it worse
Treatment– (what medications you took?)
 Name of medication: D5LR (5% Dextrose in Lactated Ringer’s Solution), Cefazolin Sodium,
Bupivacaine Hydrochloride, Tramadol, Ketorolac Tromethamine, Co-Amoxiclav, Mefenamic
Acid, Bisacodyl, Ferrous Sulfate.

b. Past Health History

1. Childhood Illness
- The patient experienced having a measles when four years old.
- The patient experienced having a pneumonia when she was seven years old.

2. Adult illnesses
- None
3. Immunizations
- BCG and Hepa B at birth

4. Allergies
- No known allergies

5. Accidents
- None

6. Hospitalization
 II. Biographic Data

- None

7. Surgical History
- None

8. Medications Used
- Paracetamol for headache and fever, 500 mg PO twice a day every 4 hrs.
- Bioflu for flu, 500 mg PO twice a day every 6 hrs.

9. Foreign Travel
- There’s no any foreign travel

10. Family History

- The patient has a family history of hypertension and diabetes in her
mother’s side and hypertension on her father’s side.

11. Obstetric/Gynecological History

 Obstetric history (GTPALM)
 G1P1
 Date of LMP – September 8, 2019
 Estimated date of confinement/delivery- June 15, 2020

LMP = August 08, 2019

8 8 2019
-3 +7 +1
5 15 2020 = May 15, 2020
AOG

c. Current Medications (Medication Reconciliation)

 Prescribed medications
 Name of medication:
o D5LR (5% Dextrose in Lactated Ringer’s Solution)
o Cefazolin Sodium
o Bupivacaine Hydrochloride
o Ferrous Sulfate
o Mefenamic acid
o Ketorolac Tromethamine
o Tramadol
o Co-amoxiclav
o Bisacodyl

d. Personal Habits
 Smoker – half a box per day
 Alcoholic – occasionally

e. Personal Setting (Environment/Hazard)

Housing and neighborhood
i. Safety of area – have concrete walls, roof and adequate electricity and water.
ii. Adequate ventilation - few windows in the house.
iii. Others - none