Mindanao State University

COLLEGE OF HEALTH SCIENCES

Marawi City

Name of Student Edres, Reihann N. Clinical Instructor Prof. Namerah Datumanong, RN, MAN, PhD (Ongoing)

Area of Assignment Medicine Online Duty Date Submitted 16/02/21

NURSING ASSESSMENT I

PATIENT’S PROFILE

Name Patient X Address Marawi Poblacion, Marawi City, Province of Lanao del Sur Age 51
Sex Male Religion N/A Civil Status Married Occupation Industrial engineer

HEALTH HABITS

Frequency Amount Period/Duration

1. Tobacco Daily 1-2 packs 20 years

2. Alcohol X X X
X X
3. OTC-drugs/ non-prescription drugs X

A. CHIEF COMPLAINTS
Epigastric pain
B. HISTORY OF PRESENT ILLNESS (HPI) {location, onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment
and results, social and vocational responsibilities, affected diagnoses}.

A 51-year-old male patient complains epigastric pain that has lasted for 1 week. On a scale of 1 to 10, patient described pain as a 10. The pain is constant, sharp and
radiated to the right upper quadrant. It is associated with nausea, vomiting, and fatty stools with liquid consistency. It is also associated with severe puritus (itching). He
has jaundice. He has no other medical problems and takes no medications. Patient’s father died of pancreatic cancer. He has weight loss of 26 lbs. in 4 weeks. He denies
drinking of alcohol and illicit drug use. He smokes 1-2 packs of cigarette every day for the past twenty years.

C. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illnesses,
allergies, medications, habits, birth and developmental history, nutrition- for Pedia)

Patient has no previous hospitalization. Immunization is unrecalled. No cardiac or psychiatric problem is noted. No known allergies for food or drugs. No known history of
trauma or accidents. He has no other medical problems and takes no medications.

D. Patient’s Perception
1. Present Illness

“Phukargenan ako kaw-kaweg, phe-sakit a tiyan aken. Ago di ako pheka-kan pipya,” was verbalized by the patient.

2. Hospital Environment

Assessment setting was done at home but this was noted from the patient,

“Di aken mapag-inengka tona gya gedamn ako ka di ako pakasung sa ospital pon sa gya virus.”

E. Summary of Interaction

Patient was notably not feeling fine by the looks of his posture but he was still able to demonstrate logical, sequential thoughts along cooperation.