HEALTH ASSESSMENT

PHYSICAL EXAMINATION (GENERAL SURVEY)

A 65-year-old patient was seen in a high fowler’s or sitting position. With regards to the
patient’s appearance, her physical features are congruent with her stated age. The body fat is
distributed properly, muscles are well –built and with a high metabolism and responsive muscle
cells that is why the patient is mesomorph. Her clothing was appropriate to the weather and it
was clean and neat without any foul odor noted. She was oriented to time, place, person and date.
The patient is showing signs of psychological distress. The patient was conscious and coherent
wherein she can open the eyes, looks at you and can respond fully and appropriately.

VITAL SIGNS
Blood pressure: 110/80
Pulse Rate: 76
Respiratory Rate: 21
Temperature: 36.5
BIOGRAPHICAL DATA
Name: Veronica Agliam Garcia
Age: 65
Address: Centro-7, Claveria, Cagayan
Gender: Female
Provider of History:
Date of Birth: March 13, 1953
Place of Birth: Brgy. 46 Nalbo, Laoag City, Ilocos Norte
Race or Ethnic Background: Filipino
Primary or Secondary Languages: Iloco, Tagalog, English
Marital Status: Married
Religion: Roman Catholic
Educational Level: Elementary
Occupation: Housekeeper
Significant other or support persons: Daughter

CHIEF COMPLAINT
Patient is experiencing dizziness, heaviness of the head and nape pain.

HISTORY OF PRESENT HEALTH CONCERN

The patient is having a bearable headache. The patient verbalized that she feels like vomiting
most specially during noontime. Her complaints started on February 2, 2019. The patient
presently taking hypertension drugs of losartan tab once a day in the morning and amlodipine tab
once a day at night.

PAST HEALTH HISTORY

The patient does not have nor didn’t received any vaccination when she was a baby. Instead, she
only recall that she was vaccinated with BCG (bacillus calmette-guerin) vaccine during her
school entrance in grade 1. The patient experienced from surgery last 1999 due to gallstone and
confined at provincial hospital. Aside from surgery, she also experienced from injury at the left
leg due to fall and she consulted to orthopedic doctor. The patient has no allergy on food and
medicines.

GENOGRAM

FAMILY HEALTH HISTORY

Both of the grandfather of the patient died due to hypertension and also, both of her
grandmothers have diabetes in which it is the cause of their death. The patients father also died
because of old age while the patients mother died due to heart attack. And her siblings including
the patient were diagnosed with hypertension and diabetic wherein the patients younger brother
and younger sister also died with heart attack.