I.

PATIENT’S BIOGRAPHICAL INFORMATION

Name: Castillo, Jane

Address: Recodo, Zamboanga City
Age: 45
Gender: Female
Race: Filipino
Marital Status: Married
Occupation: N/A
Religious Affiliation: Roman Catholic
Healthcare Financing: N/A
Admitting Diagnosis: N/A

II. CHIEF COMPLAINT

Difficulty of breathing, Vomiting of blood

III. NURSING HEALTH HISTORY

A. History of Present Illness

Hours prior admission, out of hematemesis amounting to 500Ml. Patient experienced difficulty of
breathing. Persistence of such symptom prompted patient to seek consult at the nearest hospital and
was manages subsequently. Patient then was referred to Zamboanga City Medical Center per request.

B. Past Health History

(+) Hypertension

(+) Chronic Alcoholic Liver Disease

(+) Bleeding Peptic Ulcer Disease

C. Family Health History

Father - N/A

Mother - N/A

Husband – No known disease, Occupation – Construction worker

Son – No known disease, Occupation - none

Daughter – No known disease, Occupation - none

 IV. Social Health History

Alcohol use – Always

Smoking use – Never

Drug use – Never

Travelling history – N/A

Hobbies and Leisure Act – Reading newspapers, drinking alcoholic beverages

Work Environment – Fresh air, nice working condition, good people to interact with. But if there is an
occasion where there are drinks, patient consumes a lot

Home environment – A lot of liquor bottles, well-ventilated house

Economical status and ethnic and cultural beliefs – Middle class family, Roman Catholic

Roles and Relationships – Wife, Mother