CLIENT PROFILE, CHIEF COMPLAINT, HISTORY OF PRESENT ILLNESS, CLINICAL DIAGNOSIS

CLIENT PROFILE:

Patient’s Name: I
Room Number: 112
Address: Wangag 2 Brgy, Damulaan, Albuera Leyte
Age: 45
Sex: Female
Civil Status: Single
Occupation: Govt. Employee
Religion: Catholic
Nationality: Filipino
Admission Date & Time: 10/26/21@ 3:30pm
Attending Physician: Dr. JK.RPatient’s

Data on Admission:
Temperature: 36.3
Height: In pain
Weight: In pain
Blood Pressure: 120/80mmHg
Pulse Rate:
Heart Rate: 80bpm
Respiratory Rate: 34cpm
Oxygen Saturation: 98%
Allergies: None
CBS: 174mg/dl

Chief Complaints:
Epigastric pain

Clinical History:
Hours PTA, noted onset of epigastric pain score (9/10) associated with
vomiting x1 episode. Hence prompted this admission. She has no history of
hypertension and diabetes. The client is coffee drinker 4-5cups per day. She doesn’t
smoke and drink alcohol beverage occasionally. The client has no maintenance
medications.

Clinical Diagnosis:
Choledocholithiases with cholecystitis