DISPENSING2

PATIENTDATABASE-ASSESSMENTMEDICALHISTO
RY
Name : MS
Date of Birth :
Gender : Female
Address : ---
Telephone :
Marital status : Married
Weight (kg) : 62
Height (cm) :

REASON FOR ASSESSMENT CASE PRESENTATION

An 53-year-old woman has been under maintenance medication for 3
year ago. Maintenance Medication for her hypertension

Past Medication : Losartan (50mg) , Citicoline (500mg) , Atorvastatin

(40mg) , Clopidogrel (75mg) , Gliclazide (80mg) ,Metformin (500mg)

Allergies : None

History Patient Illness (HPI)

Location : head/neurologic
Quality severty : Patient felt sudden headache which the reason why she
can’t able to work.
Quantity : Patient felt the symptoms for the last 4 days before she was
admitted.
Timing : She felt symptoms 4 days before she was hospitalized in 2021.
Setting : The patient had a mild stroke after 4 days of experiencing body
weakness, and headache. She was at home that time.
Modifying Factors :
Relieving factor/s: (Hypertension)
 Water intake
Aggravating factor/s (Hypertension)
• the patient had eaten too much
• the patient is exposed to situations that might cause stress (Nag away away
ang mga anak)
• the patient had word too much
Association Factor :
 Visual changes
 SOB
 No blood in the urine

PAST MEDICAL HISTORY (PMH)

List of medical conditions/problems : Diabetes and Hypertension (High Blood
Pressure) which cause Mild Stroke.
Date and Duration : 2021 (1week hospitalized)
Hospitalized : 2021 (1week hospitalized because of mild stroke)
Surgeries :
Accident/injuries : N/A
Recent specialist visits : Recent hospital visit on Nov 09, 2021