Archdiocese of Tuguegarao

Lyceum of Aparri
COLLEGE OF HEALTH

SAMPLE HEALTH HISTORY OUTPUTS

 PATIENT’S PROFILE

Name: D.A.I.
Age: 58 years old
Gender: Male
Address: Pajac Fuentes road, Lapu – lapu City, Cebu
Birthdate: December 10, 1954
Birthplace: Lapu – lapu City, Cebu
Civil Status: Married
Occupation: City prosecutor
Religion: Roman Catholic
Nationality/Ethnicity: Filipino

ADMISSION PROFILE
Date and time of admission: April 06, 2019 @ 4:40 PM
Chief compliant/s: Body weakness
Admitting diagnosis: Diabetes Mellitus Type II
Final diagnosis: Diabetes Mellitus Type II
Admitting physician: Dr. O

ADMITTING VITAL SIGNS

Blood Pressure: 140/100 mmHg
Temperature: 37.1 °C
Pulse rate / Heart Rate: 89 bpm
Respiratory rate: 21 cpm
PaO2 saturation: 98%

Date and time handled: September 14, 2013 @ 9:08 am

Source of information: Patient, patient’s SO and, patient’s chart

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 NURSING HEALTH HISTORY

PAST HEALTH HISTORY

Mr. DAI is not certain about his immunization status because he is not sure of the availability of
some of the vaccines during his childhood years. He had experienced having chickenpox and
measles at young age. He has no food or drug allergies nor had surgeries. Mr. DAI was known to
have hypertension 3 years ago and has been hospitalized once due to such condition. He takes
Atorvastatin (Lipitor) 10 mg as advised to maintain normal cholesterol levels and Metoprolol
(Cardiosel) 50 mg tab once a day in the morning as his antihypertensive regimen. He has
tolerated these medications but sometimes forgets to take them due to his busy schedule.

PRESENT HEALTH HISTORY

Mr. DAI felt dizzy upon waking up on September 14, 2013. He tried to ignore it as maybe he just
again woke up at the wrong side of the bed. After eating his breakfast, he still felt dizzy and went
back to bed. This went on, accompanied with the feeling of becoming more “tired and weak” as
described by the client. He taught maybe his blood pressure is rising so he decided to take his 8
AM dose of Metoprolol.

Based from his medical records and from the narration of the patient’s wife, the patient was
transported from their vehicle via wheelchair to the Emergency department of Perpetual Succour
Hospital due to experiencing body weakness. He complained of feeling so tired, relatively weak
and giddiness. On examination, he was found to be conscious, coherent and oriented.

History taking reveals that when he had his regular check – up about 6 months ago, his fasting
blood sugar test result was high. Assessment also reveals he has been experiencing excessively
urinating and easy fatigability. He was diagnosed to having Diabetes mellitus type II. He was
advised to have further medical check – up and also was advised to lose weight, but failed to
follow up and no further action was taken.

Upon admission, a casual blood glucose test reveals a high result of 231 mg/dl. This prompted
for more assessment geared towards the initial impression of Diabetes Mellitus, type II. On
assessment, a sore at the big toe and near the ankle area of the right foot was discovered. The
acquisition of the sore was not clearly known by the patient or by his wife. The client was then
admitted to the facility to maximize care and treatment at 9:08 AM.

FAMILY HEALTH HISTORY

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  (+) Diabetes Mellitus – father’s side; brother also died due to complications of DM
 (+) Hypertension – both father and mother sides
 (+) Cancer – maternal side (breast and colon cancer)
 (+) Kidney Disease – father’s side (end – stage kidney failure)
 (–) Heart disease
 (–) Asthma

SOCIAL HEALTH HISTORY

Mr. DAI had been working for decades as a city prosecutor. He goes to office on weekdays and
often at home during weekends. When not in the office, his daytime routines are that of reading
books, magazines or newspaper, having small talks with his wife and watching television. He
doesn’t have regular exercise. You can say that he has been living sedentarily. He still has
alcohol consumptions but does not smoke. He is not so much on social engagements outside
home except on official business gatherings.

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 GORDON’S FUNCTIONAL HEALTH PATTERNS
PATTERN BEFORE HOSPITALIZATION
HEALTH Mr. DAI says in general, he has been
PERCEPTION / remarkably healthy for many years. He
perceives that he had been in good
HEALTH health for he doesn’t feel weak and
MANAGEMENT still can do what he usually does. He
PATTERN rarely experiences having colds or
cough. He uses over the counter drugs
and takes vitamins. He remembers he
has regular check – ups with his doctor
at least once a year. Mr. DAI admits he
drinks alcoholic beverages in moderate
amounts but more often than social
drinking. He doesn’t smoke cigarette
and has no other vices.  He is known to
have hypertension and was prescribed
with his maintenance medications but
sometimes fails to take. Sometimes he
is not so much concern about his
health especially is he doesn’t feel that
something is wrong. He thinks he is
okay being that fat.
NUTRITIONAL / The patient says he eats at regular
METABOLIC meals trice a day but has his snacks
whenever he wants especially when he
PATTERN is at home. He eats a cup of rice a meal
but sometimes takes extra of even up
to two cups. He is into eating pork
dishes and fried menus though he also
eats vegetables. He prefers fruits for
his snacks but says he also likes
chocolates and other sweets at times.
He is also a fan of burgers and pasta
dishes. He is able to drink more than a
liter of water a day. In addition to his
fluid intake, he also drinks glasses of
soft drinks and juices at snack time and
his alcohol consumption he describes
as moderate amount for 2 – 3 times a
week.
DURING HOSPITALIZATION
At present, the patient recognizes him
being sick because he is at the hospital
and he is beginning to realize that
being healthy is not just about being
feeling fine and free from unusual
symptoms. His wife says he seems
more inquisitive on how to manage his
condition. During the last day of
assessment with him he is more
interested in talking about diet,
exercise and other treatment options.
The patient’s attending physician
imposed a full diet, diabetic, low salt,
low fat, in 3 divided meals and 2
snacks, with no source of simple sugar.
His fluid intake is maintained yet
restricted from drinking soft drinks and
so much juice. Because the facility
provides for his meals, Mr. DAI is able
to comply with his diet but his wife
confides that he sometimes asks for
something more for his snacks. He says
his appetite is good. Because being
obese influences so much his
condition, he is being thought that diet
will play a major role to his treatment
and so he is thinking about maintaining
proper diet after hospitalization and is
motivated to lose weight.
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 PATTERN BEFORE HOSPITALIZATION
ELIMINATION Mr. DAI’s bowel movement pattern is
PATTERN usually once a day at morning after
rising from bed with semi – formed
stools. He says he urinates often for
around 8 – 10 times a day. He
remembers urinating a lot and
sometimes observes that his urine is a
sweet attraction for ants.
ACTIVITY / He spends daytime on weekdays at the
EXERCISE office. If it is his leisure time at home,
PATTERN he is reading newspaper in the
morning and books or magazines later
or watch television. When asked about
his exercise he says he has none.
SLEEP REST Because he got used to it, Mr. DAI
PATTERN wakes up at around 5 or 6 AM,
although he goes to office at 8 AM. He
sleeps the earliest at 9 or 10 at night
thereby having at least 7 to 8 hours of
sleep. He says he sleeps less and
sometimes a bit late when he has loads
of work. He has neither specific
bedtime rituals nor experiencing
nightmares. However, there were
times that even he had longer and
uninterrupted sleeps, he doesn’t feel
rested. He thought that he might just
be stressed from work. He sometimes
takes nap in the afternoon.
COGNITIVE / “I believe I am of sound mind” says Mr.
PERCEPTUAL DAI. He believes his job is a good mind
PATTERN enhancer. He confidently says he is still
able to make decisions and solve
problems on his own but sometimes
consults with the family. He says he
still have good memory. He wears
corrective lenses since he was in
college but otherwise says he doesn’t
DURING HOSPITALIZATION
Mr. DAI defecates at irregular times
compared to his early morning habits
although maintains defecating daily.
When asked of the color and
consistency of his stool, he describes it
as semi – formed brown stools. His
urine output is measured per shift and
sufficiently measures at least 850 -
1200 cc. It is observed that the color of
his urine is colored yellow. He still
frequently urinates.
During hospitalization, although he has
no physical restrictions, there are
times he feels “sick” and weak. He can
perform self – care activities yet his
wife assists him with some stuffs. Since
he was informed that living sedentarily
aggravates his health problem, he
became interested about doing a little
exercise and expresses motivation of
doing them once he gets home.
During hospitalization, he admits he
sometimes has difficulty starting a
sleep. He sometimes wakes up when
nurses come to check on him. He is
able to take a little of quality sleep.
There are times that though he had
slept for longer hours, he feels terribly
weak and even describes it as “parang
walang energy ba”
During his stay in the facility, whenever
Mr. DAI is asked of something, he is
coherent and responsive. He is still
oriented with date, time, person and
place. He is cooperative with routine
care rendered to him and within the
interview. He is only less participative
once he is feeling tired and too weak.
With regards to his knowledge about
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 often experience blurring of vision. All
his other sensory functions are intact.
PATTERN BEFORE HOSPITALIZATION
ROLES / The patient is living in their humble
RELATIONSHIP abode with his wife and his youngest
PATTERN son who is often out of town due to his
schooling. He also establishes good
relations to his other children who live
apart from them and have regular
communications with them. He is a
respected city prosecutor who believes
he does his job with integrity. To be on
such job is sometimes stressful but he
devotes time doing them even after
office hours at home. “You can say I
am a workaholic buddy” the patient
confesses.
SELF – Mr. DAI feels good about himself no
PERCEPTION / matter how big he appears to be. He is
SELF – CONCEPT not easily annoyed or feels down
PATTERN about comments of other people if it’s
about his physical features. His wife
says he is often open about what he
feels and he shares his thoughts to
friends and family.
SEXUALITY The patient says he is circumcised. In
REPRODUCTIVE conjunction to a satiating marital
PATTERN status, he describes that his sexual
relationship with his wife is going very
well even until now with their age.
COPING / Whenever Mr. DAI feel stressed or
STRESS have problems at work he shared it
TOLERANCE with his trusted friends or talked it out
PATTERN to his wife. He said he sometimes
divert stresses and tensions by drinking
alcohol either alone or with friends.
But whenever he has problems in his
daily life encounters he talks it over to
his wife and he communicates more
often to his children
his condition, he had little information
about it but is eager to learn about it.
DURING HOSPITALIZATION
Mr. DAI admits he is not used on being
the one that his family is looking after
but is thankful that they are supportive
to him. He says he still makes most of
the decision and feels he still has that
paternal role in the family. Some
friends visit him in the hospital and tell
him to get well soon and be a good
patient. Regarding self – care
management to address his condition,
he thinks he has to share a role to his
wife although he is trying to motivate
himself to work hard in improving his
lifestyle so he can improve his health
status.
During interaction with him, he is very
warm and accommodating. He feels
positively he will recover from his
present condition and be back to a
good shape. Only that he admits he
has to take a lot of patience and
discipline to maintain and meet
treatment goals.
With his present medical status, the
patient describes that his sexual
relation to his wife is not of his priority
concern and interest is reduced.
Otherwise, there are no significant
alterations to his sexuality and
reproductive capabilities.
At present hospitalization, he says he
gains strength in coping with his
condition through his wife who was
always at his side and with the support
and care of his children. He believes he
has a strong family support. During
encounter with him to talk about the
management of his disease, he allows
his wife to actively participate and
share a part in the learning process. He
gives credit to his good wife as an
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PATTERN BEFORE HOSPITALIZATION
VALUE BELIEF Being a devout Roman Catholic, Mr.
PATTERN DAI clings to praying to God as his
strength in whatever he experiences in
life. He says he is grateful to have a
religious wife who helped him
strengthen his faith in God. He usually
attends Sunday masses and prays the
rosary with his wife. He has a strong
faith in God and trust that He will help
him gain strength of mind and body.
important support system to help him
manage his disease.
DURING HOSPITALIZATION
The patient doesn’t blame God for his
condition but rather regard it as his sin
of being irresponsible in looking after
his own health and abusively eating
what he wants. He says he is open and
willing to avail religious services
offered in the hospital such as
anointing of the sick or talk to a priest
for counseling when able.

This sample output was an excerpt from the Case Study presented as case colloquium requirement for the
instructor’s post – graduate studies. Hence, data collection and presentation were made way back in 2013.

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