Review

What How Answers

Registration

Name Thao

Date of Birth 25/09/2001

Address Hoang Mai- Ha Noi

Telephone 0985560062

Sex Female

Occupation Accountant

Insurance number JJ211466999

Marital status Got married, had 2

children

Next of kin Husband

Telephone 0379496605

Immunizations 3 dose HPV

Health-screening Every years

tests

Allergies Antibiotic

Surgeries When gave birth

Medications Take a medicine to

treatment hypertensio

(amplodipin)

General health Good

Vital signs

T, BP, RR, HR, P, SpO2

37oC, 120/80 after taking medicine, P: 70, RR 20, SpO295%

 History of Present Illness (HPI)

Chief complaint

SOCRATES

Site Right upper quadrant

Onset 2 month ago

Character A dull pain, constant

Radiation No radiation

Associated Loss 2 kilo for 2

symptoms month, sometimes fell

nause

Time course 3 days

Exacerbating & When I eatting too

Relieving factors much, I fell it worse

Severity 5 out of 10
Other symptoms

Past Medical History (PMH)

MAM SFS

Main diseases Hypertension

Allergies Antibiotic

Medications Amlodipine

Surgeries When gave a birth

Family history Grand father had stroke

2 years ago

Social history

SAD SAD

Smoke Yes, but I quit when I

went to high school

 Alcohol When I have a party

with my friend, just a

little, not too much

Drugs No

Sexual life Refuse to answer

Activities Badminton, 3 times a

week

Diet Plan to diet

Note: