VII.

HEALTH HISTORY

I. History of Present Illness

Two weeks prior to admission, the client experienced epigastric pain. Four days prior
to consultation, patient had experienced difficulty of breathing.

On the day of admission, worsening of condition led to seek consultation. The patient
had pale pink conjunctivae, pale nail beds, dynamic precordium, murmurs at precordial area
and retractions. Her admission diagnosis was Rheumatic Heart Disease in failure.

The client was admitted to CLMMRH on January 13, 2015 at 11:50 am.

II. Past Health History

a. Childhood Illness
The client has experienced common illnesses such as fever, headaches,
cough, colds, and stomach-aches. The client had pneumonia when she was 5
years old.
b. Past Hospitalization
The client was hospitalized in 2011 because she felt pain every time
she swallowed. She also had fever and cough. The client was diagnosed with
tonsillitis and later that year was diagnosed with RHD. She was prescribed
Penadur as her medication every month. The client was also hospitalized in
March 2014 because of difficulty of breathing. She was still diagnosed of
Rheumatic Heart Disease. She skipped 4 months of her Penadur injection
before she was admitted in January 2015. On January 13, 2015, she went to
the emergency room because of difficulty of breathing. She was then admitted
because her Rheumatic Heart Disease was in failure.
c. Serious/Chronic Illness
The client had her first attack of tonsillitis in 2011 and later that year
she was diagnosed again with tonsillitis. She felt pain every time she
swallowed and she also had fever and cough.
d. Previous Surgery
The client did not have any previous surgeries.

III. Family / Social History

 The client does not have family history of hypertension, diabetes or cancer but she has
an aunt who was also diagnosed with RHD. She is the 6th of 7 siblings.

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VIII. Assessment (Cephalo-Caudal)

 General Appearance

 Thin

 With clean clothes

 Nails cut short

 Vital Signs

January 21, 2015 January 22, 2015 January 23, 2015

8:00am 12:00pm 8:00am 12:00pm 8:00am 12:00pm
BP 90/60mmHg 90/60mmHg BP 90/70mmHg 90/70mmHg BP 90/60mmHg 90/60mmHg
Tem 36.6 oC 36.4 oC Tem 35.7 oC 35.7 oC Tem 36.4 oC 36.4 oC
p p p
RR 36cpm 34cpm RR 36cpm 34cpm RR 36cpm 36cpm
PR 78bpm 98bpm PR 94bpm 90bpm PR 98bpm 94bpm

 MIO

Date Intake Output Stool

January 21, 2015 240ml 200ml 0
January 22, 2015 80ml 30ml 1
January 23, 2015 200ml 200ml 0