Name of Patient: ---------------------------------Name of Informant: -----------------------------Date Interviewed: ______________________ (Please fill in the data being asked) A.

General Data Name: Emerita Flores Age: 57 years old Nationality: Filipino Marital Status: Married Place of Residence: 1331 Magnolia st. Maricaban, Pasay City Date of Consultation: May 2, 2011 Patient E.F., 57 years-old, female, Filipino, (RELIGION???), presently residing at 1331 Magnolia St., Maricaban, Pasay City sought consultation last May 02, 2011 at San Pablo Health Center. B. Chief Complaint The patient complaints pain on her lower right abdomen that radiates at the back. She thought that it was appendicitis. Abdominal Pain C. History of Present Illness 2004- The patient had been taking Nifedipine= used in the treatment of high blood pressure as her maintenance medication for her high blood pressure. She states that she’s been experiencing headache with a pain scale of 5 or moderate pain, (0- representing the lowest pain level & 10representing the painful level), she also states that the pain lasts for hours. -She’s been experiencing headache for over a year.

(“Don’t know his name”) prescribed her to take Metropolol= a drug that controls the activity of the heart. IS THIS INFO REALLY NEEDED FOR YOUR HISTORY OF PRESENT ILLNESS??? April 7. with her purpose to know her blood pressure and remedy for her headache. THIS SHOULD BE INCLUDED IN THE PAST MEDICAL HISTORY March 2.Prescribed he to take omeprazole= used to treat gastric ulcer. April 14. THIS SHOULD BE INCLUDED IN THE PAST MEDICAL HISTORY .her nephew & his wife arrived from Samar.With the same complaints of high blood pressure and headache.After reading her ECG result. the Dr.May 3. advised her to do an ECG (electrocardiogram)= recording of the electrical activity of the heart. Dr. . G. from Klinika ng Masa.she went back to Klinika ng Masa for check-up for her regular blood pressure check-up.Dr.she took an ECG test April 16.THIS SHOULD BE INCLUDED IN THE PAST MEDICAL HISTORY February 2011.result of ECG April 29.Dr. and stayed with the patients house for 1 month. Perez of Claudio Medical Clinic read and interprets her ECG result . . and is used to treat high blood pressure and Mefenamic acid= used to treat headache.Her first visit at Klinika ng Masa near to her residence. Perez advised her to take 4 tests. and and amlodipine= used to treat hypertension . but the patient failed to follow the Dr’s order.

she went back to the clinic and Dr. Domingo from San Pablo Health Center read the result.With a pain scale of 2 . .First meeting with Dr. fecalysis.She went to San Pablo Health Center.May 2.she had a vacation at Samar. .The patient been diagnosed of Schistosomiasis . urinalysis.said that she’d been experiencing abdominal pain since the year 2011 starts.Dr. WHEN DID THE ABDOMINAL PAIN STARTED??? LOCATION? PRECIPITATING FACTORS??? RELIEVING FACTORS?? SEVERITY??? TIMING??? THERE ARE NO DATA on THE ABOVE STATEMENTS tells us that? WHAT ARE THE ASSOCIATED SIGNS AND SYMTOMS? ANY MEDS TAKEN BEFORE CONSULTATION? ANY CONSULTATION DONE BEFORE CONSULTATION? May 9-18.Dr. . SGOT. got the result on the same day.Dr. July 15. Domingo prescribed her to take Praziquantel= antihelminthic drug used to eliminate tapeworms and schistosomes. .result of laboratory tests. to check her cervical lymph nodes or “kulani” present in her neck . AGAIN WHAT HAPPENED TO THE SYMPTOM? DOES IT WORSENS? ANY APPEARANCE OF NEW SYMPTOMS? MEDS TAKEN? CONSULTATION DONE? July 13. with a chief complaints of pain on her right abdomen.the day of her ultrasound test. that .SGPT. Antonio prescribed her to take amoxicillin= used to treat infections. Antonio advised her to take an ultrasound test. Domingo advised the patient to take laboratory tests (cbc. except for the kato katz test.Her first visit to San Pablo Health Center. May 31. the pain on her abdomen is still present. she thought that it was appendicitis. APTT and kato katz test) July 20. Carl Antonio . with a pain scale of 2.Dr.

Dr. just to check her pressure.she visit San Pablo Health Center.Prescribed to take Cefalexin= used to treat urinary tract infections The patient complaints pain on her right shoulder with a pain scale of 5 she states that she could not lift arm. As of this time the patient still experiencing pain on her right abdomen and has not been performing kato katz test. D. Past Medical History a. Dr.has not been perform yet July 22. Domingo read the and interpret the result .The patient has Urinary Tract Infection .went to the clinic . prescribed her to take paracetamol= used to treat mild or moderate pain August 19. Disease: .

Personal/Social Histoy a.The patient has a history of Hypertension. surgeries. lives with her mother. Lifestyle: Diet. e. She washes clothes. accidents: The patient been hospitalized when she gave birth to her children. The youngest is Ruby Rose Flores. d.o. cooks. Educational Attainment The patient is a high school graduate of Pambuhan National High School c. single. Her son who works abroad supports their daily living. currently living with his own family. no asthma and other forms of disease. a high school graduate. no diabetes. The eldest is Ramil Flores 33 y. Previous hospitalizations. vegetable and banana and eggs as part of her diet. 18y. E. and currently working as waiter in Jeddah. Hobbies . Saudi Arabia.o.o. married. Smoking and Drinking history The patient is a non smoker and non-alcoholic b. and regularly went to the marketplace as her work of exercise. Number of children The patient has three children. a 3rd year college student taking up Office Management Course at City University of Pasay. physical activity The patient includes fish. b. a computer software graduate. f. Occupation The patient stays at her house. single. The second child is Ryan Flores 31 y.

Obstetric History a. Gravida? Parity? OB score: G4P3T3P0A1L3 The patient has been pregnant 4 times. hair is evenly distributed. Her scalp has no presence of nits lice and dandruff.The patient is fond of cross-stitching and bag making made by beads. the head is normocephalic (normal shape of the head). 2 pads per day. G. d. moderate or heavily soaked: slightly soaked. Skin There is no presence of lesions or the like on the skin of the patient. There is no palpable lymph nodes on the neck. Throat . The patient was 14 years old b. Eyes. hypertension. Nose. and her fourth pregnancy was delivered at 36 weeks. Last normal menstrual period: when she was 46 y. therefore. Vital signs Temperature: 36 ° Celsius Pulse rate: 64 bpm Respiratory rate: 18 bpm Blood Pressure: 160/100 Head and Neck The head is proportional to the size of the body.o/ Menopausal period c.in paternal side of the patient. her third pregnancy was delivered at 36 weeks. Ears. Physical Assessment A. asthma. her second pregnancy resulted to miscarriage at 8 weeks. Menarche: Year 1967. J. She gave birth to her first child at 36 weeks. Family History Father side. F. Sanitary pads consumed per day? Slightly. diabetes is their heredofamilial disease. Hair is black with gray strands.

The throat is well modulated. The eyelashes are black in color and evenly distributed and slightly curved outward and upward. Bilaterally symmetrical of the vocal fremitus. Chest and Lungs The chest has a symmetrical expansion with breathing. Mouth is symmetrical to the lip margin. and no presence of nasal discharges. Cardiovascular The aortic and pulmonic areas have no pulsations as well as the tricuspid area of the heart. Nose in in normal position. The lips are moist and a bit pinkish in color. evenly distributed and symmetrical.Eyes are symmetrical and non-protruding (further forward than usual). symmetrical. The breath sound is normal and no abnormal sounds were heard. Lid margins are clear without scaling and secretions. The internal nares is clean and slightly moist . Skin temperature of the chest of the chest are uniform. There is symmetric contour and abdominal movement. The palate is pinkish and in normal in dome shape. The heartbeat of the patient is in regular pattern. The patient feels areas of tenderness at the tip of her tongue. The patient is experiencing pain on her lower part of her . located in the midline of the face. hearing acuity of both ears can hear whispers that were spoken 2 ft away. The eyelids are not inverted and no mass palpated. rounded convex. and proportional to the size of the head. Her ear canal has a small amount of cerumen. The contour is flat. smooth. The PMI (point of maximal impulse) has visible pulsations. The patient has no common colds. with few nasocilliary hairs. Gums are bit pinkish in color and not swelling. The patients left eye has a higher grade than the other side(the patient did not remember the grade of her eyeglasses) Ears are parallel. The tongue is freely movable. The pupils are round . Eyebrows are slightly curve. Sclera is white and clear. round and black in color. The patient is not experiencing difficulty of breathing. black in color and reactive to light and accommodation. Iris is proportional to the size of the eyes. Gastrointestinal Tract The skin integrity of the abdomen is normal. Eyes can move in full motion.

V. Trochlear nerve The patient was able to move her eyes downward easily. IV. Masseter muscles bulge when teeth are clenched. The patient’s bowel movement has a rough texture the last time we visit her. II. Oculomotor nerve The patient was able to follow and move her eyes in six ocular movements. Musculoskeletal The lower extremities of the patient are in normal condition. Trigeminal nerve Patient can clench teeth tightly. Abducens nerve The patient can easily move her eyes laterally. Optic nerve The patient’s optic nerve is functioning but the visual acuity of the patient is degraded. Neurologic (Cranial Nerves) I. The left arm of the patient is freely movable but the right arm has limited movement because of the presence of pain. Genitourinary Tract The patient has a history of urinary tract infection. both masseter muscles feel equal in size and strength. . VI. The borborygmy of the client is 18 movements per minute. III. She has no problem in urinating. Olfactory nerve The patient’s cranial nerve number 1 is functioning well because she was able to distinguish different stimuli.right abdomen. On palpation. where she can move freely and the range of motion is done with ease.

VIII. Vestibulo cochlear or Auditory nerve The patient has equal hearing in both ears. Hypoglossal nerve The patient can freely move her tongue up and down.VII. IX. Glossopharyngeal nerve and X. . Facial nerve The patient has symmetrical facial contours and lines as well as symmetrical facial movements. The patient can also perform all facial expressions asked by the student nurse. The patient was able to balance herself in different normal positions. The patient has normal gag reflex. left and right. XII. Vagus nerve The patient was able to identify the taste of the food given to her by the student nurse. XI. Air conducted tones are heard twice. Spinal Accessory The patient can resist the force applied on her shoulder and jaw. The patient voice is clear and no horseness.

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