You are on page 1of 3

HEALTH ASSESSMENT BIOGRAPHICAL DATA Name: Mrs.

CA Address: Marawi City, LDS Room Number: 239 Age: 50 Y/O Gender: Female Birth date: January 17, 1964 Birthplace: Marawi City Educational Attainment: College Graduate Occupation: Housewife Referral: Dr. Melanie Felicia G. Bascug Medical Diagnosis/Impression: Rectal Cancer Stage 3 (T4N2M0) Marital Status: Married Number of Dependents: 3 Ethnicity/Nationality: Maranao/Filipino

SOURCE OF HISTORY: Patient- 60% Significant Others- 20% Patients Chart- 20% REASONS FOR SEEKING CARE: Hypogastric Pain

PRESENT HEALTH HISTORY OR HISTORY OF PRESENT ILLNESS Prior to admission, Mrs. CA experienced on and off hypogastric pain radiating to her perianal area, she verbalized that she has been experiencing hypogastric pain for almost 1 year, but she only ignores it because the pain is bearable. She only takes Buscopan and Kremil-S to relieved the pain. One month PTA, she had an abnormal bowel movement for 10 days with freash blood & experienced diarrhea and constipation alternately. Last January 24, 2014 she decided to seek medical attention and went to CDO Medical Center to have her check up. She undergone whole abdomen ultrasound and the result found out that she has a Myoma with a diameter of 1.58 cms posterior body, she also undergone sigmoidoscopy for biopsy, and the result shows that she has a rectal mass most probably malignant. She was diagnosed of rectal cancer by Dra. Ricarte, a gastrologist. Her physician prescribed her lactulose (movelax) and paracetamol (dolcet) for take home medications. January 27,2014 at 2pm she experienced again a hypogastric pain with the pain scale of 10/10 that prompted her to admission. She was admitted in Adventist Medical Center on that same day @ 5:40 PM. She undergone a lot of diagnostic tests, and on January 30, 2014 @ 9:20 am she undergone ex-lap surgery and distal transverse colostomy, the operation ended @ 11:40 am. The procedure was done by Dr. Lucman and Dr. Batara, and Dra. Macabalang was her anaesthesiologist, she was given an epidural anesthesia during the operation. Her current medication are as follows; Tramadol 50g IV q8h PRN for pain, Metronidazole (duzomet) 500g IV q6h, ceftriaxone 1gm q12h ANST, Ranitidine 50mg IVTT q8h, Parecoxib 40mg IVTT q12h x 2 doses, Morphine 2.5 mg thru Epidural catheter q12h x 3 doses.

PAST HISTORY Mrs. CA experienced fever, cough & colds during her childhood years. She is a fully immunized child as claimed, she has no allergies to food or any medications, she doesnt had injuries or encountered accidents before, nor experienced any serious or chronic illness in the past. Mrs. CA obstetric history was G2T2P2A0L2M0. She undergone caesarean section twice, her first operation was on 1998 @ St. Mary Hospital, Iligan City when she delivered her first child, and the second time was on 2000 @ CDO Medical Center on her second child, Mrs. CA stated that she cannot recalled the physicians name and the medication that was given to her during that time.

You might also like