Address: 4c Caguioa Rd. Baguio City Gender:Female Marital status: Single Age: 19 Birthdate: February 26, 1995 Place of Birth: Urdaneta City Ethnic Background Educational Level: 3rd yr. College Occupation: Student Provider of history: Patient
Present Health Concern The character of the patient is having an amoebiasis and she encountered pain everytime her illness triggers. It started last year and it is getting worse when she eat raw foods . The pain is located at the left umbilical region of the patient and it is last for 2 days. The severity of pain of the patient is 8. "It is better when i take medicine but it is getting worse when i eat raw foods". The patient claim's that she vomit and she can't continue her activities when the pain strikes.
Aunts and uncles age and illnesses
Aunt who is 47 y/o, no illness. Aunt who is 45 y/o no illness. Uncle who is 43 y/, no illness. Childrens age and illness or handicaps: Client has no children
Review of Problems
Systems
for
Current
Health
Past Health History
Problems at birth: none Childhood Illnesses: Asthma and Weak Lungs Immunization to date: 1st Year College Adult Illnesses: Acidity and Ulcer Surgeries: none Prolonged pain: Allergies: Dust, Animal, Medicine like Antibiotics Current Medication: None
Skin,Hair and Nails: The client's skin is light
brown in color, normal temperature, it is smooth, no lesion or rashes seen. The hair is black, it is smooth and firm without hair loss and dundruff and the nails are clean, pinkish in color and smooth. Head and Neck: No headache, no stiffness, no difficulty of swallowinh and no enlarged lymph nodes.
Family Health History
Ears: No signs of hearing loss and no pain. Age of Parents (Living? Deceased date): Mother: 46 Father: 47 Deceased: September 21, 2012 Parent Illnesses: Diabetics, Asthma and Heart Problem Grandparent Illnesses: Heart Problem Aunts' and Uncles' age: Unrecalled
Eyes: The patient claim's that she is a nearsighted.
No redness seen and no black spots. Mouth, Throat, Nose and Sinuses: The patient has no mouth pain, no sore throat and no lesion. The patient claim's that she is sneezing and coughing.
Thorax and Lungs: "Nahihirapan akong huminga
kapag masakit ang dibdib ko" "Sometimes i'm experiencing shortness of breathing while i'm doing some activities" Breast and Regional Lymphatics: The patient claims that she don't feel any pain over her breast and there are no dimpling or lymph nodes in axilla. Heart and Neck Vessels: "I have a chest pain" The patient massage her chest when she feels pain. Peripheral Vascular: There are no pain noted. Abdomen:"Minsan sumasakit yung tiyan ko at ang ginagawa ko ay umiinom ako ng gatas para mawala ang sakit" Female Genitalia: No pain Anus, Rectum and Prostate: The patient claim's that she is constipated. She is drinking medicine like diatabs and she drink greater 2L of water. Musculoskeletal: No pain, no swelling, no redness and no stiff joints Neurological: "Laging sumasakit ang ulo kaya naman lagi kong tinutulog" "Minsan paiba-iba ang mood ko"