B.

Family Health-Illness History

The diagram above shows that the grandparents of Ms. Annie on both his father and mother side died and she does not know the cause and their age when they died. Her father died of Anemia and her mother died of hypertension. Two of her brother has hypertension and had a cerebrovascular accident. Her sister also has hypertension. C. History of Past Illness According to Ms. Annie, she has a history of cholelithiasis which was diagnosed when she was in her mid-30s (2008) at a hospital at Baguio City. She undergone cholecystectomy and was given home medication which, according to her, she cannot remember. She also had peptic ulcer disease when she was twenty-one years old until present which she does not know if gastric or duodenal. She was given appropriate management at Ospital Ning Angeles (currently Rafael Lazatin Memorial Hospital) and given home medication including the following: Maalox, Zantac, and Novalocine which she only takes if she feel abdominal pain. Aside from the illnesses mentioned above, Ms. Annie also experienced fever, cough and colds. D. History of Present Illness At the earlier months of 2005, Ms. Annie experienced insomnia for days and suddenly fainted. She was then rushed to Ospital Ning Angeles and was confined for one week. She has received several medications and four bags of packed RBC. All she can remember is that her diagnosis was anemia, not specifying what type. She also undergone five bone marrow aspirations at the same hospital and was given medications for home management. Two weeks prior to admission to Jose B. Lingad Memorial Regional Hospital (JBLMRH), Ms. Annie experienced paleness, insomnia, nausea and vomited 3-4 times a day. Three days before admission, she admitted herself at JBLMRH emergency room at about 8 in the morning until 1 in the afternoon but did not receive any attention from the staff. She went home and take rest but after 3 days, Friday, but her manifestations persist and worsens. She was the admitted and received appropriate treatment.

With her work as a cook, Ms. Annie cannot even drink adequate amount of fluid. She drinks approximately 3 glasses of water per day and is fond of carbonated drink consumption. Three days prior to admission she also experiences fever but did not have any pain during urination or changes in urine color.

E. Physical Examination DATE General Appearance During the initial stage of physical examination, the patient is conscious and coherent with generalized pallor, body malaise and easy fatiguability.

Vital Signs -------------------------------------------------------Skin: moist; when pinched, skin goes back to previous state immediately- good skin turgor; pallor, warm to touch Hair: equal distribution, long and a bit oily, no presence of infection Lymphnodes: upon palpation of the occipital, submandibular and sub mental lymphnodes, no remarkable findings noted Head: normocephalic; no lumps noted upon palpation Eyes: symmetrical, noted pale palpebral conjunctiva; eye lids and eyebrows are symmetrical Ears: symmetrical; no Darwinian tubercle, cysts and discharge noticed. Outer cantus of the eye and the upper tip of the pinna are on the same level; with intact hearing. Nose: nostrils are symmetrical and no evidence of septum deviation, discharge, polyps and exudates detected. Sense of smell is intact. Mouth and throat: noted pale lips, soft and hard palate, with no signs of swelling and ulceration noticed in the buccal mucosa. Tongue has normal innervation and is pink in color. Teeth are yellowish in color and have dental caries on lower part of the teeth. Neck: no masses or tenderness noted upon palpation; no signs of jugular vein distention noticed and carotid arteries are palpable.