I. II.

INTRODUCTION NURSING HEALTH HISTORY A. Biographic Data Name Age Birthdate Sex Ethnic Background Civil Status Address Religion Occupation Admitting Diagnosis Admitting Physician Date and time admitted B. Chief Complaints Hypogastric pain, dysuria C. History of Present Illness According to the patient, the present condition started few hours prior to admission. She was experiencing hypogastric pain and when she went to urinate she noticed that there was blood in her urine. This made her mother brought her to Bontoc General Hospital for consultation and was she subsequently admitted. D. Past Health History The patient was first diagnosed and hospitalized of acute pyelonephritis last June 20, 2012. On March 13 of 2011 she was hospitalized due to enteric fever, hemorrhagic cystitis;on July 4, 2005 she was hospitalized due to dento alveolar abscess and tooth extraction was performed on the same day; on August 17, 2001 and August 21, 2002 she was hospitalized due to acute bronchitis and cotrimoxazole was prescribed as her medication; on the year 1997 she was hospitalized three times due to the following illnesses acute bronchitis, herpez simplex-infected mouth in which cloxacillin was prescribed as her medication,and abrasion on the left leg.

:Patient XYZ :21 years old :July 17, 1991 :Female :Bontok Tribe :Single :Upper Caluttit, Bontoc Mountain Province :Roman Catholic :Student :PU 22-23 wks AOG Acute Pyelonephritis (G1P0) :Dra. Imelda Sabog :November 26, 2012 at 12:45pm

The patient claims no allergies on certain foods and drugs. She also cited that she completed her childhood immunization as to what her mother had told her before. E. Family History of Illness Her father has a history of kidney stone at the age of 31 and died due to gun shot at the age of 38. The patient is the youngest among the 6 siblings and one of her brother has asthma which was then resolved. She also claims that both side of her parents has a familial history of hypertension. Health problems such as diabetes mellitus, tuberculosis, heart disease and mental illness was verbalized to be absent in their family. Other than that,no other health problem is inherited in their family. No present illness is currently experienced by any member of the family. F. Obstetric History The patient recalls her last menstrual period to be last June 27, 2012. She is gravida 1 and para 0. On November 27, 2012 she had her ultrasound with a result of intrauterine fetus, live, 22 weeks 0 days AOG presently transverse with the expected date of delivery on April 2, 2013. It was on September 13,2012 at 11 weeks AOG she was hospitalized due to controlled threatened abortion and acute gastroenteritis and on the following months, October 10,2012 at 15 weeks AOG when she was again hospitalized due to the same reason and with an additional diagnosis of condyloma accuminiata;cervico vaginitis and acute pyelonephritis. G. Lifestyle The patient verbalized that she smokes and drinks liquor.She was a smoker since she was in high school and she just stopped recently. She prefers to stay at home during day time and seldom performs an exercise. She spends her leisure time watching television. The patient cited that she loves eating salted foods and she seldom eat vegetables. She prefer to eat meat and processed foods. She takes in over the counter drugs whenever she experienced common health problems such as cough,colds and fever.

H. Social Data Patient is a native of Bontoc, Mountain Province, living with her mother and two brothers. She is now on 3rd year college taking up Bachelor of Science In Secondary Education. At times she goes out at night to socialize with her friends. She claims that they have a close family ties with her 5 siblings especially to her mother. I. Psychologic Data The patient was received awake, sitting on bed. She appears weak and pale, with limited movements because of pain she is experiencing. Her hygiene is fair and is properly groomed. Her speech is clear. He is responsive to questions being asked to her during the interviews. She is cooperative with medical and nursing interventions and is compliant with her drug regimen during the 3 day duty. III. PHYSICAL ASSESSMENT 1. Head 2. Eyes Normocephalic and hair evenly distributed, no areas of pain or tenderness during palpation. Able to distinguish colors,pinkish conjunctiva, sclera white without increase vascularity or lesions noted, pupils equally round and colored black,eyelashes are evenly distributed,eyelids have no discoloration, they open and close symmetrically Ears are symmetrical to each other, colored pink and without lesions and able to understand and hear spoken language correctly. Septum is located midline,no flaring noted, no episodes of epistaxis during the shift Lips are slightly dry without lesions or swelling, gums are intact and color pink, teeth is slightly yellowish in color, Neck is symmetric with head centered and without bulging masses Moves symmetrically on breathing with no obvious masses, no chest retraction noted With regular cardiac rhythm, capillary refill of 1-2 seconds, BP of 120/80mmHg and radial pulse of 71 bpm Not assessed Skin color is the same with rest of the body, with minimal striae, no rashes and lesions noted, with sensation of pain in the hypogastric area and bloated abdomen as a positive

3. Ears

4. Nose 5. Mouth 6. Neck 7. Chest 8. Cardiac 9. Breast 10. Abdomen

sign of pregnancy 11. Genitals Not assessed 12. Muscoloskeletal Muscle strength of extremities= 3/5, no visible tremors noted, 13. Integumentary Skin is warm to touch, pale in color, good skin turgor, hair is straight and evenly distributed, skin has no infestations and infections, nail is convex in shape,nail bed is color pink. IV. LABORATORY/DIAGNOSTIC EXAMINATIONS Diagnostic Description of Date Findings and Implications Procedure the procedure performed Results Normal Interpretation Value Urinalysis November 26, 2012