CHRISTINE JOY A.

ALA

2NUR1
HISTORY

Patient L.E.E., female, 71 years old is currently living at 53-G MRT ave. Lower Bicutan,
Taguig City. She was born on March 11, 1944 in Gubat, Sorsogon. She is a Roman Catholic and
is already widowed as well as a good mother to her six children. She is a Philhealth member and
upon admission she was accompanied with her daughter.
Patient L.E.E. complains of feeling of incomplete voiding, her clinical history shows that
one year prior to admission, patient complained of feeling of incomplete voiding accompanied
by dysuria. After 9 months, introital mass appreciated measuring approximately 2 x 2 cm and
with persistence of symptoms. She went to University of Santo Tomas Hospital Out Patient
Department for consultation, it shows that UA & pap smear was normal and a 3 day bladder
diary was done. Her assessment show POP stage II Aa Bb C and Stage III ApBp, patient was
offered colpocleisis after attaining CV clearance.
Patients past history shows positive to hypertension and was diagnosed last 2013. Family
history shows positive to hypertension to her mother side but negative sign for diabetes mellitus,
cancer and thyroid disease. She had past hospitalizations and surgeries wherein she had medical
surgical history of prolonged and heavy menses in 1989 and amoebiasis last 2009. She was also
confined due to dilatation and curettage in 1989 and didnt received blood transfusions.
Patients Obstetrical History shows she has six children and experienced one abortion.
Her first baby was born on 1964, live term baby boy delivered via NSD at home by traditional
birth attendant. Her next baby was born on 1966, she also gave birth through a traditional birth
attendant to a live baby girl via NSD at home. She again gave birth to a live term baby boy via
NSD at home by traditional birth attendant in 1968, 1970 and 1972. In 1974, her sixth child was
aborted and she didnt have a complete curettage. In 1986, her seventh baby was born and was
delivered via NSD through a traditional birth attendant at home. Her menstrual onset was at the
age of 14 years old, with an interval of 28-30 days, during her menstrual period she experiences
dysmenorrhea every first day of her period. And at the age of 45 years old, she was already
menopaused.
Patient is not allergic to anything except to .a drug name Cefazolin. She sees herself as
normal and fine. Patient verbalized that she is sad because she underwent surgery. Upon
interviewing, she also verbalized that she is having difficulty of sleeping due to the pain felt on
her lower body because her indwelling catheter was already removed on the morning of April 23,
2015 and she cant move freely and when she move theres pain felt in her lower part of her
body. She is also in a progressive diet, Before hospitalization, patient verbalized that she only
eats half of her food or 50% of the food in her plate but eats three times a day because she needs
to have a diet due to her hypertension. And while she is in the hospital, she still eats half of the
food served for her. Her vital signs were Temperature is 37.4 degrees Celsius, Pulse rate is 76,

respiratory rate is 20 and Blood pressure is 90/70. Patient verbalized that after the surgery her
blood pressure was already low.