Name of Patient: ---------------------------------Name of Informant: -----------------------------Date Interviewed: ______________________ (Please fill in the data being asked) A.

General Data Name: Emerita Flores Age: 57 years old Nationality: Filipino Marital Status: Married Place of Residence: 1331 Magnolia st. Maricaban, Pasay City Date of Consultation: May 2, 2011 Patient E.F., 57 years-old, female, Filipino, (RELIGION???), presently residing at 1331 Magnolia St., Maricaban, Pasay City sought consultation last May 02, 2011 at San Pablo Health Center. B. Chief Complaint The patient complaints pain on her lower right abdomen that radiates at the back. She thought that it was appendicitis. Abdominal Pain C. History of Present Illness 2004- The patient had been taking Nifedipine= used in the treatment of high blood pressure as her maintenance medication for her high blood pressure. She states that shes been experiencing headache with a pain scale of 5 or moderate pain, (0- representing the lowest pain level & 10representing the painful level), she also states that the pain lasts for hours. -Shes been experiencing headache for over a year.

THIS SHOULD BE INCLUDED IN THE PAST MEDICAL HISTORY February 2011- Her first visit at Klinika ng Masa near to her residence, with her purpose to know her blood pressure and remedy for her headache. - With the same complaints of high blood pressure and headache, the Dr. (Dont know his name) prescribed her to take Metropolol= a drug that controls the activity of the heart, and is used to treat high blood pressure and Mefenamic acid= used to treat headache. THIS SHOULD BE INCLUDED IN THE PAST MEDICAL HISTORY March 2- May 3- her nephew & his wife arrived from Samar, and stayed with the patients house for 1 month. IS THIS INFO REALLY NEEDED FOR YOUR HISTORY OF PRESENT ILLNESS??? April 7- she went back to Klinika ng Masa for check-up for her regular blood pressure check-up. - Dr. from Klinika ng Masa, advised her to do an ECG (electrocardiogram)= recording of the electrical activity of the heart. April 14- she took an ECG test April 16- result of ECG April 29- Dr. G. Perez of Claudio Medical Clinic read and interprets her ECG result - Prescribed he to take omeprazole= used to treat gastric ulcer, and and amlodipine= used to treat hypertension - After reading her ECG result, Dr. Perez advised her to take 4 tests, but the patient failed to follow the Drs order. THIS SHOULD BE INCLUDED IN THE PAST MEDICAL HISTORY

May 2- Her first visit to San Pablo Health Center, with a chief complaints of pain on her right abdomen, she thought that it was appendicitis. - said that shed been experiencing abdominal pain since the year 2011 starts. - With a pain scale of 2 - First meeting with Dr. Carl Antonio - Dr. Antonio advised her to take an ultrasound test. WHEN DID THE ABDOMINAL PAIN STARTED??? LOCATION? PRECIPITATING FACTORS??? RELIEVING FACTORS?? SEVERITY??? TIMING??? THERE ARE NO DATA on THE ABOVE STATEMENTS tells us that? WHAT ARE THE ASSOCIATED SIGNS AND SYMTOMS? ANY MEDS TAKEN BEFORE CONSULTATION? ANY CONSULTATION DONE BEFORE CONSULTATION? May 9-18- she had a vacation at Samar, the pain on her abdomen is still present, with a pain scale of 2. May 31- She went to San Pablo Health Center, to check her cervical lymph nodes or kulani present in her neck - Dr. Antonio prescribed her to take amoxicillin= used to treat infections. AGAIN WHAT HAPPENED TO THE SYMPTOM? DOES IT WORSENS? ANY APPEARANCE OF NEW SYMPTOMS? MEDS TAKEN? CONSULTATION DONE? July 13- the day of her ultrasound test, got the result on the same day. July 15- she went back to the clinic and Dr. Domingo from San Pablo Health Center read the result. - The patient been diagnosed of Schistosomiasis - Dr. Domingo prescribed her to take Praziquantel= antihelminthic drug used to eliminate tapeworms and schistosomes. - Dr. Domingo advised the patient to take laboratory tests (cbc, fecalysis, urinalysis, SGOT,SGPT, APTT and kato katz test) July 20- result of laboratory tests, except for the kato katz test, that

has not been perform yet July 22- went to the clinic - Dr. Domingo read the and interpret the result - The patient has Urinary Tract Infection - Prescribed to take Cefalexin= used to treat urinary tract infections The patient complaints pain on her right shoulder with a pain scale of 5 she states that she could not lift arm. Dr. prescribed her to take paracetamol= used to treat mild or moderate pain August 19- she visit San Pablo Health Center, just to check her pressure. As of this time the patient still experiencing pain on her right abdomen and has not been performing kato katz test.

D. Past Medical History a. Disease:

The patient has a history of Hypertension, no diabetes, no asthma and other forms of disease. b. Previous hospitalizations, surgeries, accidents: The patient been hospitalized when she gave birth to her children. E. Personal/Social Histoy a. Smoking and Drinking history The patient is a non smoker and non-alcoholic b. Educational Attainment The patient is a high school graduate of Pambuhan National High School c. Number of children The patient has three children. The eldest is Ramil Flores 33 y.o, a high school graduate, married, currently living with his own family. The second child is Ryan Flores 31 y.o, single, a computer software graduate, and currently working as waiter in Jeddah, Saudi Arabia. The youngest is Ruby Rose Flores, 18y.o, single, lives with her mother, a 3rd year college student taking up Office Management Course at City University of Pasay. d. Occupation The patient stays at her house, Her son who works abroad supports their daily living. e. Lifestyle: Diet, physical activity The patient includes fish, vegetable and banana and eggs as part of her diet. She washes clothes, cooks, and regularly went to the marketplace as her work of exercise. f. Hobbies

The patient is fond of cross-stitching and bag making made by beads. F. Family History Father side- in paternal side of the patient, hypertension, asthma, diabetes is their heredofamilial disease. G. Obstetric History a. Menarche: Year 1967. The patient was 14 years old b. Last normal menstrual period: when she was 46 y.o/ Menopausal period c. Sanitary pads consumed per day? Slightly, moderate or heavily soaked: slightly soaked, 2 pads per day. d. Gravida? Parity? OB score: G4P3T3P0A1L3 The patient has been pregnant 4 times. She gave birth to her first child at 36 weeks, her second pregnancy resulted to miscarriage at 8 weeks, her third pregnancy was delivered at 36 weeks, and her fourth pregnancy was delivered at 36 weeks. J. Physical Assessment A. Vital signs Temperature: 36 Celsius Pulse rate: 64 bpm Respiratory rate: 18 bpm Blood Pressure: 160/100 Head and Neck The head is proportional to the size of the body, therefore, the head is normocephalic (normal shape of the head). Her scalp has no presence of nits lice and dandruff. Hair is black with gray strands, hair is evenly distributed. There is no palpable lymph nodes on the neck. Skin There is no presence of lesions or the like on the skin of the patient. Eyes, Ears, Nose, Throat

Eyes are symmetrical and non-protruding (further forward than usual). Eyebrows are slightly curve, evenly distributed and symmetrical. The eyelashes are black in color and evenly distributed and slightly curved outward and upward. The eyelids are not inverted and no mass palpated. Lid margins are clear without scaling and secretions. Sclera is white and clear. Iris is proportional to the size of the eyes, round and black in color. The pupils are round , black in color and reactive to light and accommodation. Eyes can move in full motion. The patients left eye has a higher grade than the other side(the patient did not remember the grade of her eyeglasses) Ears are parallel, symmetrical, and proportional to the size of the head. Her ear canal has a small amount of cerumen, hearing acuity of both ears can hear whispers that were spoken 2 ft away. Nose in in normal position, located in the midline of the face. The internal nares is clean and slightly moist , with few nasocilliary hairs. The patient has no common colds, and no presence of nasal discharges. Mouth is symmetrical to the lip margin. The lips are moist and a bit pinkish in color. Gums are bit pinkish in color and not swelling. The tongue is freely movable, smooth. The patient feels areas of tenderness at the tip of her tongue. The palate is pinkish and in normal in dome shape. The throat is well modulated. Chest and Lungs The chest has a symmetrical expansion with breathing. The breath sound is normal and no abnormal sounds were heard. The patient is not experiencing difficulty of breathing. Bilaterally symmetrical of the vocal fremitus. Skin temperature of the chest of the chest are uniform. Cardiovascular The aortic and pulmonic areas have no pulsations as well as the tricuspid area of the heart. The PMI (point of maximal impulse) has visible pulsations. The heartbeat of the patient is in regular pattern. Gastrointestinal Tract The skin integrity of the abdomen is normal. The contour is flat, rounded convex. There is symmetric contour and abdominal movement. The patient is experiencing pain on her lower part of her

right abdomen. The borborygmy of the client is 18 movements per minute. The patients bowel movement has a rough texture the last time we visit her. Genitourinary Tract The patient has a history of urinary tract infection. She has no problem in urinating. Musculoskeletal The lower extremities of the patient are in normal condition, where she can move freely and the range of motion is done with ease. The left arm of the patient is freely movable but the right arm has limited movement because of the presence of pain. Neurologic (Cranial Nerves) I. Olfactory nerve The patients cranial nerve number 1 is functioning well because she was able to distinguish different stimuli. II. Optic nerve The patients optic nerve is functioning but the visual acuity of the patient is degraded. III. Oculomotor nerve The patient was able to follow and move her eyes in six ocular movements. IV. Trochlear nerve The patient was able to move her eyes downward easily. V. Trigeminal nerve Patient can clench teeth tightly. Masseter muscles bulge when teeth are clenched. On palpation, both masseter muscles feel equal in size and strength. VI. Abducens nerve The patient can easily move her eyes laterally.

VII. Facial nerve The patient has symmetrical facial contours and lines as well as symmetrical facial movements. The patient can also perform all facial expressions asked by the student nurse.

VIII. Vestibulo cochlear or Auditory nerve The patient has equal hearing in both ears. Air conducted tones are heard twice. The patient was able to balance herself in different normal positions. IX. Glossopharyngeal nerve and X. Vagus nerve The patient was able to identify the taste of the food given to her by the student nurse. The patient has normal gag reflex. The patient voice is clear and no horseness. XI. Spinal Accessory The patient can resist the force applied on her shoulder and jaw. XII. Hypoglossal nerve The patient can freely move her tongue up and down, left and right.