St. Paul University Surigao
St. Paul University System
8400 Surigao City, Philippines
Nursing Health History
PATIENT INFORMATION
Name: Patient A
Age: 63
Address: Brgy. Ipil, Surigao City, Surigao Del Norte
Status: Married
Religion: Roman Catholic
General Observation:
Sex: M
Occupation: N/A
HT: 5 ft 8 in; WT: 72 kg; RR: 21 cpm, BP: 130/90 mmHg; Temp: 36.8°C; BMI: 24.13 KG/M2 (normal weight).
The patient's respiratory rate and blood pressure are within normal limits for his age and gender. The
patient appears to be his stated age. He has wrinkles on his forehead and on the sides of his eyes and mouth.
The patient's skin has no visible signs of a rash or lesions. He also has moles on his face and body. He has
baldness on the middle part of his head. His beard is well-groomed and has overgrown nose hair. He has a
big and deep scar on his right leg, under the knee. The patient is attentive and well-spoken, with fluent
speech despite having a slight hearing impairment; he answers the questions with as much relevant detail
as he can remember and speaks interchangeably in Bisaya and Tagalog. His sitting posture is slouched. He
was yawning halfway through the interview. The patient's general appearance and behavior appear to be
consistent with his stated age and health status.
HEALTH HISTORY
A. Chief Complaint/s:
“Magsakit usahay ako tangkugo (back of the neck) tapos mag-blurry sab ako vision pag mutaas ako
sugar kung mukaon ako mga tam-is”, as verbalized by the patient.
B. History of Present Illness : (Location, onset, character, intensity, duration, aggravation and alleviation,
associated symptoms, previous treatment and result, social and vocational responsibilities)
The client is a 63-year-old male who has been diagnosed with diabetes since 1990. He complains that when
his blood sugar rises, he experiences dizziness accompanied by blurry vision and feels tired. He recently
experienced it last month, which, according to him, lasted about 15–20 minutes. He has maintenance
medication, which is metformin 5 mg, and he takes it twice a day. He visits the public health center near
their area to have check ups twice a week for his diabetes and to monitor his blood sugar. He also has
hypertension, and his physician prescribed him a maintenance dose of losartan 50 mg and amlodipine 5mg.
He is also taking ascorbic acid once a day as a vitamin. In terms of his food intake, he now eats moderately:
1 cup of rice with veggies or fish at each meal; he only eats chicken and beef once a week; and he doesn't eat
pork. The patient had inconsistent sleeping patterns due to the nocturia or frequent urination at night. He
also walks every morning for at least 15-25 minutes. He still drinks alcohol occasionally, but soft drinks and
sweets have been cut from his diet.
C. History of Past Illness/es: (Previous hospitalization, injuries, procedures, infectious disease,
immunization/health maintenance, major illness, allergies, medication, habits, birth and development
history, nutrition – for pedia)
The client had never had any infectious disease, suffered any injuries, or undergone surgeries or procedures
before. The patient got his measles and chickenpox vaccine in 1997, in the month of November. He stated that
he doesn't have any allergies to foods or medications. He admitted that he was a heavy drinker in his early
twenties and could consume 12 bottles of 330-ml San Miguel Pale Pilsen every night. He also smokes
cigarettes, specifically Marlboro, and consumes one or more packets a day. On August 14, 2018, he was
diagnosed with an enlarged prostate, but it was prevented from getting worse as he immediately got it
treated. He had his COVID-19 vaccination in 2021 with Sinovac Vaccine, first dose and second dose, but no
booster. He eats a lot of high-cholesterol foods, and in fact, he stated that he loves eating fried chicken skin.
He had an unhealthy sleeping pattern before, with only 3-5 hours of sleep in a day, and his insomnia worsened
because of stress.
D. Family History of Illness
The patient stated that he doesn’t know any information on her paternal side because his parents have been
separated during his elementary level. On his maternal side, his grandmother died at the age of 50 from a
heart attack, while his grandfather died at the age of 70 because of a brain tumor. His mother died at the age
of 65 from an acute pulmonary disease, and the older sibling of his mother died at the age of 43 because of
measles. Thus, his family's lineage has a history of brain tumors, diabetes mellitus, myocardial infarction, and
acute pulmonary disease, and there is a sign or symptom of one of these diseases that the patient experiences,
particularly diabetes mellitus.
E. Lifestyle
The client perceived himself to be a healthier person than before since he is now able to maintain his
lifestyle, which include regular exercise, eating a well-balanced diet (rice, carrots, squash, and cabbage),
making food for the family, gardening, watering plants, feeding the chickens, and other housework. His
hobbies include playing chess and watching basketball. When the patient feels sick or experiences pain, he
meditates by taking deep breaths and goes outside to get some fresh air. When he has arguments with his
family, he generally spends time with his one male best buddy.
F. Social Data
The client is a 63-year-old former barangay councilor who lives in the same house with his 51-year-old wife
and their 10-year-old youngest daughter. He said he has always felt loved and well taken care of by his family.
Aside from being a senior citizen official, he is also an active member of their Kalahi-CIDSS organization and
he is active in their church. As a senior citizen, he spends most of his time watering plants, feeding chickens,
cooking food for his family, and doing household chores. The client considers himself a healthy person and
someone who has a healthy lifestyle because he is able to perform his daily activities well, exercises regularly,
and eats a healthy and well-balanced diet. He consumes alcohol moderately and occasionally. He denies using
illicit drugs and quit smoking tobacco in 2018. The client is a member of the social insurance programs of
SSS, PhilHealth, and the Card Bank Association. The client denies being active in sexual activity in the present
due to his enlarged prostate. His family's lineage has a history of tumors, diabetes mellitus, myocardial
infarction, and acute pulmonary disease, and there are signs or symptoms of one of these diseases that the
patient experiences, particularly diabetes mellitus.
G. Psychological Data
The patient stated that his major sources of stress are household expenses and family problems that cannot
be solved immediately. He said that his way of eliminating or lessening stress is through playing cards,
watching cockfights, and, most importantly, praying. The patient also reports occasional feelings of anxiety
related to his diabetes management but states that he has been able to cope with these feelings through
education and support from his healthcare provider. He reports feeling motivated to stay healthy for his
family and loved ones.
H. Patterns of Healthcare
His prescription and non-prescription drugs include losartan 50 mg once a day, amlodipine 5 mg as needed
, metformin 5 mg twice a day, and ascorbic acid 500 mg once a day. He visits the health center twice a week
to have his health condition checked. He also admitted that there are times he is occasionally tempted to eat
food he is forbidden to eat, especially on special occasions. He reports feeling satisfied with the care he has
been receiving from his healthcare providers and has been consistent with his follow-up appointments. The
patient also reports being open to alternative therapies, such as herbal remedies, as a complementary
approach to his conventional medical treatment.