I Personal Data

I PERSONAL DATA

Patient name: Alvero Remedios Sotto Age: 58 y/o Address: Tacumbao Gerona Tarlac Sex: Female Birthday: Jan, 21, 1951 Nationality: Filipino Chief Compliance: Abdominal pain Religion: INC Highest Education Attainment: Elementary Under Graduate Occupation: Made Compliance: Stomach ache Date of Admission: July, 31 2009 AP: Dr. Mendoza Noel First Diagnosis: Hepatic Abscess First Diagnosis: Acute cholecystitis/cholilithisis Source of history: The patient

II HISTORY

A) Present history:

This is the second time Mrs. Alvero been admitted into this hospital (tarlac provincial hospital). On his first admission into this hospital she had undergone throidectomy operation. Which is almost 3 years ago? She also added that she had an asthma when she 7 years old that last when she is 21 years old, B) ST HEALTH ILPALNESS

According to Mrs. Alvero that the familial disease she knows that they have in their family was the hypertension that is on his father’s side. His father died because of heart attack and her mother died of natural cause. She also added that cholecystitis is prone to their family, because of one of his siblings also had acquired this disease.

III. PHYSICAL ASSESMENT Day 1

I VITAL SIGNS

Day 2

Day3

Day4

Temperature:

38.5 c

37.8 c

37.5 c

Pulse rate/ Cardiac rate:

85

88

90

84

95

Respiratory rate:

39

42

30

35

38

Blood pressure:

120/80

120/80

120/90

120/90

120/90

37 c

Day5

II INTEGUMENT

A) Skin B) Mucous Membrane C) Nail D) Hair

: yellowish : pinkish : pail, normal shape but long : Dry hair

III HEENT

A. Head

: normal cephalic

36.5.c

B. Eyes

: Color is yellowish and conjunctiva is not pinkish but slightly orange.

C. Nose

: Dry mucosal condition

D. Mouth/ Throat/Pharynx/Teeth: Colour: pinkish to whitish Lesions: No lesions Smoothness: soft but slightly dry. Presence of cavity: Their accumulation of white tissue in its side. F. Face/Facial Muscular • Symmetric, poor response E. Neck and lymph nodes •

Normal and palpable lymph nodes and no tenderness.

G. Pulmonary (Breath sounds) • Clear breath sound, symmetrical chest wall. H. Breast and Axillary’s • Symmetrical round but flat • No discharge. • Its growth is not normal. • No retraction

I. Cardiovascular • Normal rhythm and regular sounds J.Musculoskeletal • Poor response due to body weakness. K. Genitals • Growth is not normal due to child delivery. L.Rectum and anus • No hemorrhoids or no fissures.