Past Medical History

Patient X was able to have her check up at O.P.D three times before she was admitted and had her
operation last November 22, 2017 at Callang General Hospital and Medical Center, during interview the
patient was asked of any vaccines she had in the past but the patient said that no vaccines was given to
her that she could think of, no reported injuries and allergies in the past as patient stated.

One month prior to admission the patient’s past medical history at O.P.D was at Lucas Paguila
Medical Clinic Hospital under Dr. Agtarap with a complaint of flank pain at the right side and followed by
different laboratory tests such as Urinalysis, UTZ, and a take home meds of antibiotic to take for 14 days
due to renal mass on the right that was detected during ultrasound. November 14, 2017 the patient
went for follow up check at Adventist Medical Hospital still under Dr. Agtarap at O.P.D with the same
complaint, followed by further laboratory test like Urea and Creatinine as well as C.B.C. ; that very same
day the doctor told the patient that she needed to undergo operation and scheduled her to comeback
Last November 21, 2017 at Callang General Hospital and Medical Center.

History of Present Illness

Patient X’s daily routine is to go to her restaurant starting from 4 am until 5 pm, in her
restaurant she is also the cook in the morning as well as cashier in the afternoon, she only has 2 helpers
that helps her all throughout the day and after work she goes home at 5 pm and she always sleeps early
at 6:00 pm in the evening. They always have an early dinner every night; she lived with her grand child
who is 16 years old and her son who is a single dad; where in they are the ones who takes care of
patient X while she is at the house and escorted her every now and then together with her daughter
especially when the patient started to go to hospital for follow up checkups. One week prior to
admission the patient decided to pass the restaurant business to her sister to be manage temporarily
because the patient said that she needed to undergo operation under Dr. Agtarap at Callang Medical
Hospital.

Prior to admission Patient X together with her son and grandchild went to Callang Medical
Hospital and went to Dr. Agtarap’s Clinic and requested for patient’s latest laboratory test like C.B.C,
Chest X-ray, Blood typing, E.C.G and PTT and was scheduled to have her Intra Renal New Growth
Bilateral surgery at 3pm the day after admission.

Family History

They have a history of Hypertension in the mother side and Heart Disease on the father as
stated by the patient. They also have a family history of Cancer and Diabetes Mellitus. Her father died
with Alzheimer’s disease and her mother died because of Sepsis Hypertension. No one in their family
have any renal condition, she was the first in the family to have a Nephrolithiasis.
Social History

OB History

The client is a widow. She is a mother of 7 (2 boys and 4 girls) children all born via NSD at her house. The
eldest was born in 1967, next was in 1968, 1970, 1976, 1978, 1980, and the youngest was 1982. She
never used contraceptives. Menarche was when she was 13 years old. She described her menstrual
cycle as normal with 4 days menstrual flow. Menopause was when she was 45 years old. She is
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