I.

PERSONAL DATA

Name: Marcela F. Leano

Age: 70 years old

Sex: Female
Date of Birth: July 28, 1948

Place of Birth: Piddig, Ilocos Norte

Address: Brgy 2 Sta. Joaquina, F. Julian Rd., Laoag City, Ilocos Norte

Educational Attainment: College Graduate

Course: Bachelor of Science in Education

Nationality: Filipino

Religious Affiliation: Iglesia Ni Cristo

Civil Status: Widow

Chief Complaint: Pain on her forehead for 2 days

II. FAMILY HEALTH HISTORY

The hereditary disease of the family includes high cholesterol level,

hypertension, and a heart condition which is the abnormal enlargement of the
heart. The patient’s siblings namely Uncle Verio, Auntie Luz, Uncle Francing,
and Auntie Maming acquired these conditions through heredity.

Also, these conditions mentioned were acquired through the lifestyle of the
patient’s family members including her father Lolo Doming who had high
cholesterol level, high blood, and a condition in the heart, and two of her siblings
namely Uncle Mario and Uncle Jr. who have a heart condition, hypertension, and
high cholesterol level. Also, the patient’s mother acquired a bone fracture on her
right arm resulting to bonce cancer due to an accident.

The patient’s mother who had a bone fracture on her right arm experienced
pain in her right arm resulting to activity intolerance. The condition occured after
her mother fell on the ground during an earthquake at Brgy. Bagut, Dingras, Ilocos
Norte which resulted to bone cancer. The patient’s mother was confined at the
Philippine Orthopedic Center at Quezon City for chemotherapy and bone
transplant from her left foot grafted to the right arm. The management done was
effective but according to the patient, her condition re-occured and worsened after
six years.

According to the patient, three of her siblings, namely Auntie Luz, Uncle
Francing, and Auntie Maming, having high cholesterol gets easily tired and
experience pain in the forehead. Cooking and eating fried foods was the primary
cause of the condition and it was managed by regular exercise and taking taking
medication like Atorvastatin that was taken once a day. These management were
proven effective in maintaining their cholesterol level.

Also, four of the patient’s siblings having hypertension experience pain in the
forehead accompanied with dizziness and activity intolerance. Increased
consumption of fatty foods especially meat and vices such as cigarette smoking
and excess intake of alcohol most specially to one of her siblings, were identified
as the cause of hypertension. The condition was managed by observing regular
exercise, consumption of nutritious foods, and taking prescribed medicines such
as Amludipin and Simvastatin which maintained their normal blood pressure.

Three of the family members, including her father and 2 of her siblings, who
acquired a condition which is the abnormal enlargement of the heart experience
chest pain and activity intolerance. The patient claimed that the cause of the
condition was unknown. Two of her siblings namely Uncle Mario and Uncle Jr.
undergo heart bypass in order to manage the condition and it was proven
effective
III. GENOGRAM
IV. PAST HEALTH HISTORY

The patient has already experienced having common illnesses such as cough
and cold. For the cough and cold, the patient managed it by drinking plenty of
water, taking medications such as Robitussin DM 10 mL every 6 hours taken
orally for cough, and it was accompanied with adequate rest.

At childhood, the patient experienced fever related to chicken pox, and tooth
pain. For the chicken pox it was manifested by fever and reddish brown spots on
the skin with itchiness starting from the patient’s chest radiating to her arms and
all over the body. They managed the condition by covering the patient with thick
clothing and blanket in order for the lesions to come out.

In association with the fever, she took medication namely Aspilets 80mg
every four hours to relieve the fever. The management was effective. As for the
cold, it was manifested by difficulty of breathing on the patient’s nose and sinus.
The patient applied coconut oil mixed with kerosene in a warm water on the chest
and at the back which acted as a decongestant to relieve the cold. The
management according to the patient was proven to be effective.
 As for the tooth pain, it was manifested by difficulty of chewing and pain on
the central incissors and canines. The patient consulted a dentist namely Dr.
Rumbaoa and conducted health teachings on proper oral brushing and prescribed
medications for pain relief. It was proven effective for the patient.

At her adolescence, the patient noticed an abnormal enlargement of the heart

and it was manifested chest pain, shortness of breathe, and sudden and
increased thumping of the heart. According to the patient, the condition worsened
due to active participation in school activities. The patient consulted a specialist,
Dr. Rizal Peralta, requested for x-ray for further examination and took medications
in order stabilize the condition.

At the age of 67, the patient was diagnosed from aneurysm at Stanford Stroke
Center, California and she had been admitted for 10 days. Prior to the condition,
she experienced sudden low of voice tone, numbing of the left foot radiating to the
right foot and the patient fell unconscious after she took care of the her sister’s
pets. The cause of the condition was primarily due to hypertension. She took
medications as prescribed: Amludipin 5 mg taken once per day and Atorvastatin
20 mg take once per day

V. PRESENT HEALTH HISTORY

The patient is currently experiencing pain in the forehead for two days,
radiating to the both sides of her eyes having a rating of 5 out of 10 from the pain
scale. Prior to the assessment, she complained about dizziness and fatigue which
started for 2 days due to disturbed sleeping pattern from her travel from Manila to
Laoag.