A.

Nursing Health History

Mr. X, 57 years old, Roman Catholic, married. He was admitted

on November 14, 2010. He was born on October 2, 1953 and a Filipino,
his birthplace is Majayjay, Laguna but is currently residing at 314
Inocentes St. Brgy. Pag-asa, Mandaluyong City. He is a garbage
collector. His primary language spoken is Tagalog.

Chief Complaint:
Loss of appetite, deterioration of mental function, easy
fatigability, weight loss, edema and fever few days prior to admission.

History of Present Illness:

For the past years, the patient did not have any serious illness
related to his present condition. But on October prior he had headache,
dull abdominal pain, felt nauseated and dizzy. The patient even his
wife had never thought it was a manifestation of an underlying
problem and so they did not take it seriously. They did not seek
medical attention instead his wife gave him over the counter
medication such as Paracetamol for his headache which he take four
times during that day and one Diatabs for his stomach pain which is
actually not appropriate since the medication itself was wrong and that
underlying condition was not taken into consideration. The condition
however did not last long since it was relieved and day after it
occurred. The patient and his wife were relieved and thought it was
just dyspepsia and pain.

2 weeks prior to admission, his wife noticed that his husband had
abdominal distention which is abruptly noticed. The patient felt loss of
appetite, stomach pain which radiated to patient’s back and prodromal
vomiting.
Past Medical History
Other than fever, cough and flu, which they treat over-the
counter drugs and no consultations, the patient didn’t have any serious
illness.

Family Health History

We don’t have gathered data about the grandparents of our
client because he cannot remember it anymore. Both parents of our
client had already passed away due to old age.

Social History
The patient at his young age was a typical adolescent who
goes with friends and often explores things around. The patient
was curious at all things and because of that he was inclined to a
number of vices which may actually have affected his health
status. He was smoking badly as he was able to consume 1 pack of
Memphis cigarette a day and drinks enormously as he was able to
drink 2 “Gin bilog” on his own. At times he goes beyond 2 Gins
when he is not yet drunk. As stated by his wife, his husband does
not stop drinking unless becomes drunk. They also use same glass
when drinking with colleagues.
Adulthood, works as a garbage collector still continued to
drink whenever he has time. Last year 2009, he finally stopped
doing his usual things when he experienced such things.