CHRISTINE JOY A. ALA 2NUR1

HISTORY

Patient L.E.E., female, 71 years old is currently living at 53-G MRT ave. Lower Bicutan, Taguig City. She was born on March 11, 1944 in Gubat, Sorsogon. She is a Roman Catholic and is already widowed as well as a good mother to her six children. She is a Philhealth member and upon admission she was accompanied with her daughter.

Patient L.E.E. complains of feeling of incomplete voiding, her clinical history shows that one year prior to admission, patient complained of feeling of incomplete voiding accompanied by dysuria. After 9 months, introital mass appreciated measuring approximately 2 x 2 cm and with persistence of symptoms. She went to University of Santo Tomas Hospital – Out Patient Department for consultation, it shows that UA & pap smear was normal and a 3 day bladder diary was done. Her assessment show POP stage II Aa Bb C and Stage III ApBp, patient was offered colpocleisis after attaining CV clearance.

Patient’s past history shows positive to hypertension and was diagnosed last 2013. Family history shows positive to hypertension to her mother side but negative sign for diabetes mellitus, cancer and thyroid disease. She had past hospitalizations and surgeries wherein she had medical surgical history of prolonged and heavy menses in 1989 and amoebiasis last 2009. She was also confined due to dilatation and curettage in 1989 and didn’t received blood transfusions.

Patient’s Obstetrical History shows she has six children and experienced one abortion. Her first baby was born on 1964, live term baby boy delivered via NSD at home by traditional birth attendant. Her next baby was born on 1966, she also gave birth through a traditional birth attendant to a live baby girl via NSD at home. She again gave birth to a live term baby boy via NSD at home by traditional birth attendant in 1968, 1970 and 1972. In 1974, her sixth child was aborted and she didn’t have a complete curettage. In 1986, her seventh baby was born and was delivered via NSD through a traditional birth attendant at home. Her menstrual onset was at the age of 14 years old, with an interval of 28-30 days, during her menstrual period she experiences dysmenorrhea every first day of her period. And at the age of 45 years old, she was already menopaused.

Patient is not allergic to anything except to .a drug name Cefazolin. She sees herself as normal and fine. Patient verbalized that she is sad because she underwent surgery. Upon interviewing, she also verbalized that she is having difficulty of sleeping due to the pain felt on her lower body because her indwelling catheter was already removed on the morning of April 23, 2015 and she can’t move freely and when she move there’s pain felt in her lower part of her body. She is also in a progressive diet, Before hospitalization, patient verbalized that she only eats half of her food or 50% of the food in her plate but eats three times a day because she needs to have a diet due to her hypertension. And while she is in the hospital, she still eats half of the food served for her. Her vital signs were Temperature is 37.4 degrees Celsius, Pulse rate is 76,

respiratory rate is 20 and Blood pressure is 90/70. Patient verbalized that after the surgery her blood pressure was already low.