I.

Nursing History

A. Past Health History:

Childhood Illness: We didnt obtain any data about the childhood illness of the client because he is intubated and currently on bag valve masks (ambubag).

Immunization: We didnt obtain any data about the clients immunization because he is intubated and currently on bag valve masks (ambubag).

Allergies: There is no known allergy on the client.

Hospitalization: According to the clients wife, her husband was hospitalized in Iba, Zambales before admitted in James Gordon Memorial Hospital. Beside this information she didnt know if her husband has been hospitalized in his childhood days.

Medication use and currently taken: The client is currently taking the following medications: Mannitol, Citicoline, Amlodipine, Piperacillin+Tazobactam Ranitidine, Kalium Durule, Sucralfate tablet,

The client is taking the following medications before hospitalization: Neobloc and Lipitor

Foreign travel: The client didnt travel abroad.

Domestic travel: The client has no known domestic travel.

B. History of Present Illness 8 days prior to admission, there is positive dizziness experienced after waking up and theres no other associated signs and symptoms like headache and vomiting. He was brought to health center and his blood pressure was taken revealing 200/140mm Hg. He was brought immediately to Iba and he was admitted there. Managed as CVD probably bleeding; with positive progression of neuro deficit (right sided body weakness) while admitted. However there is mo cranial CT scan done at the said hospital. Patient eventually transferred to JLGMH per patients request. C. Family History ( + ) Hypertension mother side ( - ) Diabetes Mellitus negative on both sides ( - ) Tuberculosis negative on both sides ( - ) Cancer negative on both sides ( - ) Heart disease negative on both sides