Baradi, Samantha U.

BSN 1-A, Group 1

Health Assessment RLE (NCM 101b)

BIOGRAPHICAL DATA
Name: Old Navy
Address: 18 San Nicolas, Ilocos Norte
Age: 15
Sex: Male
Date of birth: March 30, 2004
Place of birth: 18 San Nicolas, Ilocos Norte
Marital status: Single
Occupation: Student
Religion: Roman Catholic
Educational Attainment: Junior High School Student

CHIEF COMPLAINT
Client reports cough and colds for four days. Symptoms include abundant production of
yellow sputum, nasal congestion, sore throat, mild cough, and mild body pains. No fever and
headache. Increasing fluid intake to relieve symptoms.

GENERAL SURVEY
Old Navy, 15, walks in the room for the interview. The client holds his phone in his left
hand. He is dressed in a t-shirt and shorts. The choice of clothing is appropriate for the situation
and weather. He also wears eyeglasses. He exhibits a comfortably erect posture and walks in an
upright position, with body stability, balance, and good foot control. He appears to be around
two years older than his stated age.
The client sits across from me. He has a light brown skin color. He has an apple-shape
body fat distribution and is of endomorphic build. Old Navy weighs 83 kg and is 163 cm tall. His
BMI (31.24) suggests that he is obese. No obvious anomalies/deformities are observed.
The hair is somewhat unruly and his nails appear bitten. All in all, Old Navy’s mood is
appropriate for the situation and he is cooperative. He appears casual. He seems to be in a good
mood. His speech is clear and coherent. He maintains consistent eye contact during the
interview. Old Navy’s affect matches his mood.
Signs of distress demonstrated by the client are limited to coughing and labored breathing
experienced occasionally due to nasal congestion.
He is alert/conscious and responds fully and appropriately to external stimuli.
He seems to have no problems in his cognitive abilities and mentation. His immediate
recall and remote memory are well-functioning. He does not present signs of distraction,
confusion and negativism. He shows good judgment when asked to provide solutions to
hypothetical situations.
Vital signs are elicited from the client. Old Navy has body temperature: 36.9C, PR: 88,
RR: 18, and B/P: 120/90.

FAMILY HEALTH HISTORY

As shown in the genogram, there are no hereditary diseases nor familial diseases present
among the members of Old Navy’s family. There are no common causes of morbidity within the
family identified and the most common cause of mortality is also unknown.
Old Navy’s paternal grandfather (Ad) was born on January 1, 1944 as the second of five
children. During his time of birth, hospital deliveries can be deemed nonexistent. Thus, he was
delivered normally with the aid of a hilot in Baduang, Pagudpud, Ilocos Norte. He was not
vaccinated due to the unavailability of vaccines back then.
Rd, the client’s father, stated that Ad died of relatively young age. He recounts that the
grandfather was involved in a bike accident. Ad was not rushed to the hospital because he
insisted that he was fine. However, three days after, the client’s paternal grandfather was
suddenly coughing up blood. His signs and symptoms were not managed. Ad was 49.
The paternal grandmother, Is, was born via normal delivery on May 30, 1945 at Saguigui,
Pagudpud, Ilocos Norte. She was an only child. For the same reasons as in Ad’s case, her birth
was assisted by a hilot and she was unable to receive vaccinations.
When she was aged 17, she gave birth to her firstborn and at 39, she gave birth to her last.
She gave birth to all nine of her children through normal delivery with the help of a hilot.
 She was admitted to the Mariano Marcos Memorial Hospital and Medical Center at Batac
City last 2017 because of complications brought about by her old age. The client’s father cannot
recall the admitting physician anymore. She died of pneumonia in October 29 of the same year.
Jo, the oldest of the nine children of Ad and Is, was born on the year 1962. According to
Rd, around 40 years ago, his brother felt discomfort in his right hand. Upon consultation of a
forgotten physician at the Bangui District Hospital, it was found out that Jo had a cyst. Jo went
through a surgery to improve his signs and symptoms.
Two years after Jo, Fr was born. It was claimed by the client’s father that Fr was taking
Lanoxin (unknown frequency, unknown dosage, unknown route) to alleviate the symptoms he
was experiencing because of a heart disease that Rd can no longer recall. Allegedly, the disease
affected other body systems and caused complications like goiter. Fr was diagnosed by a doctor
and in a healthcare institution that Rd now fails to remember. For a cause that Rd is unable to
specify, Fr died in 2015.
As for Fe, he was born in 1967. Rd stated that his brother was a heavy smoker who
smoked one or more packs a day. Eventually, Fe started to experience breathlessness, chest pain,
back pain, and weight loss. Upon consultation of a doctor in a hospital (both unknown by Rd), it
was discovered that he has a lung spot. Unrecalled medications taken in unknown frequency,
dosage, and route, and reduced frequency of smoking helped to improve Fe’s condition.
Ry, on the other hand, was born year 1969, two years after Fe.
The client’s father is the fifth of the nine children. He was born on May 25, 1971.
Recently, Rd experienced toothache that lasted for 3 hours. He rated it as 5 in a pain scale of 10.
He consulted Dr. Leovita Liwanag Oducayen of the Corpuz, Oducayen Dental Clinic in Batac
City. The dentist gave him a filling for his aching tooth. It helped in relieving the pain felt by Rd.
The first daughter born among the nine children of Ad and Is is Cr. She was born in 1976.
She has seven children of her own, all born via normal deliveries at the Mariano Marcos
Memorial Hospital and Medical Center (for the first two) and at the Nueva Vizcaya Provincial
Hospital (for the remaining five). She was 17 when she gave birth to her firstborn. It was only
two years ago when she last gave birth to what was actually a set of triplets. She was 42 then.
Following Cr was Ct, now 40, who is the second daughter and seventh child in the
family. She was born in 1979. She gave birth to three children through normal deliveries at the
Bangui District Hospital. Like her sister, she was also 17 when she gave birth to her eldest. Her
youngest child is born when she was 26.
Fl is the eighth of the nine siblings. He was born in 1982 while Kh was born in 1984 and
is the youngest.
Rd further reiterated that all nine of them were born via normal delivery with the
assistance of a hilot at Baduang, Pagudpud, Ilocos Norte because back then, giving birth at home
is most common. They were also unable to receive any vaccinations since vaccines are not as
available as they are now. In addition, Rd also claimed that not even one of them experienced
any childhood illnesses such as the chicken pox, measles, and mumps. Growing up, they only
suffered from illnesses like the common colds, cough, and fever. The family, as it turned out,
primarily resorted to self-medication. They used medicinal plants in making remedies for their
symptoms. For instance, a bunch of calamansi is squeezed into a glass. The juice is then added
with sugar and water. The calamansi juice was used for common colds and cough.
It shall also be noted that information about the paternal side of the client’s family are
limited because there are certain things that the client’s father (Rd) cannot recall anymore or is
simply unaware of. Moreover, aside from the fact that Rd failed to present proofs of his claims,
accounts regarding Rd’s siblings were not also as verified as they should have been because the
siblings are now living in locations far from each other. (Jo lives in Batac. Fe and Cr are in
Nueva Vizcaya. Ry, Ct, and Fl still resides in Pagudpud. And lastly, the youngest, Kh, is living
in Sampaloc, Manila.)
On the other hand, the client’s maternal grandfather (An) was born on August 2, 1940 via
normal delivery with the aid of the hilot at San Pedro, San Nicolas, Ilocos Norte. He is the third
of six children. Akin to the case of the paternal side of client’s family, An did not receive
vaccinations. The mother of the client (Ma) also claims to be unaware whether or not her father
encountered any childhood illnesses growing up.
According to Ma, however, her father usually complains of toothache. During such times.
she gives An Ibuprofen 200 mg, taken as needed and taken orally. An’s pain would then be
relieved by the medication.
Mr, the client’s maternal grandmother, was born on January 1, 1944. Because of the same
reasons as stated above, she was born by means of normal delivery with the hilot at San Pablo,
San Nicolas, Ilocos Norte. She also has not received vaccinations. Mr claimed that she did not
experience any childhood illnesses as she grew up.
She was 22 when she gave birth to the first of her five children and she was 29 when she
gave birth to her youngest. All five children were born via normal delivery at San Pedro, San
Nicolas, Ilocos Norte with the assistance of a hilot.
It was year 2014 when Mr started to experience dim vision, sensitivity to light and glare,
fading or yellowing of colors, increasing difficulty with vision at night, and clouded, blurred
vision. She consulted Dr. Aquino at an unrecalled ophthalmology clinic at Laoag City. The
ophthalmologist diagnosed her with cataract. November of the same year, she underwent a laser
eye surgery for the removal of her cataract at the Metro Vigan Hospital.
Mr also wears eyeglasses of unrecalled grade that she got from RM Que Optical.
From time to time, Old Navy’s maternal grandmother experiences mild to moderate pains
from time to time. She opts not to consult the doctor because it is still manageable and she
believes it is mostly caused by her old age. She manages her symptoms by taking Ibuprofen 200
mg as needed and orally.
Al is the eldest son of An and Mr. He is now 55. He was born in 1964. It is both claimed
by Mr and Ma that Al is a heavy drinker. According to them, he drinks around two bottles of gin
daily.
Md was born in 1968. She is the second of the five siblings. She has two daughters of her
own. Both of which she gave birth two by normal delivery. Her firstborn was born in 2005 at the
Gaoat General Hospital while her youngest in 2007 at the Clinica De Marasigan.
Last 2017, she underwent myomectomy at the Mariano Marcos Memorial Hospital and
Medical Center.
Mi was born four years after Md, year 1972. She would have been 47 by now.
Unfortunately, after a week, Mi died because of an unrecalled cause.
The client’s mother, Ma, was born in October 17, 1974. Ma suffers from urinary tract
infection from time to time. She experiences hematuria, dysuria, frequent urination of every few
minutes, moderate to severe pain in the lower back and side, nausea, fever and chills. Vomiting
are not among the symptoms. The urine would also be pink, cloudy, and foul-smelling. During
such, the mother rates her pain as 10 on a scale of 10 saying that “Kaslang matmatayak nukwa ti
sakit nan.” Signs and symptoms are relieved by consulting Dr. Geminiano Gertes of the Gertes
Hospital and Clinic, taking tablets of Potassium Citrate 1.08 g, three times a day and orally,
adequate rest, and avoidance of salty and acidic food and drinks.
A year after Ma, Ml was born. Unfortunately, like her sister Mi, she did not survive long.
She died after 2 days. She would have been 45.
Like Rd and his siblings, the five children of An and Mr were born through normal
delivery with the help of a hilot. They were all born at San Pedro, San Nicolas, Ilocos Norte.
Because the Extended Program on Immunization of the DOH was only established in 1976,
vaccines were not as accessible. Furthermore, both Mr and Ma claimed that the siblings did not
experience any childhood illnesses growing up. According to Mr, illnesses were not really as
prevalent as they are now. For common colds, cough, and fever, the family manages their
symptoms by using medicinal plants. An example would be how they chopped eggplants into
halves and placed it on the face of the member with a fever. Such method helped to lower the
temperature of the person.
Nowadays, Old Navy’s family also manages their symptoms by taking medications such
as the Paracetamol 500 mg, every four hours and per-orem. If symptoms persist, the family
proceeds to consult Dr. Geminiano Gertes at the Gertes Hospital and Clinic.
Additionally, the family prefers to consult medical professionals rather than traditional
health practitioners when they encounter illness. They use medicinal plants such as the calamansi
and eggplant when they experience illnesses such as the common cough, colds, and fever.

PAST HEALTH HISTORY

Old Navy is the second child of Rd and Ma. He was born on March 30, 2004 through
natural childbirth with the help of a midwife in the family’s house in 18 San Nicolas, Ilocos
Norte. His mother claimed that he completed his vaccinations. However, his mother failed to
present his vaccination record as proof. Upon checking the client’s right upper thigh, it was
found out that he possesses a vaccine scar.
He had childhood illnesses such as chicken pox, measles, and mumps. He was given
unrecalled medications by the Dr. Geminiano Gertes of the Gertes Clinic and Hospital at San
Nicolas. Proper diet, increased fluid intake, and adequate rest also helped in his recovery.
He often experienced earaches associated with colds too. Such caused him severe
discomfort and fever. Old Navy would be taken to the Estrella EENT Clinic at Laoag City. Dr.
Estrella alleviated his earaches by cleaning his ear and prescribing medications that his mother
cannot remember anymore.
It is also claimed by his mother that Old Navy was confined a few times at the Gertes
Clinic and Hospital during his childhood due to diarrhea. His symptoms included increased
frequency of bowel movements, loose and watery stool, fever, irritability, fatigue, and abdominal
pain. He also experienced vomiting. His stays in the hospital would be around three to five days
depending on his condition. He was relieved via proper diet, increased fluid intake, adequate rest,
and medications (now unknown) given by the Dr. Geminiano Gertes.
In addition, when he was in Grade 4, the client complained of severe and burning pain in
his eyes, accompanied by frequent headaches, dizziness, squinting, blurry vision, and difficulty
seeing objects near him. The symptoms worsened with more exposure to cellphones, laptops, and
other gadgets. The client consulted a Dr. Aquino at an unrecalled ophthalmology clinic at Laoag
City. He was prescribed eyeglasses for his condition that were allegedly graded 180 and 165.
However, he was unable to show proof. The client also claims that the grade of his eyeglasses is
yet to be updated.
During the recent years, he consulted two different dermatologists with reports of burning
and stingy sensations on his skin and itching. He had red patches all over his arms and upper
chest and his skin was thickened, cracked, and scaly. His signs and symptoms lasted several
weeks. He was prescribed with unrecalled ointments and medications by Dr. Emma Joy Bareng
of the Family Wellness Clinic (Laoag City) and Dr. Amaryllis M. Saguiguit, Abellon of the
Amaryllis Saguiguit Dermashoppe (Batac City).
The client was again confined to the Gertes Clinic and Hospital last July 13, 2019. He
was diagnosed of dengue fever by Dr. Geminiano Gertes. Prior to confinement, he suffered from
high fever, headaches, severe joint muscle pain, fatigue, and nausea. He also had skin rashes. His
mother claimed that his laboratory results showed below normal numbers for his WBCs and
platelets, but she was not able to show copies of his results. Unrecalled medications were given
by the doctor to manage his signs and symptoms. Proper diet, increased fluid intake, and
adequate rest were observed.
Three months ago, Old Navy was involved in a minor accident. He fell from the backseat
of a tricycle and from it, he obtained gashes in his left and right forearms. His injuries were
treated with the first-aid kit at their house.
 The client spends most of his time playing mobile games at home. He also observes
irregular eating habits.

PRESENT HEALTH HISTORY

Four days prior to interview, the client suddenly started to experience cough and colds.
The associated manifestations are abundant production of yellow sputum, nasal congestion, sore
throat, mild cough, and mild body pains. He has not experienced fever and headache. He further
stated that upon lying down, “Marigatan nak nukwa aganges,” and the other symptoms worsen.
No medications were taken to manage the symptoms of the client. He claimed that increasing his
fluid intake helped to relieve his symptoms.
The client is regularly exposed to stress. He habitually stays up late at night and manages
to get only around 5 hours of sleep daily.