I.

PATIENT’S BIOGRAPHICAL INFORMATION

Name: Mr. N.C

Address: Laguna City
Age: 60
Gender: Male
Race: Filipino
Marital Status: Married
Occupation: Military (retired)
Religious Affiliation: Roman Catholic
Health Care Financing: Sibling’s Income
Admitting diagnosis: Pleural Effusion

II. CHIEF COMPLAINT

Chest pain, Difficulty of Breathing

III. NURSING HISTORY

I. History of Present Illness

One month prior to client’s admission, the client felt chest pain which he
could still tolerate. Client’s significant others stated that the client has been
hospitalized at a hospital in laguna due to an intolerable pain in the chest
area. Then he was reffered to Veterans Memorial Medical Center and based
on lab results it was ruled out that the patient has pleural effusion among with
some complications like tuberculosis, abdominal pain cyst in the liver and
malignant ischemia.
 II. Past Health History
 Medical History- Diabetes Mellitus, Hypertension
 Surgical History-none
 Accidents-none
 Medications- multivitamins
 Prescribed Medications- insulin, Calcibloc
 Childhood Illnesses and Immunizations- Chickenpox, Complete
Immunization
 Allergies- no known food and drug allergies

III. Family Health History

 Mother- HPN, DIABETES MELLITUS, (deceased)

 Father- HPN, DIABETES MELLITUS, (deceased)
 Wife- No known disease, Occupation- Nurse
 Son- No known disease, Occupation- none

IV. Social Health History

Alcohol use- occasionally
Smoking use-never
Drug’s use-none
Travelling History- parts of mindanao (surigao del norte and del sur,
Agusan del norte and del sur, Basilan, Cagayqan de Oro).
Hobbies and Leisure Act- Reading books and newspapers, jogging.
Work Environment- fresh air, nice working area, good people to
interact with.
Physical Environment- nice neighbourhood, clean, fresh air.
Home Environment- clean, well ventilated house.
Economical Status and ethnic and cultural beliefs- Middle class
family, Roman Catholic.
Roles and Relationships- Husband, father