3P’s

Personal Profile

Name: Mrs. TH
Age: 40 years old
Birthdate: March 25, 1982
Birthplace: Solano, Nueva Vizcaya
Sex: Female
Blood Type: A+
Address: Brgy. Quezon, Solano, Nueva Vizcaya
Religion: Roman Catholic
Height: 5’6”
Weight: 55 kg
Marital Status: Married
Occupation: Painter
Educational Attainment: College Graduate
Nationality: Filipino
Ethnicity: Ilokano
Dialect: Tagalog and Ilokano
Date of Admission: April 1, 2022 at 10:00 AM
Chief complaints: Heartburn, Dysphagia, Regurgitation 
Admitting Diagnosis: Achalasia
Final Diagnosis: Reflux Esophagitis secondary to Achalasia
Admitting Physician: Dr. K
Date of Discharge: April 6, 2022

Significant Others:
Name of Spouse: Mr. B
Age: 42 years old
Occupation: Hgh School Teacher
Educational Attainment: College Graduate

Name of Child: Child J

Age: 10
Occupation: Student

Health History

I. Present History

Mrs. A experienced discomfort in her umbilical area of her abdomen after

eating breakfast on August 21, 2021, two days before admission. She exhibited a
guarding and grimacing behavior and reported that it was uncommon because she
had no problems with food or drink intake. She soon began to vomit as well, and she
vomited everything after eating. The patient vomits almost 4-5 times in a day. She
then goes to the toilet to defecate and discovers she has a watery stool. She tallied
the number of times she went to the bathroom and discovered that she went 6 to 8
times each day, indicating that she is suffering from diarrhea. She responded that it
was possible that the meal she ate in the morning had already spoiled. When her
temperature was taken, it was normal, with no indications of fever. She cannot really
sleep that night because of the problems she was having. She was unable to sleep
due to vomiting, abdominal pain, and diarrhea. The next day, she had more vomiting,
abdominal pain, and diarrhea. When she pees, she finds out that her urine output
was decreased from her normal urine output. She said that she does not want to go
to the hospital because she is frightened of contracting the COVID 19 virus. So, she
just drinks loperamide for her diarrhea.
The next day, August 23, 2021, upon waking up at 8 in the morning, she
continued to have diarrhea, abdominal pain, and excessive vomiting, so she and her
son immediately headed to R2TMC for a check-up at 10 AM. During the assessment,
the attending Physician Dr. K and the other healthcare workers communicate with
Mrs. A and asked her about her chief complaint, which is abdominal pain in her
umbilical part of the abdomen, excessive vomiting (she stated that she pukes
everything she eats), and diarrhea 6-8 times per day (watery stool). The patient also
exhibits sunken eyes, a dry mouth, and dry skin, all of which indicate severe
dehydration. She added that she had discomfort upon urination. The nurse utilized
the numeric pain scale to determine how much abdominal pain Mrs. A was
experiencing, and it was determined to be 7/10, which is considered severe
discomfort. The skin when pinched on her abdomen does not return immediately to
its original position. The following vital signs were acquired after assessing the
patient's vital signs: BP-140/90 mmHg, PR-105 bpm, RR-23 cpm, and T-37°C.
Dr. K immediately ordered a battery of tests and a more comprehensive
examination. Urinalysis, hematology, CBC, complete blood chemistry, urine
clearance test, renal function test and renal sonogram were all performed around
10:30 a.m. Following that, the doctor ordered a renal ultrasound to evaluate the
kidneys. The outcomes of laboratory testing and diagnostic investigations were
scrutinized. The patient's urine color was found to be abnormal in her urinalysis, with
an orange to amber color pee and a urine transparency with a hazy look. Mrs. A's
renal test results in a urine output that is below the normal range which is 400
mL suggesting that she has Oliguria, which is defined as a urine output of less than
500 mL. The patient's sodium level shows an electrolyte imbalance produced by the
patient's diet and the sodium levels in her body. Mrs. A exhibits increased creatinine
as a result of dehydration, as well as excessive BUN, a waste product of protein
activity. Mrs. A was diagnosed with prerenal acute kidney failure based on the
results. Since the patient verbalized that she was diagnosed before with hypertension
and upon admission, her BP increased to 140/90 mmHg. This serves as a triggering
factor to her disease. The patient was also assigned to Nurse Z, who specializes in
caring for patients with renal disease.

II. History of Past Illness

Mrs. A admitted to consuming alcoholic beverages during her high school and
college years. Then, when she began teaching, she decided to give up drinking for
good. After that, she was diagnosed with hypertension when she was 55 years old.
The doctor prescribed her to take 5mg of Amlodipine once a day. She also stated
that she does not consume tobacco products. She has a shrimp allergy, but she does
not have an allergy to any drugs. Ms. A said that she experienced a headache
around six months prior.
 III. Family Health History

According to Mrs. A., her mother has a history of high blood pressure. Her
mother was diagnosed with hypertension at the age of 54 and died at the age of 60
from renal failure. They have a history of diabetes on her father's family, but no
hereditary diseases or illnesses on her husband's side.

IV. Social Health History

Mrs. A is a 65-year-old married woman who was born and raised in Brgy. Don
Domingo Maddela Quirino, Bayombong, Nueva Vizcaya. She was a dressmaker for
25 years. Mrs. A attends the mass every Sunday at 6 a.m. through online mass
celebration ever since pandemic begins. Also, she spends time talking with her grand
kids, especially on weekends. Mrs. A mentioned that they have a good relationship
with their neighbors as well as other people. During this time of pandemic, the family
uses face-mask, face-shield and social distancing. When there is a guest, the family
follows the COVID-19 procedure for safety.

V. Environmental History

According to Mrs. A, they live in a two-storey house located at Don Domino

Maddela Quirino in Bayombong which is half kilometers away from the Barangay Hall
and from the Barangay Clinic. She mentioned that because they live close to town,
they can readily get their daily necessities. Her spouse always provides for the
family's basic necessities. She also said that they did not have any smokers in their
home.

VI. Lifestyle and Health Practices

Mrs. A claimed that she sometimes consumes processed foods because they
are simple to prepare. She goes for a morning stroll to gain some exercise and
sweep the yard. Mrs. A dressed neatly and she also takes a bath regularly. In the
afternoon, she likes television shows such as "Eat Bulaga," and she enjoys drinking
fruit juice while watching. Mrs. A goes to bed as early as 9:30 p.m., but wakes up
around 5:00 a.m. However, she has a sleep disturbance two days ago due to
abdominal pain in her umbilical part of the abdomen, excessive vomiting (she stated
that she pukes everything she eats for about 4-5 times a day), and diarrhea 6-8 times
per day (watery stool). She speculated that her diarrhea may be caused by the food
that had already gone bad in the when she ate it.