Republic of the Philippines

SULTAN KUDARAT STATE UNIVERSITY

ACCESS Campus, EJC Montilla, Tacurong City

College of Health Sciences

NCM 101 HEALTH ASSESSMENT

FINAL COURSE REQUIREMENT

In fulfillment of Final Requirement in NCM 101- Health Assessment

JUNE 2020

Submitted to:
Submitted by:
GRACIELA MANA-AY NALLOS
TUAZON, JUSTINNE MAE L.
NCM 101- Clinical Instructor
 Republic of the Philippines
SULTAN KUDARAT STATE UNIVERSITY
ACCESS Campus, EJC Montilla, Tacurong City

College of Health Sciences

NCM 101 HEALTH ASSESSMENT

COMPLETE HEALTH HISTORY

1. Biographic data
 Name: Mrs.Virgie Barrometro Romagos
 Address: Kalawag 3,Isulan,Sultan Kudarat
 Phone: 09058511061
 Gender: Female
 Provider of history (patient or other): Patient
 Birth date: September 25,1972
 Place of birth: Kalawag 3, Isulan, Sultan Kudarat
 Race or ethnic background: Hiligaynon
 Educational Level: High School
 Occupation: Saleswoman
 Significant others or support persons: Mr. Alex Romagos

2. Reasons for seeking health care

For guide questions:
 Reason for seeking health care: Severe headache and pain in the
nape associated with High Blood
 Feelings about seeking health care: “Nahadlok ako”, as verbalized by
the patient
3. History of present health concern
For guide questions:
 Character (How does it feel, look, smell, sound, etc.?): “Sakit gid ang
akon ulo kag sa akon batok”, verbalized by the patient
 Onset (When did it begin; is it better, worse, or the same since it
began?): It started on the year 2018, now, situation is better unlike
before
 Location (Where is it? Does it radiate?): The pain is in the head and
nape, and no, it does not radiate
 Duration (How long it lasts? Does it recur?): Just a couple of minutes,
and yes, it does recur
 Severity (How bad is it on a scale of 1 [barely noticeable] to 10 [worst
pain ever experienced]?): Patient rate it as 5
 Pattern (What makes it better? What makes it worse?): It is better when
she take her medication, it is worst when she works to much
 Associated factors (What other symptoms do you have with it? Will you
be able to continue doing your work or other activities [leisure or
exercise]?): The pain can be handled

3. Past health history

For guide questions:
 Problems at birth: None
 Childhood Illnesses: None
 Immunizations to date: None
 Adult illnesses (physical, emotional, mental): High Blood
 Surgeries: None
 Accidents: None
 Prolonged pain or pain patterns: None
 Allergies: None
 Previous Hospitalizations: None
 Current Medications (Maintenance): Lotensin, 50mg.

4. Family health history

For guide questions:
 Age of parents (Living? Deceased date?):
Father: Deceased
Mother: 69 years old
 Parent illnesses:
Father: None
Mother: Diabetes
 Grandparents’ Illnesses: None
 Aunts’ and uncles’ age and illnesses: None
 Children’s ages and illnesses or handicaps:
Eldest: 25 years old, none
Youngest: 17 years old, none
5. Review of body systems (ROS) for current health problems

For guide questions:

 Skin, Hair, and Nails: color (normal), temperature (36.5°C), condition
(normal), rashes (none), lesions (none), sweating (none), hair loss
(none),dandruff (none)
 Head and Neck: headache (yes), stiffness (none), difficulty swallowing
(none), enlarged lymph nodes (none)
 Ears: pain (none), ringing (none), buzzing (none), drainage (none),
difficulty hearing (none), exposure to loud noises (none), dizziness
(none)
 Eyes: pain (none), infections (none), vision (blurry), redness (none),
tearing (none),halos (none), blurring (yes), black spots (none), flashes
(none), double vision (none)
 Mouth, Throat, Nose, and Sinuses: mouth pain (none), sore throat
(none), lesions (none), hoarseness (none), nasal obstruction (none),
sneezing (none), coughing (none), snoring (none), nosebleeds (none)
 Thorax and Lungs: pain (none), difficulty breathing (none), shortness of
breath with activities (none), orthopnea (none), cough (none), sputum
(none), hemoptysis (none), respiratory infections (none)
 Breasts and Regional Lymphatics: pain (none), lumps
(none),discharge from nipples (none), dimpling or changes in breast size
(none), swollen tender lymph nodes in axilla (none)
 Heart and Neck Vessels: chest pain or pressure (none), palpitations
(none), edema (none), last blood pressure (120/80 bpm), last ECG(
none)
 Peripheral Vascular: leg or feet pain (none), swelling of feet or legs
(none), sores on feet or legs (none), color of feet and legs (normal) .
 Abdomen: pain (none), indigestion (none), difficulty swallowing (none),
nausea and vomiting (none). Gas (none), jaundice (none), hernias
(none)
 Male Genitalia: painful urination, frequency or difficulty starting or
maintaining urinary system, blood in urine, sexual problems, penile
lesions, penile pain, scrotal swelling, difficulty with erection or
ejaculation, exposure to sexually transmitted diseases
 Female Genitalia: pelvic pain (none), voiding pain (none), sexual pain
(none), voiding problems (dribbling, incontinence) (none),age of
menarche or menopause (date of last menstrual period)(46 years
old,last 2017), pregnancies and types of problems (none), abortions
(none), sexually transmitted diseases (none), hormone replacement
therapy
(none), birth control methods (none)
6. Lifestyle and health practices profile
Contents/Components:
 Description of a typical day (AM to PM): “Himuon ang mga urubrahon
sa balay”
 24-hour dietary intake (foods and fluids): Vegetables with little amount
of rice, water
 Who purchases and prepares meals: Patient
 Activities on a typical day: “Trabaho kag relax”
 Exercise habits and patterns: “Ang trabaho na ang exercise”
 Sleep and rest habits and patterns: Sleeps at 8pm,waking up at 4 am
 Use of medications and other substances (caffeine, nicotine,
 alcohol, recreational drugs): Maintenance drug
 Self-concept: “Buot ako kag loyal nga tao”
 Self-care responsibilities: “Mag-iwas sa mga bawal”
 Social activities for fun and relaxation: None
 Social activities contributing to society: None
 Relationships with family, significant others, and pets: “Good”
 Values, religious affiliation, spirituality: Christian
 Past, current, and future plans for education: None
 Type of work (Saleswoman), level of job satisfaction (“okay lang”), work
stressors (none)
 Finances: no financial problems
 Stressors in life (“mga urugtason”), coping strategies used (“magrelax”)
 Residency, type of environment, neighborhood, environmental risks:
Peaceful environment, no environmental risk

7. Developmental level

STAGE OF PSYCHOSOCIAL JUSTIFICATION/

DEVELOPMENT DESCRIPTION
Age: 49 years old
In this stage, important events
includes work and parenthood. Adults
Developmental Task: need to create or nurture things that
Middle Adulthood will outlast them, often by having
( Generativity vs Stagnation) children or creating a positive change
Develop generativity, or the that benefits other people. Success
desire to expand one's leads to feelings of usefulness and
influence and commitment to accomplishment, while failure results
family, society, and future in shallow involvement in the world.
generations
References
Kendra C.(2021), Erik Erikson's Stages of Psychosocial Development. Retrieved
from: https://www.verywellmind.com/erik-eriksons-stages-of-psychosocial-
development-2795740

Anonymous (n.d.), Developmental Psychology. Retrieved from:

https://www.cliffsnotes.com/study-guides/psychology/development-psychology/
psychosocial-development-age-4565/crisis-in-middle-adulthood-age-
4565#:~:text=Erikson%20stated%20that%20the%20primary,and%20guiding%20the
%20next%20generation.