DELA CRUZ, KAILA T.

HEALTH ASESSMENT LEC

BSN-1 MR. ROY QUITO

HEALTH ASSESSMENT INTERVIEW:

 BIOGRAPHIC DATA:
o Name: E.D.D
o Address: B8 L11 Marigold St. Bonair Homes, Molino 3,Bacoor Cavite
o Ages: 52 yrs/old
o Sex: Female
o Marital Status: Married
o Occupation: Housewife
o Religion: Catholic
o Health Care Financing: None
o Source of Medical Care: Buying medicine in Pharmacy
o Source of Information: Patient/Client
o Admission Date:
o Discharge Date:
o Interview Date: February 15, 2023
o Admitting Diagnosis:
o Final Diagnosis:
 CHIEF COMPLAINT:

o ‘’Wala naman akong nararamdaman kahit ano, pero magpapa konsulta ako at
magpapa laboratory sa Feb 18 “ As verbalized by patient.

 HISTORY OF PRESENT ILLNESS ( HPI)

o Two years prior to consultation (2014) She said that she had lost
weight, urinating a lot, that her vision is blurry, she feels always
hungry, and that when she gets wounded, it takes a long time to
heal.
o One year prior to consultation (2015) Patient verbalized that she
always experiencing all of that symptoms day by day , but she did not
took any medical consultation that time because she thought that
 was normal. By that time patient didn’t know that at the age of 45
she will be having a chronic disease which is Diabetes type 2.
o One months prior to consultation (2016) she said that those
symptoms that she experiencing was making her to regulate her
sugar every other day to maintain the normal sugar level.
o One day prior to consultation (2016) According to her, she asked for a
consultation about what was happening to her that time or if she was
sick, because she had a wound on her leg and it had been several
weeks and it has not healed. So she took a medical consultation and
did a laboratory and other test, and she found out that she has
diabetes type 2. From then on, Patient started taking maintenance
such as Metformin, Gliclazide, Glutamine Prime and Vitamin C
ascorbic acid and BeNerv. Also she’s using Glucometer to regulate her
blood sugar.

 PAST MEDICAL HISTORY:

o According to the Patient, she never had chicken pox, measles or
anything. When she was young but she got vaccine for Chicken pox,
measles because of the healthcare workers who went from house to
house. And other vaccine but she can no longer remembered those
vaccine because she was injected at school.
o Diabetes Type 2 medical condition that patient had previously
experienced way back 2016. Until now she’s taking maintenance such
as Metformin, Gliclazide, Glutamine Prime and Vitamin C ascorbic
acid and BeNerv.
o Patient received COVID vaccines 2 shots and was both Pfizer, She had
allergies on seafood’s and chicken that’s why her food always
vegetables and/or fish. But when she was eating those food, she
always taking a Cetirizine to help with her allergy.
o She also got Anti tetanus every 5 years and has UTI, sometimes the
treatment that she was taking was thru vials.
o Patient has never been engaged to any vehicular accident or any
injury that led to hospital admission.
 FAMILY HISTORY OF ILLNESS:
o Her Father died because of High blood pressure and old age. Same as
her Grandparents on father’s side died because of High blood
Pressure and old age. Her Aunt and Uncle died because of High blood
Pressure and Pulmonary Edema. The other aunt are still alive but
apparently have High blood pressure.
o On the Mother’s side, both her Grandparent’s died because of
Diabetes and old age. Same as her mother, died because of Diabetes
and but She stated that she no longer reached out to her mother
because she was still young when she died. Her Aunt and Uncle died
because of kidney failure, Diabetes and High blood.
o Currently she is taking a maintenance for her Diabetes, her older
brother is currently having a stroke and her younger sister have also
diabetes and kidney problem.
 ‘’FAMILY GENOGRAM’’

LEGEND:

MALE HUSBUND & WIFE

FEMALE DEAD

CLIENT SIBLINGS

Father’s Side Mother’s Side

80’s 80’s 70’s 75

High Blood High Blood Diabetes Diabetes

65 68 90’s 48 80 90’s 60’s 65 83

High Blood High Unknown cause Diabetes Diabetes Kidney Diabetes
Pulmonary & High Blood Failure
Edema Blood
Pulmonary
Edema

70 60 62 56 66 59 48 52 55
Stroke Hemorrhage Diabetes Diabetes Kidney Diabetes Husband
Unknown
Problem/ T2
cause
Diabetes
PROOF OF HEALTH ASSESSMENT INTERVIEW