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Nursing Health History General Data: Vital Signs

Mr. UR is a 46 year old Filipino male admitted to the hospital with bipedal edema and a diagnosis of chronic kidney disease secondary to diabetes mellitus type 2. He has a 15 year history of diabetes which he manages with oral medications. His family history is significant for diabetes, hypertension, and chronic kidney disease in his mother who passed away at age 48. He works as a butcher and has a history of smoking and alcohol use.

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Duane Liloc
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167 views3 pages

Nursing Health History General Data: Vital Signs

Mr. UR is a 46 year old Filipino male admitted to the hospital with bipedal edema and a diagnosis of chronic kidney disease secondary to diabetes mellitus type 2. He has a 15 year history of diabetes which he manages with oral medications. His family history is significant for diabetes, hypertension, and chronic kidney disease in his mother who passed away at age 48. He works as a butcher and has a history of smoking and alcohol use.

Uploaded by

Duane Liloc
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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NURSING HEALTH HISTORY

GENERAL DATA
NAME: MR. UR
ADDRESS: DAANG BAGO DINALUPIHAN
DATE OF BIRTH: SEPTEMBER 12,1973
AGE: 46 y/o
SEX: M
MARITAL STATUS: MARRIED
NATIONALITY: FILIPINO
RELIGION ORIENTATION: ROMAN CATHOLIC
OCCUPATION: BUTCHER
ADMISSION
DATE: 10/05/2019
TIME: 9:48 am
ATTENDING PHYSICIAN: NIVERA, RHANIEL, MD
CHIEF COMPLAINT: BIPEDAL EDEMA
CONDITION UPON ARRIVAL: CONSCIOUS, COHERENT, AMBULATORY
DIAGNOSIS: CHRONIC KIDNEY DISEASE V SECONDARY TO DKA DM TYPE II
VITAL SIGNS

BP: 150/100

T: 36.9

PR: 73

RR: 20

O2 Sat: 97

Wt: 82 kg (180.78 lbs)

Ht: 6’2 ft (187.96 cm)


NURSING HISTORY
A. HISTORY OF PRESENT ILLNESS

- 2 months prior to admission, patient had (+) progressing bipedal edema, (-) cough, (-) DOB, (-) chest pain, (-) easy fatigability, (-) abdominal pain and (-) n/v. He claimed to have no changes in
frequency and amount of urine so they’ve decide not to bring Mr. UR in the hospital.
- 3 days prior to admission, the patient was (+) progressing bipedal edema, so he and his wife decided to get laboratories on that day. He was referred and hospitalized for the first time in Bataan
General Hospital and Medical Center on October 5th 2019, Saturday at 9:48 am with the chief complaint of bipedal edema which he verbalizes that he has difficulty or trouble walking, impaired
sensation in the foot and cutaneous ulcers in the lower leg and swelling.
- Diagnosis was CKD Stage Five s/t DKA DM Type II, she had undergone Placement of central venous catheter for hemodialysis last October 10th, 2019 at 11:45 pm.

B. PAST MEDICAL HISTORY


- Mr. UR is (+) DM Type II, and was diagnosed 15 years ago, he was 31 y/o back then. (-) Hypertension and (-) Heart disease. He takes Metformin (500 mg orally BID) and Glibenclamide (5 mg
OD) as a medication/maintenance for his Diabetes. As verbalized by his wife, Mr. Ur is experiencing difficulty breathing when he is taking metformin. As verbalized by his wife, according to his Attending
Physician, one of the factor that contributes to his kidney disease is taking Metformin.
- According to his wife, He is yearly getting laboratory tests and often checking his blood sugar or CBG test for his condition.
- Mr. UR has no known allergies, and completely immunized. He had chicken pox when he was seven. He had frequent episodes of sore throat since childhood without seeking medical advice.
- Mr. UR is a smoker and an alcoholic.

C. FAMILY HISTORY OF ILLNESS


No. of Family Members – 5

DISEASE FATHER’S RELATION MOTHER’S RELATION


TUBERCULOSIS ABSENT ABSENT
CANCER ABSENT ABSENT
HEART DISEASE ABSENT ABSENT
HYPERTENSION ABSENT PRESENT
ASTHMA ABSENT ABSENT
DIABETES PRESENT PRESENT
KIDNEY DISEASE ABSENT PRESENT
The patient’s family consists of 5 family members. They have three (3) children. Her Father’s side has only a history of Diabetes while her Mother’s side has a history of Hypertension, Diabetes and
Hypertension. Her mother died at the age of 48 due to Chronic Kidney Disease Stage III.
D. SOCIAL HISTORY
- Mr. UR is a 46 y/o presently unemployed because of his condition but works before in a Chicken Diner and recently as a Butcher.
- Mr. UR is a smoker and an alcoholic.
- With preference on taking soda (four 8 ounce-bottles per day) and consuming only at least 4 half glasses of water per day.
- He is third in a brood of four in the family.
- Hobbies before includes; playing basketball and billiards.

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