health history dm2

7/30/2019 Health History DM2

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HEALTH HISTORY

HISTORY OF PAST ILNESS

According to the client, she did not have immunizations during her childhood since the

Expanded Program on Immunization was not yet introduced during her time but she completed

her Tetanus Toxoid vaccination. According to her, she experienced having mumps, measles and

chicken pox as her childhood illnesses. When the client has fever, cough, colds, or pain, the

client manages it with over the counter medications like Paracetamol, Mefenamic acid, and

Neozep. She uses herbal plant such as guyabano leaves decoction to treat her diabetes.

Whenever the client has fever, cough, colds, head ache and stomach ache, she manages them

by resting, increasing fluid intake and tepid sponge bath specifically for fever. The client does

not immediately take medications or seek medical attention. She said that as long as she can

manage her condition, she will not do so. The client also verbalized that she was hospitalized at

Tuguegarao City Peoples General Hospital twice due to diarrhea. She is currently diagnosedwith hypertension and prescribed to take amlodipine for her maintenance but she is not

compliant with it due to financial constraints. The client believes in quack doctors. She gave

birth to her children at their home with the help of a hilot. The client has no allergies to food

and medication medications. She does not smoke nor drink alcohol.

HISTORY OF PRESENT ILLNESS

6 months prior to admission, the client was diagnosed to have Diabetes Mellitus at PeoplesGeneral Hospital. She was prescribed with metformin to manage DM but she wasnt compliant

in buying her medicines since October 2012 due to financial problems. One day prior to

consultation, she experienced nausea, and she vomited twice after eating with approximately

30 ml of emesis. She experienced abdominal pain on the epigastric region of her abdomen with

a pain scale of 8/10. The following morning she vomited again once after eating breakfast with

approximately 15 ml and she still has her abdominal pain. She also felt body weakness and

dizziness, and nausea. She was brought to Peoples General Hospital, and she vomited there

once with approximately 15 ml of emesis. She was then referred to Cagayan Valley Medical

Center, and was admitted with a chief complaint of nausea, vomiting, and body malaise.

FAMILY HISTORY (PATERNAL AND MATERNAL SIDES, RESPECTIVE)

Cancer ( )

Asthma ( )

TB ( )

DM ( )

Heart Disease ( )

Hypertension ( X)

Cancer ( )

Asthma ( )

TB ( )

DM ( )

Heart Disease ( )

Hypertension ( X)


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died because of heart disease. Her children support her with her financial needs because she

does not have any work. When she cannot handle her problems anymore, she asks for help

from her children and friends. According to her, she also mingles with her neighbors and she is

in good terms with them. Regarding her relatives, they help one another in times of need. The

client usually celebrates birthdays by preparing food and inviting her parents and relatives to

the said occasion. The client is not involved in any organizations in the community.

OB HISTORY

The client stated that her menarche was when she was 15. She had her telarche when she was

14. Her menstruation is regular and occurs every after 4 to 5 weeks. Her menstruation lasts 2-3

days and consumes 1-2 pads per day. She didnt experience dysmenorrhea. According to the

client she had her coitarche when she was 18 yrs Old. The client has five children with an OB

score of G5P5(T5P0A0L5). She gave birth at their house with the help of a hilot. She gave birth

with her first child with the age of 21. Her childrens ages are 39, 38, 36, 32, and 31. She

completed her Tetanus Toxiod vaccination. She used pills as contraceptives but stopped using it

after her 2nd

delivery. She had her menopause at the age of 50.


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health history dm2

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