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Past Health History
The patient was born on January 01, 1989. She was delivered full term through Normal Vagina Spontaneous Delivery. The patient was completely immunized. She was never admitted to a hospital but she experienced common illness such as cough and mefenamic acid for pain. She occasionally drinks liquors such as red wine and beer. Her usual diet includes food that are high in protein, junkfoods, softdrinks and canned goods. She prefers meat products in her meal than leafy vegetables.
Present Health History
Several days prior to admission the patient experienced an abdominal pain at the right lower quadrant. These prompted her to seek medical advice, thus confined in Kidapawan Medical Specialist Incorporated last February 08, 2012 with the admitting diagnosis of Acute Appendicitis under the service of Dr. Edwin Mudanza. Her medications were Ranitidine, Metronidazole and Ampicillin. She was confined at private room #523.
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PHYSICAL ASSESSMENT Genearal Appearance at First Sight
Patient was received awake, responsive and coherent with an IVF D5LR 1L at 80 cc per hour, infusing well at the right metacarpal vein. Patient has a mesomorphic type of body built and weighs 54.5
kilograms and stands 5’4” tall. The patient was certainly oriented to
time, place and persons. She was able to deal with her emotions appropriately as the interview went on. Wearing a cotton T-shirt and jogging pants, patient looked neat and tidy