I.

BIOGRAPHIC DATA
Name: patient X
Adress: Tala, Kalookan city
Age: 54 Gender: F
Religion: Roman Catholic
Marital status: M
Occupation: NA
Room and bed no: FMW miscellaneous bed 1
Chief complaint: dizziness
Provisional diagnosis: S/P CVA
Attending physician: Dra. Dasallia

II. Nursing History

A. Past health history
The client doesn’t have any severe illness during her childhood
except from the usual common colds, cough and headache. And for
these instances, she usually self prescribed. The client stated that she
has not completed vaccination during earlier years and when asked
what these vaccines are the client said she can no longer remember.
Further she said she has no known allergies to any food or drugs. Also
she stated that she has not suffer from any injuries like fall, burn etc.
but she continued that when she was in highschool, she was bitten by
a dog and she treated it with medicinal plant only (sambong). The
client said that she doesn’t have any foreign travel as well. During her
childhood the client was never hospitalized but in October 2001, she
was admitted to East Avenue Medical Center with chief complaints of
dizziness, headache, vomiting and diagnosed with
CVA(CerebroVascular Accident), wherein her half body was paralyzed.
Moreover, she was prescribed with Metropolol , Losartan and Catapress
and a 1 month confinement. Also she was required to have a check up
every 2 weeks (Diosdado Macapagal). And reoccur the following year
(2002). Had her 3rd attack in 2005 and was again confined to East
Avenue Medical Center. And had her 4th attack this September 2010
and was admitted to Jose N Rodriguez Medical Center. The client had
her first attack of HPN in lieu of giving birth to her first baby.

B. PTA, the client experienced extreme dizziness after doing her daily
chores. She rested for a while to ease the dizziness and take her
maintenance medications which she failed to do so on time. When the
severe dizziness was not relieved she was rushed to Jose N. Rodriguez
Medical Center where prompt treatment was given and she was
confined. She was diagnosed with S/P CVA, with initial vital signs of
200/100 mmhg(bp), FUCK FUCK FUCK FUCK BITCH