DEMOGRAPHIC DATA

Name : Patient N
Age: 52
Sex: Male
Birthday: September 12, 1969
Birth Place: San Francisco Alicia, Isabela
Marital Status : Married
Religion: Roman Catholic
Address: San Francisco Alicia, Isabela
Occupation: Farmer and Carpenter
Race: Filipino
Ethnic Origin Ilokano
Educational Attainment: High School Undergraduate
Primary Language Spoken: Ilokano, Tagalog
Attending Physician: Dr. Maria Celine Nieva Paguila
Significant Othis or support person: Wife, and Aunt
Chief complaint: Stomach and Back pain
Final Diagnosis Calculus of gallbladder without cholecyctitis
Type of Surgical Procedure: Cholecystectomy
Date of Admission: June 28, 2020
Time of Admission: 2:09 pm
Date of Discharge: July 01,2020

Time of Discharge: 12:05 pm

Days of Confinement: 3 days

Source of Data Patient N -------- 80%

Wife --------- 20%
FAMILY BACKGROUND
Patient N belongs to a nuclear type of family. They got married on November 16, 2002.
They are blessed with 1 female child. They are currently residing at San Francisco Alicia,
Isabela. Patient N and his family are currently living in their 15x20 m semi-concrete house in
which the floor is made of cement and they have galvanized roof. Their house has 2 rooms with
a receiving area and a kitchen. The room is occupied by the whole family. The first room is for
their only child and the other one is for Patient N and his wife. The distance between the comfort
room and kitchen is about 5meters. In their kitchen they using gas stove for cooking which is
used daily by the family. In terms with their waste disposal, he said that their waste is place to a
sack and burn it afterwards in their backyard. The burning area is 10 meters away from their
house.
The appliances available in their house are electric fan, television, radio, laptop, speaker,
oven and refrigerator. In terms of communication to their relatives, they have wifi connection,
laptop and cellphone. The type of their comfort room is a water-sealed, they own it and it is 2
meters from their kitchen but the safety tank is 15 meters away from their house. Their water
source is from the pump well 4 meters from their house and for their potable drinking water is
mineral water they buy in rolling water refilling station. On the other hand, with regards to their
home and environment condition, they are secured from any health threats and accidents inside
their house. Their surrounding has trees and habitat of animals like pigpen which is 10 meters
away from their house.
Patient N is High School Undergraduate (3rd year) and his wife is High School graduate.
Currently, his wife is a housewife and she do all the household chores such as dishwashing,
cleaning the house, washing clothes and also taking care of their daughter . While Patient N is a
farmer to their own farm which is about 1.8 hectares and they plant rice on it. Also, he work
sometimes as carpenter as his part time job. The monthly income of Patient N is about 60,000
per cropping in his farm and about 5,000 in his part time job as carpenter. Moreover, when they
experience financial shortage they borrow to their relatives.
In terms of nutrition with enough source of income, the family is able to eat 3 times a day
and sometimes more than that. For breakfast, the food they usually consume are rice, egg,
vegetables, pork, fish, coffee and milk. For lunch is rice, pork, chicken, fish or vegetables as
well as for dinner. Usually for the snacks is bread, juice and fruits. Patient N favorite food are
fatty foods like “pork and chiken adobo”, “pork patatim”, “beef bulalo”, “chiken tinola”, and
“sinigang na baboy”. He also love putting oil to his rice every meal, he love to eat chicken skin
and he also drink liquor moderately with his friends 3 times in a week. Eating is the bonding of
the family. Also their family’s hobbies are watching tv and playing mobile games.
On the other hand, their only child was deliver through normal spontaneous delivery in
their home and received vaccines which are BCG, Hepa B, DPT, OPV and AMV. There is also
newborn screening and hearing test. Their child is normal and currently she was 17 years old, a
grade 12 student and taking HUMMS strand at Northeast Luzon Adventist College.
FAMILY HEALTH HISTORY
Patient N’s family is in the middle class of the society. On his paternal side, his
grandfather died at the age of 76 due to aging at their home while his grandmothers died at the
age of is 78 due to unknown reason at their home, and according to the patient he doesn’t
remember the year because he is too young that time. They were blessed with 6 children and
Patient N’s father was the first child among his siblings. Patient N’s father died at the age of 80
due to aging at their home.
Whereas, on his maternal side, his grandfather died at the age of 75 in their home and
Patient N doesn’t remember the cause of death and year because she is only 3 years old that time.
While his grandmother died at the age of 83 in their home and the patient also stated that it is due
to aging. Their family were bestowed with 6 children and Patient N’s mother was the 4th child
among his siblings. Patient N’s mother is 82 years old and living healthy at their home in Nueva
Viscaya.
Patient N’s mother and father were blessed with 6 children and his mother gave birth all
of his children through normal spontaneous delivery. Likewise, all of them are delivered at home
with a traditional midwife in their town. Also all of them are breastfed and in terms of
immunization as stated by the patient, they are fully immunized however they didn’t remember
the vaccines but they all have mark of BCG in their deltoid area.
The family also experienced common illnesses such as colds, fever, toothache, headache,
boils, LBM, and they usually managed this through home remedies using herbal medicines and
sometimes also over the counter drugs such as Neozep for colds, Paracetamol for fever and
headache, salt and chili peppers for toothache, gumamela flower which is applied to boils and
when they experiences LBM they takes diatabs. Also, their family sometimes use “atang” when
one of their family member got simple illness like fever and also consult to albolaryo.
PAST HEALTH HISTORY
Patient N was born on the 12th day of September year 1969 through normal spontaneous
delivery and was breastfed by his mother. She was the 5th born child among 6 of his siblings.
Patient N stated that he has complete vaccine however she didn’t remember the vaccines but she
has mark of BCG in his deltoid area.
She also suffered from common illnesses such as colds, fever, toothache, headache, boils,
LBM, and they usually managed this through home remedies using herbal medicines and over
the counter drugs such as Neozep for colds but sometimes it get worse and become flu and
hospitalized sometimes , Paracetamol for fever and headache, salt and chili peppers for
toothache, gumamela flower which is applied to his boils and when he experienced LBM he
take diatabs. Also, Patient N take buscopan whenever he felt stomach pain and apply ointment
like Pau liniment on his backpain. Patient N doesn’t have allergies on foods, drugs or objects like
latex or rubber.
Patient N has his circumcision when he was 10 years old. His circumcision healed after 2
weeks and there are no complications happen. When she was 14 years old his axillary and pubic
hair grew and his voice started to change. He also experienced to have acne and he just ignore it.
Patient N also gets taller, and that time he love playing basketball with his friends.
Patient N got married on November 16, 2002 wherein he was 33 years old that time, he
told us that he experienced his first sexual intercourse when she was 32 years old with his first
girlfriend which is his wife now. After 6 months of their relationship, Patient N’s wife had her
first pregnancy and it was born in their home with a traditional midwife through normal
spontaneous delivery. He stated that his first child was fully breastfed and received complete
immunization.
Patient N handled his farm and spent some of his time in taking care of it. Their income
is enough for them since they only have one child. They gave all the needs and wants of their
child and they save money for her study. They also have animals like 2 dogs, 55 hens and 32
chicks, 20 rosters and 10 pigs. The chickens and pigs served as their source of food daily. Patient
N love pork and chicken recipe like “pork and chiken adobo”, “pork patatim”, “beef bulalo”,
“chiken tinola”, and “sinigang na baboy”. He also love putting oil to his rice every meal, he love
to eat chicken skin and he also drink liquor moderately with his friends 3 times in a week.
Although, Patient N is a farmer and carpenter he live with sedentary lifestyle since she
only go to the farm twice a week only to see it and he hire tenants to work for him. Also , he
work as carpenter only if he wants to and if he is not in condition he don’t work. Most of his
time, he spent it in sleeping, eating and watching. Patient N doesn’t exercises and no diet routine
to follow. He can eat whatever he wants especially his favorite’s food anytime. His wife always
reminds him to diet and minimize eating fatty foods but Patient N don’t listen to her. Although
there are vegetables, fish and fruits in their daily meals, Patient N always choose to eat more
pork and chicken than vegetables and fruits.
PRESENT HEALTH HISTORY

In the months of January to May 2020, Patient N noticed that there is pain in his stomach
especially when he is full. But he just ignored it and takes over the counter drugs like buscopan.
He also forces to defecate and limit to drink liquor and eating too much food. He doesn’t go to
any clinic to have a checkup because he taught that it’s normal to have a stomach pain when he
is full.
Until, June 28, 2020, Patient N on his regular day at around 1:30 o clock in the afternoon
while he is sitting in their sofa chair, he experienced minimal pain in his stomach. He stands up
and went to the bathroom thinking that it is urge to defecating. But the pain become more strong
and intense and the pain spread to his waist line up to the back. Because of pain he even cry and
shout to ask for help. His wife immediately run to him and called barangay tanod to take him in
the hospital.
Patient N was rushed at Lucas Paguila Medical Hospital using the van of his brother.
They arrived at around 2:09 o clock in the afternoon at the hospital. In the hospital they infused
IVF and take his blood pressure, it was 130/80. On June 29, 2020 in the morning she undergo
ultrasound examination and for observation at the mean time. In the afternoon they stated that he
needs to undergo cholecystectomy because he has stone in his gallbladder and it becoming
bigger and it is cause by eating too much fatty foods according to the physician. He was
instructed to NPO and explained the surgery he need to undergone as well as the instructions he
need to follow like removing of jewelries and other metal objects in his body.
On June 30, 2020 in the morning he signed the consent letter and placed him in the
Operating Room. He was instructed to lay down in the OR table and after a minute he instructed
to a lateral position and then the anesthesia provider inject to him the anesthesia on her lower
back. After an hour the operation for cholecystectomy was done, this type of surgery is to
remove the gallbladder to prevent further complications such as infection or choleycyctitis.
On July 1, 2020 , Patient N is discharge in the hospital around 12:05 in the afternoon. His
physician Dr. Paguila, Maria Celine Nieva gave him take home medicines such as cefuroxime
500 ml tab (7:00 am and 7:00 pm) 2 time a day for 1 week, celecoxib 200mg tab (8:00am and
8:pm) 2 times a day for pain and bearse 1 tab (7:30 am and 7:30 pm) 3 times a day for 1 week .
After he was discharge, Patient N felt pain in his stomach because of his incision in
which it is about 4 inches diagonal to the upper right quadrant of his stomach. His daily activity
was altered because of his condition. Moreover, his eating pattern also changes because he can
only eat 3 spoons of rice and vegetable soup. He also drink half cup of water every meal because
according to him he felt pain when his stomach is full. That’s why his weight decreases from 90
kl before to 70 kl until now. He stops eating fatty foods and drinking alcohol because of his
condition. Furthermore, he needs to rest and not allow in doing heavy work.
 One week after he takes all his take home medicine, he felt better and don’t experienced
any problem. That’s why he just rest on their house and don’t back to the hospital since he felt
fine. His routine after his surgery, is to walk around their house, and relaxed on their garden. Her
wife helped him in bathing, changing clothes and dressing his incision site. Their daughter also
helped him in eat nutritious food and do slight exercise like walking and stretching of his arms
and legs.
Currently, after 3 months of his surgery I saw him fine. The incision site healed, no
discharges, no swelling, or redness just scars. Patient N can now walk and run as well as he can
also play basketball. As his exercise he do biking and jogging together with her daughter. He
also have good eating pattern and he stop eating fatty foods. In breakfast he eat 1 cup of rice, 1
boiled egg and 1 hotdog, or 1 fish , while in afternoon and dinner he eat vegetable ,fish and pork
but he didn’t eat the fats. Also he don’t put oil in his rice and he drink 1 cup of water every meal
and for his snack he eat low fat bread and fruit juice. In order to still have fats in his body, her
physician recommends him to eat fruit and vegetables that contain good cholesterol like avocado
and peanuts. His current blood pressure is 130/90, temperature is 36.5 and Respiratory rate is 20.
He is active, coherent and able to cooperate during the interview. Thus, he admit that all his
records was left in the hospital and all the boxes of his medicines was threw and gone.

Documentation: