Health History

Published on July 2016 | Categories: Documents | Downloads: 79 | Comments: 0 | Views: 571
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I.

Health History A. DEMOGRAPHIC DATA

Client’s Name: Baby Girl Briguel Gender: female Age: Birthdate: March 26, 2013 Birth Place: Naic, Cavite Race: Filipino Religion: Roman Catholic Address: Labac, Naic, Cavite B. SOURCE AND RELIABILITY OF INFORMATION  The mother who is conscious and coherent about questions being asked to her.  Hospital records that were made available during the clinical exposure. C. REASONS FOR SEEKING CARE OR CHIEF COMPLAINTS 1. Difficulty of breathing few seconds after normal spontaneous delivery 2. Possible meconium aspiration as manifested by greenish discoloration of amniotic fluid. D. HISTORY OF PRESENT ILLNESS OR PRESENT HEALTH The patient was born March 26,2013 at 6: 31 am in the morning in RHU-Naic Lying in . Prior to admission , the patient’s mother had delayed delivery due to possible rupture of membrane early at 10pm that day and wasn’t able to go to hospital immediately. It took several hours before normal spontaneous delivery was conducted resulting to fetal distress. E. PAST MEDICAL HISTORY OR PAST HEALTH 

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