I.

BIOGRAPHIC DATA
Name: Age: Sex: Nationality: Date of Birth: Place of Birth: Civil Status: Address: Religion: Educational Attainment: Occupation: Mrs. JMG 42 years old Female Filipino January 25, 1970 Mulanay, Quezon Married Purok 2 Sucol, Calamba (54), Laguna Roman Catholic High School Graduate

II.

Nursing History a. CHIEF COMPLAIN: b. ADMITTING DIAGNOSES:

Right Upper Quadrant Pain T/C Acute Cholecystitis

PRESENT HEALTH HISTORY

Symptom (PTA)

Patient prior to admission, Mrs.JMG experienced right upper quadrant pain associated with a sense of bloatedness, without nausea and vomiting. The pain was tolerable so she did not seek medical attention yet. She said she also had an increased level of pain tolerance so she also didnt mind to take any pain relievers. Until three days prior to admission, patient had severe right upper quadrant pain, which was said to be intolerable. Moreover, when pressure is applied on the RUQ of the abdomen, pain is elicited. He had also lost her appetite because of the pain