SANTOS, GAIL LIAN B

BSN III-C4

BIOGRAPHICAL DATA
This is the case of Morareng, John Maratag, 69 years old, married, Filipino, male, retired government
employee, college graduate, born on May 15, 1948 in Bontoc Mt. Province, currently residing in Tocucan,
Bontoc, Mt. Province. With a chief complaint of Gallstone.
HISTORY OF PRESENT ILLNESS
One year prior to admission the patient had right upper quadrant pain described as crampy, intermittent,
rated as 8/10, radiating at the back area, associated with nausea and vomiting of previously ingested food.
Consult was done and ultrasound was requested revealing gallstone. Patient opted for cleansing by taking
apple juice with Epson salt and olive oil twice.
One week prior to admission patient experienced severe pain at right upper quadrant, characterized as
crampy, radiating at the back with associated nausea and vomiting. Consulted with cardiologist and requested
for another ultrasound revealing enlargement of stones. He was referred to a surgeon and was advised
surgical intervention.
PAST MEDICAL HISTORY
The patient is known hypertensive with heart problem since 2015 and has a following maintenance
medications: Clopidogrel, Trimetazidine, Telmisartan and atorvastatin. He was hospitalized year 2015 due to
mild stroke. He also had appendectomy last 2011.
FAMILY HISTORY
With no family history of diabetes mellitus, hypertension, stroke, and heart problems.
SOCIAL and ENVIRONMENTAL HISTORY
The patient is a non-smoker and non-alcoholic drinker. He lives on a two storey house and 2 bedrooms with 3
occupants on a well ventilated area. . The source of water for domestic purposes is from spring and drinking
water is form refilling station. He takes care of pigs, hens and dogs at their backyard. Their garbage is collected
once a week. The patients diet usually are rice, vegetables, and fruits with less meat. His daily activities
composed of household chores, taking care pf animals, and gardening.