A Case Presentation on Obstructive Uropathy: Ureterolithiasis

Bachelor of Science in Nursing III 2021 - RLE Group B

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III. HEALTH HISTORY

A. PAST HEALTH HISTORY

As recalled by the mother of the patient, she stated that the patient completed his immunizations
during childhood. The mother claimed that, patient experienced common childhood diseases such
as chicken pox and measles. Whenever he experiences cough and common colds, he would usually
resort to natural remedies such as drinking lots of water and drinking calamansi juice and take a
good rest. However, he usually self-medicate with over the counter drugs such as Alaxan or
Paracetamol for fever and headaches. The patient also stated that, he doesn’t have any allergies on
foods or anything. At the age of 15 he started drinking alcohol. The patient admitted consumption
of alcohol almost every day with his friends. He admitted consumption of coffee every day, usually
in the morning. He denied the use of illicit drugs.

According to the patient, he started feeling different illnesses since 2010, such as abdominal pain
and back pain. He sought medical advice at CVMC.

B. PRESENT HEALTH HISTORY

Last 2017, the patient stated that, he fell from his bed and was rushed to CVMC because of
high blood attack for 4 days. The patient stated he did not know that he was having hypertension
when it happened. The patient said, “na-half paralysis ako noong time na yun”. That was the time
he started taking his anti-hypertensive medication, as prescribed by the doctor. Afterwhich,
diagnostic and laboratory test results of the patient revealed high creatinine level and presence of
kidney stones. Consequently, the patient had his kidney stones removed at PGH in the same year

1 month prior to admission, the patient suffered from recurrent abdominal and back pain. He
usually experiences pain on the upper abdominal area and the back muscles on the right side, during
nighttime with pain scale of 6 over 10, as validated.

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 A Case Presentation on Obstructive Uropathy: Ureterolithiasis
Bachelor of Science in Nursing III 2021 - RLE Group B
11

C. FAMILY HEALTH HISTORY

Paternal Maternal Maternal

Paternal Grandmother Grandfather Grandmother
Grandfather (+)
(+) Hypertension Hypertension

Father
(+) Mother
Hypertension
Diabetes Hypertension
Mellitus

LEGEND:
Patient AI = Female
44 y/o
1st born Obstructive 3rd born = Male
Uropathy
secondary to (+) = Deceased
Ureterolithiasis
HPN

23 y/o
21 y/o

The patient stated that he never met his paternal grandfather and grandmother, thus, he had no data
regarding the cause of their death nor any history of significant hereditary diseases that they had. On
the other hand, he stated that both his maternal grandparents are still alive. His maternal grandfather
and grandmother had a significant hereditary disease which is hypertension.

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 A Case Presentation on Obstructive Uropathy: Ureterolithiasis
Bachelor of Science in Nursing III 2021 - RLE Group B
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According to the patient, his father died due to a heart attack and complications of Diabetes. His
mother, on the other hand, is still alive and has Hypertension. Patient AI is the 2nd child of 3 off
springs. 2 of his siblings do not have any significant present illnesses. He also stated that both of his
children do not have any notable present illnesses.

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