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Name: T. F. L Sex: Male Age: 77 y/o Race: Asian Occupation: Carpenter Birth Date: 08/03/34 Nationality: Filipino Educational Attainment: High School Undergraduate Address: Sta. Catalina Place of Birth: Sta. Catalina Civil Status: Widowed Religion: Roman Catholic Room and Bed Number: MPS Doctor(s) in charge: Dr. Mark Anthony Aranas
Date and Time of Admission: January 30, 2012; 10:16 am Date and Time History was Taken: February 3, 2012; 1:30 pm
Chief Complaints Pain primarily at the umbilical area rated as 8 over 10, and persistent nausea and vomiting. History of Present Illness October of 2011, patient started to feel on and off pain over his abdomen. Rated 4 over 10 (10 as the highest) by then. A month after, began to felt change in bowel movement (decreased frequency and amount) and appetite. Last December, recognized a sudden drop of his weight with increased in the intensity of the pain in his abdomen (umbilical area), now rated 7 of 10. Decided to have a check-up and was prescribed with acetaminophen, buscopan and ranitidine by Dr. Corbadilla. However, the pain was still not resolved. Last January 21, 2012, persistent nausea and vomiting in large amounts was experienced along with severe abdominal pain all over his abdomen, rated 10 of 10. Immediately went to Holy Child Hospital, and from them, endoscopy and biopsy was done per order by Dr. Carriaga. Instructed to take in only milk (sustagen) while waiting for the results, pain relievers were prescribed. On January 30, 2012, a mass growth at his antrum was ruled out, and has decided to have it removed at the soonest time possible which then lead to his admission at NOPH surgery ward companied by his son, Rodrigo Tomias, on the same day at 10:16 am.
General Impression of Client Client lying in bed is awake, alert and responsive to external stimuli; oriented to time, place and person. Developmental level is on old age. With #2 D5LR infused at 30 gtts/min at left metacarpal vein with #5 Aminogen 500 ml 16 gtts/min via sidedrip. With NGT tube inserted at left nostril, drainage bag empty of gastric contents. Observed to have difficulty in speaking which he associated with the NGT tube at his pharynx. Complained of unending pain over the umbilical region of his abdomen rated as 5 of 10 (10 as the highest). Verbalized also fear for the upcoming operation, lack of sleep and hunger. However, was seen as calm and peaceful. Observed to have dry mouth and pale mucous membranes. Abdomen is hard and rigid when palpated lightly. Able to answer HWs questions with clarity and objectivity.
22 y/o. No chest pain, palpations, murmurs, HTN, DM, coldness/numbness/color changes in hands or feet, varicose veins, or swelling. Claimed of having no allergies since birth. Claimed to be fully immunized since birth. Hospitalized only once due to a vehicular accident when he was 55 y/o. Does not consider it as a serious injury. Verbalized, maau, makalingaw when asked about his perception of his previous life.
tumor sa iyang tiyan. Claims, sige kog pangihi, ikadaghan Claims, kulang kog tulog diri when asked if hes feeling alright with his stay in the hospital. Claims, wala raman pud ko hilanti atong gasakit ni akong tiyan, pero namiba lang jud akong timbang Had bed bath since admission. Finds easy to follow doctors order. Undergone biopsy and endoscopy as diagnostic tests. Verbalized fear regarding the upcoming surgery. Family members feel relieved that heir father would undergo surgery to removed to tumor in his antrum. Has #2 D5LR infused at 30 gtts/min at left metacarpal vein with #5 Aminogen 500 ml 16 gtts/min via sidedrip. With NGT tube inserted at left nostril, drainage bag empty of gastric contents. Medications include: Ampil Salbactam 750 mg q8h qNST Metronidazole 500g q8h IVTT Ranitidine 50 mg q8h IVTT Vitamin K 1 amp IVTT q8h Laboratory results are as follows: Urinalysis: Color: yellow Transparency: Shagy Specific Gravity: 1.015 Glucose: neg Urobilinogen: neg Protein: neg pH: 6.5 Microscopic Examinaton of Urine: Pus cells: 1-3/hpf RBC: 30-40/hpf
Vitamin K 1 amp IVTT q8h Captopril 1 tab SL q8h prn Bp>160 As of 8am, V/S were recorded as: T= 36.8C P= 69 bpm, regular and bounding. R= 19 cpm, effortless and regular Bp=160/90 mmHg As of 12nn, V/S were recorded as: T= 37.2C P= 84 bpm, regular and bounding. R= 18 cpm, effortless and regular Bp=150/80 mmHg
Bacteria: moderate Mucus Thread: neg Urates: few Blood Chemistry Na: 131.9 mmol/L RBS: 99 mg/dL BUN: 43 mg/dL Creatinine: 1.45 mg/dL ABO: AB+ CBC WBC: 10.5 K/uL Hgb: 9.0 Hct: 25.1 Platelet: 398 K/uL Lymphocyte: 15 % Monocyte: 7% Neutropjils: 75% Eosinophils: 2% Basophils: 1% As of 12 noon, V/S were recorded as: T= 37.6C P= 83 bpm, regular and bounding. R=22 cpm, effortless and regular
Fruits/Vegetables Snacks
1 cup Crackers, kamote, saging Claims, dili man ko pilian ug ka-on Verbalized, daghan when asked if he eats vegetables. Claims, panalagsa malipasan pud ko ug kaon labi na kung daghan trabaho No problem in chewing/swallowing. No pain felt in oral cavity. Client usually drinks at 10 oz of water every day. Drinks Sustagen 8 cups per day since he had his check up last January 21, 2012 Does not drink coffee but occasionaly drinks softdrinks. Does not take in vitamins or supplements Has complete set of teeth with 2 tooth extraction. Does not use dentures. No suspicious lesions throughout the body. Verbalized by his daughter in lawkung ma samad siya dali ra man pud mayo, iya ra tambalan ug lana Nail color: nail bed is pinkish, nail plate is transparent, free edge is translucent. Trims nails as necessary. No changes in hair color. Had remarkable drop in weight of 10 kilos since October
Verbalized, kinahanglan para sa akong operasyon when asked if he knows why he is places on NPO Daughter in law claims, na wad-an na ni siya ug gana mukaon sukad atong gasakit ni iyang tiyan ato Oktubre, mas samot na atong sige na siya ug sukasuka Has NGT tube inserted at his left nostril with clear drainage bag, free of gastric contents Complained of pain on his stomach (rated 5 of 10 with 10 as the highest), feels hard and rigid all throughout with light palpation. Verbalized, musakit basta mukaon ko Undergone biopsy and endoscopy as diagnostic tests. Endoscopy findings: Antrum is a huge ulcerating, beeding, infiltrating mass obliterating the pyloric ring Endoscopy Dx: Obstructing gastric malignancy Radiologic Remarks: Ascites Incidental finding of thickened stomach wall Bilateral pelvoliectasia Daughter in law verbalized, bantog rang sige siya ug suka-suka ug pangdug-ab, gatapok ra diay sa iyang tiyan ang iyang kinaon kay dili naman kaagi tungod sa nitubong tumor. Daughter in law claimed, katong gi endoscopy siya gi suction na lang pud iyang mga kinaon nga naa ra sa sulod sa tiyan. Claimed to have no weight changes since admission. Client receives Has #2 D5LR infused at 30 gtts/min at left metacarpal vein with #5 Aminogen 500 ml 16 gtts/min via sidedrip.Had taken 6oz of water since admission. Is not experiencing indigestion or vomiting. No suspicious lesions throughout his body.
Elimination Pattern .
Bowel movement is usually once every week. Stool is usually formed and brown reaching to about 1/4 cup. No history of kidney stones and kidney diseases. Urinates about 5 times daily. Claims of urine as yellow and reaching to about glass. No difficulty in bowel movement or in urination. Claimed dili ra man pud ko singtanon Had difficulty in evacuating fecal material since December 2011, but claimed as not painful. Defecated twice since admission. Claimed, mura ra ug tudlo kadako Verbalized, mu-utong man ko pero wala man jud mugawas, when asked if he does valsalva maneuver when defecating. Urinates usually about 8 times per day which he associates with presence of IV fluid. Claims, muras ra man gihapon ang color sa iyang ihi. (Light yellow in color) Voids freely without pain or discomfort. No sign of uneasiness or discomfort towards the environment Cool environment noted No foul odor noted Urinalysis: Color: yellow Transparency: Shagy Specific Gravity: 1.015 Glucose: neg Urobilinogen: neg Protein: neg pH: 6.5 Microscopic Examinaton of Urine: Pus cells: 1-3/hpf RBC: 30-40/hpf Bacteria: moderate Mucus Thread: neg Urates: few Defecated once since yesterday. Claimed, gamai ra kaayo Urinated usually about 4 times since yesterday. Had a catheter inserted at 9 am. Urine is yellowish and clear. Voids freely without pain or discomfort. No sign of uneasiness or discomfort towards the environment Cool environment noted No perspiration. \No foul odor noted
Slurred speech observed, associated with presence of NGT tube Does not wear eyeglasses/hearing aids. Responsive to clients questions. Answers with objectivity No problem in vision, hearing, smell, taste and touch. Verbalized dry mouth due to NPO status. Feels tired but is able to respond to HWs stimulation.
Slurred speech observed, associated with presence of NGT tube Does not wear eyeglasses/hearing aids. Responsive to clients questions. Answers with objectivity No problem in vision, hearing, smell, taste and touch. Verbalized dry mouth due to NPO status.
loss of cognition or memory, no balance or coordination problems, no loss of sensations. Learns things at moderate. Able to be pacified when feels uneasy through diverting his attention from the source of irritability. Feels good to see be able to work and see his grandchildren. The one who makes decision for himself and for his family
Responsive to environment. Able to listen to children when told of what is not to be done.
Feels tired but is able to respond to HWs stimulation. Responsive to environment. Able to listen to children when told of what is not to be done.
Has his own income, uses it to augment the necessities of the household. Language spoken at home: cebuano. Able to follow simple instructions/advices by significant others Claims, wa raman, when asked if he has someone from the family or neighborhood that he has a fight with Has good relationship with family members and neighborhood Lives with the family of his 2nd child (9 members in their household) Senior citizens member Some relatives and friends live near their house. Feels good with this situation. Daughter in law claims, wala man na siyay kaaway. But0an rajud na siya sa amo Considers himself as a little bit of a spoiler to his apos Daughter in law claims, palangga ra man niya tanan iyang mga anak ug apo, pero kung masayop, mangasaba jud siya
Value- Belief
Believes in some superstitions with regards to health because family believes so. Religion is Roman Catholic. Does not have any regular schedule of attending mass Able to do the sign of the cross Considers believing in GOD a helpful tool in coping with problems in life Considers praying as important with his current situation. Does not correlate any previous experiences or hobbies with his current situation. Believes that this admission might cause some changes in his future life (may not be able to go back to work) Does not have any questions or clarification that he wish to be answered Considers praying as important with his current situation. Does not correlate any previous experiences or hobbies with his current situation. Does not have any questions or clarification that he wish to be answered
SUBMITTED TO:
Asst. Prof. LEIZL JOY ESCOBAR
SUBMITTED BY:
RIMEL VON PATULA TARAH STEFI ANNE T. MEJORADA
February 8, 2012