COMPREHENSIVE HEALTH HISTORY

MEDICAL WARD
I. PRIMARY INFORMATION: A. Patient Profile Name: Age: Gender: Birth Date: Birth Place: Status: Occupation: Religion: Nationality: Educational Level: Home Address: Date of Admission: Time of Admission: Diet: Admitting Physician: Admitting Diagnosis: Source of Information: Patient D 62 y. o. Male October 9, 1949 Lope de Vega, Northern Samar Live-in Laborer/Construction worker/Farmer Roman Catholic Filipino Elementary graduate Brgy. Hibunawan, Lope de Vega, N. Samar December 30, 2011 11:25 AM Low salt and Low fat Dr. Castillo Consider cardiac VS renal pathology Primary: Patient Secondary: Daughter, Patients Chart B. CHIEF COMPLAINT: The patient was admitted due to generalized edema and difficulty of breathing.

MEDICAL HISTORY: Current Medical History The patient was admitted on December 30, 2011 (Friday) in NSPHER @ around 11:20 AM with a chief complaint of generalized edema and difficulty of breathing. According to the patients daughter, he developed generalized edema and DOB a month prior to hospital admission. He was immediately attended by ER nurses and was rendered with the care needed. At 11:25 AM, his admitting physician, Dr. Castillo, initially ordered to admit him to Medical Ward; to secure requests for CBC, blood typing, 12 lead ECG, UA, serum Na+, K+, and creatinine; to obtain V/S q 1h and record; to put on NPO temporarily; to insert FBC; to refer to IMCOD for further evaluation; and to administer the following medications: D5W 1L to infuse at 30 gtts/min; furosemide 20mg IV q 8h & defer for systolic BP
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100 mm Hg; cefuroxime 750mg 1v q 8h ANST; and O2 inhalation at 2-3 LPM for moderate to severe dyspnea. At 1:50 PM, Dr. Castillo ordered additional medications namely: ranitidine 50 mg IV q 8h and isosorbide mononitrate 30 mg tablets OD. On December 31, 2011 @ 9 AM, the physician ordered to continue medication administration; to follow IVF with D5W 1L @ same rate; to change diet to low salt & low fat; to secure 2 U packed RBC for transfusion after proper cross matching and blood typing; and to repeat Hgb & Hct post BT. At 2 PM, doctor ordered to administer furosemide 40mg stat and to please refer to IMCOD. After which, the IMCOD ordered to start dobutamine drip 2 ampule in D5W 500 cc at 25 gtts/min and to regulate present IVF using a microset. On January 1, 2012, the attending physician ordered to follow IVF with Plain NSS 1L @ KVO; to continue giving furosemide; and to limit fluids to 1L/day. On January 2, 2012, the AP ordered to start dopamine drip 2 ampules in D5W 500 cc @ 15 gtts/min; to titrate both dopamine and dobutamine drips by 50 gtts/min in every 30 minutes until systolic BP is 100 mm Hg; and to start furosemide IV once systolic BP is 100 mm Hg. Childhood Illness During the patients childhood, the usual illnesses he encounters are cough, common colds, and fever. He would always treat these diseases with alternative or herbal medicines. Hospitalization This is the second time the patient is hospitalized. About 2 months PTA, the patient started to develop generalized edema associated with DOB and on November 2011 he was admitted for the first time in NSPH and was discharged after 3 days. However, the edema and DOB recurred about 4 days after discharge and for less than a month, the patient is admitted for the second time in NSPH for the same reason. Immunization The patient said that he has not received any immunization. Waray man kami siton sadto kay diri pa man iton uso, as verbalized. Allergies The patient said that as far as he knows, he has no known allergies to any kind of food, drugs, animals, etc. FAMILY HISTORY: The patient has a wife for more than 50 years now but was not married. They have 9 children and he said that he does not know if there are hereditary
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diseases in their blood line. Both of his parents died of abdominal pain according to him. OCCUPATIONAL HISTORY: He worked as a laborer/construction worker in Manila for 20 years. He just retired 3 years ago. He is also a farmer in his hometown in Lope de Vega. RELIGIOUS, SPIRITUAL, CULTURAL HISTORY: The client is a Roman Catholic and mentioned that he seldom goes to church. FUNCTIONAL HEALTH PATTERNS: A. Health Perception-Health Management He verbalizes no pain but complains of body malaise and difficulty of breathing. He was admitted due to generalized edema and DOB last December 30, 2011 and added that this is his second hospitalization. His daughter said that they could hardly comply with medication orders due to lack of financial support. B. Nutritional-Metabolic Prior to admission, the patient has no problem with his appetite in eating. Upon admission, according to the daughter, the patient barely eats. On January 1, 2012, the patients dietary intake is less than his body requirement due to decreased appetite. According to the daughter, prior to admission, the patient can eat 23 cups of rice coupled with a vegetable dish or fish and he drinks 6-8 glasses of water per day. He seldom eats meat because their barangay is far from the town. Upon admission, the ff table shows the patients food and fluid intake for the past 24 hours. Breakfast 2-3 tbsp. rice Fish tinola 1 glass water Lunch 3-4 tbsp. rice Fried fish Chopsuey 1 glass water Dinner 2-3 tbsp. rice Fish, paksiw 1 glass of water

C. Elimination Prior to admission, he defecates 1-2 times a day and usually voids 3-4 times a day. During admission, he has not defecated yet. He has an inserted FBC with urine output upon endorsement (8 AM) of 1000 mL for the past 8 hours. Urine is amber-colored.
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Patients skin color is brown, pale, and edematous with pitting edema 2+ grade 4. D. Activity-Exercise Prior to admission: His daily activities would include doing house chores. On weekends he would go to their farm to do some farm works. During admission: His ROM and ADL are limited. He is dependent in any way. He has dyspnea on exertion and weak-looking. E. Sleep-Rest Prior to admission: He usually sleeps for 8-10 hours daily. He has no problems with sleeping at night. He also takes naps at the middle of the day. During admission: The patients sleep pattern is deprived/disturbed because of the intermittent DOB he is feeling. The hospital environment also adds to his sleep deprivation due to anxiety. F. Cognitive-Perceptual The patient is able to respond and comprehend to questions and information asked. But talking to him is limited for CBR is of a priority nursing care. He is approachable and cooperative during the interview. He showed willingness to learn from the health teachings imparted by giving responses. He is oriented to person, place, and time. He utters words softly but clearly. G. Self-Perception Self-Concept The daughter said that his father is responsible and loving. H. Role Relationship He is living in his daughters house, the interviewee. His daughters house is located near the river (about 20 meters away from the river) in Brgy. Hibunawan, Lope de Vega, N. Samar. I. Sexuality-Reproductive The patient said that he is satisfied with his role as a male. J. Coping-Stress Tolerance Faith through praying to the Almighty Father is his one way of coping to relieve the stress brought by problems. He also comforts himself by sleeping or taking a nap. K. Value-Belief He is a Roman Catholic and he seldom goes to church.
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REVIEW OF SYSTEMS Date of Examination: Time of Examination: Name of Patient: General Appearance: January 2, 2012 8:30 am Patient D The Patient was lying on bed at a moderate high back rest wearing a white printed shirt and black shorts. He appears weak and pale. He is generally edematous and complains dyspnea. He has a Foley bag catheter connected to a urine bag at 1000cc level. With ongoing D5W 1L @ KVO via right cephalic vein at 720cc level, Side Drip- dopamine temporarily closed. Respiration Rate (bpm) Pulse Rate (bpm) Blood Pressure (mmHg) 3-11 11-7

Date Temperature (C) 7-3 Dec. 30 Dec. 31 Jan. 1 Jan. 2 Jan. 3 Jan. 4 Jan. 5 Jan. 6 37.2 37 36.9 37 36.8 36.8 36 36.4

3-11 11-7 7-3 36.4 36.4 28 36.9 37.6 37 37 25 30 28

3-11 11-7 7-3 24 28 29 21 21 28 28 23 18 20 19 98

3-11 11-7 7-3 92 106 109 89 98 83 -

110/80 120/80 120/80 80/60 120/80 90/70 130/80 90/70

110 98 105 104 100 93 77 72 81 97 -

100/80 90/70 90/70 90/60 90/60 90/70

36.6 36.8 22 37.2 36.8 20 36.8 20 24

110/70 110/70 100/70 100/80 90/60 100/80 90/70 -

INTEGUMENTARY:
SKIN: Color: Brown complexion Texture: Smooth Warm to touch Turgor: poor due to edema Pitting edema, 2+ , grade 4 Scars in the lower extremities noted

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HAIR: Black and gray hairs Evenly distributed on scalp Thin and short Dry Silky and resilient No infestation of lice

NAILS: Long & untrimmed nails (dirty) Angle of nail plate above 160, no clubbing is noted Nail bed: pale Convex curvature Epidermis surrounding the nails of both extremities are intact Capillary refill: 2 seconds

HEENT:
HEAD: Skull: rounded with prominent frontal area Circumference: 52 cm Absence of nodules, masses, and depressions Face symmetric at rest and with movement Scalp: lighter in color than complexion; no scars and dandruff noted EYES: Eyebrows: symmetrical and in line with each other. Non-protruding, equal palpable fissure. Eyelashes: thin; evenly distributed Conjunctiva: pale; no foreign objects Sclera: white Pupils are equally round and reactive to light and accommodation (PERRLA) Pupils are black and mid-positioned, 4 mm in diameter Pupils constrict when looking at near objects and when illuminated EARS: Color the same as facial skin Auricle aligned with outer canthus of eye Pinna recoils when folded Canals with small amount of cerumen No discharges and lesions
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NOSE and SINUSES: Nasal septum intact No discharges and lesions Moist nasal mucosa MOUTH: Pale and dry lips; symmetrical Moist gums; no bleeding Tongue is in central position; pinkish with white taste buds on the surface; no lesions Uvula is positioned mid-line Presence of gag reflex Complete permanent teeth; yellow in color NECK and LYMPH NODES: No stiffness Neck muscle bilaterally symmetric Visible and prominent carotid pulse Neck circumference: 31 cm No masses or swelling BREAST and AXILLA: Equal in both sides Areola is brown and dark brown No masses, tenderness, or nodules

RESPIRATORY:
THORAX and LUNGS: RR= 14 bpm; deep breathing No adventitious breath sounds heard upon auscultation No tenderness or masses on chest wall Chest circumference: 88 cm

CARDIOVASCULAR:
HR= 80 BPM Capillary refill: 2 sec to return BP= 90/70 mmHg Peripheral vascular pulse: 1+ Pulse rate= 104bpm

GASTROINTESTINAL:
Abdominal girth: 83 cm
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 No abdominal distention Bowel sound: normoactive Stool: color is brown; hard

GENITO-URINARY:
Urine color: amber ; clear Urine output (for 8 hours): 1000 mL

MUSCULO-SKELETAL:
Height= 51 Edematous extremities Limited ROM Elbow can flexed and extend

NEUROLOGICAL ASSESSMENT:
LANGUAGE: Voice is soft and clear Able to name person, object, places and time Able to respond to verbal command ORIENTATION: Oriented to person, time, and place GLASGOW COMA SCALE: Eyes open Verbal Motor TOTAL CRANIAL NERVES: Cranial Nerves I II III IV V Names Olfactory Optic Oculomotor Trochlear Trigeminal: Ophthalmic Findings Identified scent (body spray) correctly with each nostril. Can read newsprint even 1 foot away. Pupils constrict when looking at near objects & dilates when looking at far objects Both eyes are coordinated while assessing the six ocular movement Blinks when the sclera is touched with
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Spontaneously = 4 Oriented =5 Obeys command = 6 15

Implications Normal Normal Normal Normal Normal

Branch

a wisp of cotton

VI VII

VIII

Maxillary Branch Can feel light touch to ear & reacts to blunt objects Mandibular Able to clench teeth Branch Abducens Can move eyes laterally Facial Can smile & raise eyebrows -frowned, -blown out cheeks -closed eyes tightly as instructed, -facial movements are symmetrical Acoustic: Vestibular Able to stand with assistance Branch Cochlear Branch Able to hear normal voice tone Glossopharyngeal Can move tongue from side to side, up & down Presence of gag reflex Vagus Presence of gag reflex Able to talk without any pain felt on the muscle used Spinal Accessory Symmetrical, strong contraction of trapezius muscles Hypoglossal Able to protrude tongue on the midline Symmetrical tongue with smooth outward movement and bilateral strength

Normal Normal

Normal

IX X XI XII

Normal Normal Normal Normal

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