SKIN, HAIR AND NAILS February 27, 2010: First Assessment Skin was pale, dry, and warm

to touch. No sign of edema, lesions or dehydration noted. Hair was black and equally distributed with fine textures. Fingernails

S k i n w a s p a l e , d r y , w a r m t o t o u c h . No signs of edema, lesions or dehydration noted. Hair was black a n d e q u a l l y d i s t r i b u t e d w i t h f i n e texture.Fingernails and toenails were pale in color and cool to touch. Nolesions or abnormalities noted except for the right big toenail that wascolored black due to trauma

Chief Complaints: Abdominal Pain Current Health History: For the p ast year , the patient had bee n e xperien cing abdo minalpain, feeling of weakne ss, tarr y st ool and vo mi ting tha t hindere d hi mf r o m d o i n g h i s d a i l y a c t i v i t i e s . B e c a u s e p a i n w a s b e c o m i n g m o r e intense, patient decided to seek medical advice at EVRMC. After which,patient wa s given medication for his co mplaint, b ut still the patientsc o n d i t i o n d i d n o t i m p r o v e d . D u e t o f i n a n c i a l d i f f i c u l t y , Mr. Gonatoendured the illness that he was experiencing until t h e t i m e t h a t h e could no longer bear the pain.On February 22 , 20 10, p atient was transferred by t he Kana nga Municipal Health Center to ODH for further evaluation in considerationof the symp to ms tha t the patient manifested. It was decided up on b yDr. Ag udo b ased on t he physical e xa mination that the patient was tobe admitted and to be closely monitored. PAST MEDICAL HISTORY: Patient claimed that he experienced common childhood diseasesand minor illnesses, su ch a s co mmo n cold, chicken po x, mu mp s and m e a s l e s . H o w e v e r , p a t i e n t a l s o m e n t i o n e d t h a t i n y e a r 2 0 0 0 h e acquired PT B an d und er went treat me nt f or si x mo nth s and was cured without being hospitalized.F r o m t h e n o n , w h e n e v e r h e c o m p l a i n e d o f c o u g h i n g h e w o u l d immediately submit a sample of his sputum to be examined, and so farthe results were negative. Patient does not recall of having any historyof allergies. FAMILY HISTORY: Both of his paren ts p assed a way due t o old age. The pa tient isf i f t h among the nine si bli ngs of whi ch four are femal es and fi ve a r e males. T wo of his siblings died on e beca use of h yperte nsion an d theother one was murdered.His wife aban doned hi m leaving their si x kids behind. Currently,the patient lives with his new partner who has one kid.E x c e p t f o r h i m s e l f , h e c l a i m e d t h a t h i s f a m i l y m e m b e r s a r e healthy. It had the same color with the skin of the face, no tenderness orl e s i o n s n o t e d i n t h e e x t e r n a l n o s e . A i r m o v e s f r e e l y a s t h e c l i e n t breathe s. Th e i nternal nasal cavi ty was norm al , the mucosa was pi nk,a n d h a s c l e a r , w a t e r y di scharge. The sinuses were pal pated and noevi dence of swelling or lumps noted, and no pain felt by the p a t i e n t either. HEALTH PERCEPTION & HEALTH MANAGEMENT: As stated by the client, he perceived himself not so he a l t h y individual for he had a history of PTB and currently suffering from PUD.Right

now his normal activities are affected due to his present illness.Every ti me the patient ha s a health pr oble m, he woul d usuallyself me dicate wi th o ver th e counter drug s su ch a s bioge sic for fever,kre mil S for his a bdo mi nal pain. And if the sympt o ms p ersist then hes e e k s m e d i c a l a s s i s t a n c e a t t h e b a r a n g a y h e a l t h c e n t e r i n t h e i r municipality. He considers his work as a farmer as his daily exercise. The patient used to drink beer or sioktong but only on occasionalb a s i s . H e a l s o s m o k e d b u t w a s m o t i v a t e d t o s t o p d u e t o h e a l t h reasons. NUTRITION & METABOLISM PATTERN:Before Hospitalization: 24-hour dietary intake review (her usual daily menu) B r e a k f a s t : 1 / 2 c u p o f r i c e , c u p v e g e t a b l e s S n a c k s : 1 p c . S a g i n g , 1 p c . c a m o t e L u n c h : 1 / 2 c u p o f r i c e , c u p v e g e t a b l e s D i n n e r : 1 / 2 c u p o f r i c e , c u p v e g e t a b l e s The patient normal l y ate hi s meal bef o r e h o s p i t a l i z a t i o n a t 8 a m - 1pm-7pm. Due to the far distance between the farm and his home, thepatient would rather skip meals and finish his work. He didnt take anyv i t a m i n s u p p l e m e n t s . H e o c c a s i o n a l l y d r a n k b e e r a n d a l c o h o l i c beverages. The patient took 6 to 8 glasses of water daily. During Hospitalization: 24-hour dietary intake review (her usual daily menu) B r e a k f a s t : 2 c u p o f r i c e p o r r i d g e L u n c h : 2 c u p o f r i c e p o r r i d g e D i n n e r : 2 c u p o f r i c e p o r r i d g e The patient was advised by the doctor to have a soft diet meal. Thepatient ate his me al at 7a m-11a m-6 p m. He wa s given ferrou s sulfateand multivitamins to supplement his dietary intake. The patient took 6to 8 glasses of water daily. After Hospitalization:

24-hour dietary intake review (her usual daily menu) B r e a k f a s t : 1 c u p o f r i c e , 1 c u p v e g e t a b l e s S n a c k s : B i s c u i t s a n d 1 c u p o f M i l o L u n c h : 1 c u p o f r i c e , 1 p c o f f i s h S n a c k s : B i s c u i t s a n d 1 c u p o f M i l o D i n n e r : 1 c u p o f r i c e , 1 c u p v e g e t a b l e s The pat ient nor mally eat s her me als 8a m12nn-7p m. He takeshis multivita mi ns a nd ferrou s sul fate d aily. Pa tient no w ea ts anythingh e w a n t s . H i s a p p e t i t e i m p r o v e d s i n c e h e l e f t t h e h o s p i t a l . T h i s indicates that his recover y is doing well. He is drinks 6 to 8 glasse s of water everyday.

BLADDER ELIMINATION PATTERN:Before Hospitalization: T h e p a t i e n t h a d n o r m a l b l a d d e r e l i m i n a t i o n b e f o r e hospitalization. He voided three to four times a day. The amount of hisd a i l y v o i d i n g w a s a p p r o x i m a t e l y t h r e e t o four glasses of urine withy e l l o w c l e a r c o l o r . A c c o r d i n g t o p a t i e n t , h e e x p e r i e n c e d n o p a i n everytime he urinated. During Hospitalization: T h e r e w a s n o c h a n g e w i t h r e g a r d s t o h i s b l a d d e r e l i m i n a t i o n pa ttern. After Hospitalization: Bladder elimination pattern still appeared normal. BOWEL ELIMINATION PATTERN:Before Hospitalization: The patient had a regular bowel elimination twice daily. The coloro f h i s s t o o l w a s t a r r y b l a c k w i t h a n o r m a l c o n s i s t e n c y a s a manifestation of GI bleeding. During Hospitalization: He only had o ne bo wel eli mination dur ing his four d ays sta y int h e hospital. The color of his stool was still tarry black with n o r m a l consistency. After Hospitalization:

He had a re gular bo wel eli mination on ce daily but still the stool was color tarry black and with nor mal con sisten cy as a manife stationof GI bleeding and the effect of taking Ferrous Sulfate supplement.

SLEEP-REST PATTERN:Before Hospitalization: The patient usually sleeps only two hours every night b e f o r e hospitalization and didnt take nap during the day. This w a s d u e t o abdominal pain. During Hospitalization: His sleeping pattern increased from two hours to fours hours buts t i l l h e d i d n t t a k e n a p d u e t o h e a t a n d d i s c o m f o r t s i n t h e i r environment. He was still experiencing pain but it was relieved due tothe medication given to him. After Hospitalization: The patients health condition has improved, which led t o a nor mal sl eeping pattern o f 6 t o 8 h o u r s e v e r y n i g h t . H e n o w t a k e s occasional naps in the afternoon. ACTIVITY & EXERCISE PATTERN:Activity of Daily Living: Before Hospitalization: P a t i e n t w a s r e s t r i c t e d o f d o i n g h i s normal daily activities due to increasing pain. During Hospitalization: Patient was confined in the hospital forrecovery thus his daily activities were altered. After Hospitalization: He was still recovering fro m his illnessand confined himself to bed most of the time. Exercise Routine: The patient didnt have any exercise routine. Occupational Activities: T h e p a t i e n t s a c t i v i t i e s f o c u s o n f a r m i n g only. COGNITION & PERCEPTION PATTERN:A b i l i t y t o U n d e r s t a n d : T h e p a t i e n t c o u l d u n d e r s t a n d a n d express his feelings well. He couldnt read and write well due to lack of e d u c a t i o n . H e o n l y f i n i s h e d g r a d e f o u r . H i s b e s t w a y t o l e a r n som ething new was by listening to a radio. Ability to Communicate: T h e p a t i e n t c o u l d i n t e r p r e t h i s physical condition with regards to his illness and doesnt have difficultyexpressing himself to his family and others. Ability to Remember:

H e

c o u l d r e c a l l important events of her life. Ability to Make Decisions: T h e p a t i e n t i n f o r m e d t h a t i n maki ng ma jor deci si ons, the w hole fami ly di scussed and together

i n f o r m e d

t h a t

h e

decides. Patient did not have difficulty in decision making regarding hisconfinement. SELF-PERCEPTION & SELF CONCEPT PATTERN: The patient describes himself as a happy person. His family givesh i m s t r e n g t h . H i s f a m i l y f e e l s s a d d e n e d w i t h h i s i l l n e s s b u t t h e y learned to accept it.He is satisfied with his physical appearan ce an d feels sad dened with other people who had disabilities and illness. ROLES & RELATIONSHIP PATTERN: As the head of the family, his major responsibility was to providefinancial support to his fa mily. His f a mily is the mo st i mpor tant in hislife.His neighborhood is peaceful and good community and they livedthere a long time already. He didnt participate in any social groups orneighborhood activities. COPING & STRESS TOLERANCE PATTERN: Hi s present conditi on i s hi s most stressful si tuation i n hi s l i f e because it affects them financially and emotionally. The major change in his life is being incapable of earning moneyto sustain his family needs. His family supports him to cope up with hispresent condition. The patient is not so religious, but he often prays toGod for guidance and blessings. His family serves as his motivation inlife. SEXUALITY & REPRODUCTION PATTERN: The patien t used co ndo ms wh en he was yo unger. Sinc e he wasliving with her 5 0 ye ar old live in part ner, h e was not using condo msanymore.His level of sexual satisfaction now is 6 out of 10, as 10 being thehighest level of satisfaction. T h e p a t i e n t d i d n t f e e l a n y p a i n e v e r y t i m e h e h a s a s e x u a l contact with his partner, but he experienced shortness of breath.He informed that he is having a hard time achieving orgasm duet o d e l a y e d e r e c t i o n . T h e p a t i e n t n e v e r e x p e r i e n c e d a n y s e x u a l l y transmitted disease. VALUES & BELIEF PATTERN: The most i mportan t for hi m is to have a good life toget her with his fa mily and be able to provide their need s. He also believed in G odand prays for good health, guidance and blessings.His major source of hope and strength in life is God and God.

GENERAL APPEARANCE February 27, 2010: First Assessment The pati ent is 67 years ol d, mal e wi th fai r complexi on, w i t h a height of 56 ft. and weighs 45.4 kilos.He looked f rai l and pal e, sl ouchi ng postu re, sl ow gai t and w eakm o t o r a c t i v i t y . H e w a s n o t w e l l - g r o o m e d a n d l a c k p e r s o n a l h y g i e n e with slight odor of the body and breath.T h e p a t i e n t h a d a p l e a s a n t f a c i a l e x p r e s s i o n a n d m a n n e r . H e welcomed our intrusion very well and answered our questions withoutany appreh ensi ons. Despi te the pati ents adv ance age , he coul d sti ll c o n v e r s e a n d l i s t e n w e l l , h a d g o o d c o m p r e h e n s i o n a n d l e v e l o f consciousness. March 07, 2010: Second Assessment The patient now weighs 46.4 kilos, height was still the same. Hiscondition had improved since our last visit. He was now well-groomed,n o t s o m u c h pallor and frail anymore, although still with s l o u c h i n g posture due to old age, but his skin color returned to normal. VITAL SIGNS February 27, 2010: First Assessment T e m p e r a t u r e 3 6 . 9 C a x i l l a r y H e a r t R a t e 7 6 b p m R e s p i r a t o r y R a t e - 2 0 c p m B l o o d P r e s s u r e 1 2 0 / 6 0 m m H g t a k e n a t R a r m March 07, 2010: Second Assessment T e m p e r a t u r e 3 6 . 4 C a x i l l a r y

H e a r t R a t e 6 3 b p m R e s p i r a t o r y R a t e - 1 6 c p m B l o o d P r e s s u r e 1 3 0 / 7 0 m m H g t a k e n a t R a r m MENTAL STATUS February 27, 2010: First Assessment Pati ent was con sci ou s and al ert t o al l questi ons bei ng aske d. Hecoul d an swe r promptl y, but n ot abl e to expand hi s an swe rs. He wasoriented to time, place, person and present situation. He was also ablet o r e c a l l b o t h l o n g t e r m a n d s h o r t t e r m m e m o r i e s .

The Di git Spancognitive function was tested on the p a t i e n t , a n d r e s u l t e d t o a v e r y poor performance. March 07, 2010: Second Assessment No changes in the patients assessment as of this date. SKIN, HAIR AND NAILS February 27, 2010: First Assessment Ski n was pale, dry, wrinkled, cool to touch and rough d u e t o aging. No signs of edema, lesions or dehydration noted.H a i r w a s g r e y d u e t o a g i n g a n d e q u a l l y d i s t r i b u t e d w i t h f i n e texture.Fingernails and toenails were pale in color and cool to touch. Nolesions or abnormalities noted except for the right big toenail that wascolored black due to trauma. March 07, 2010: Second Assessment No changes in the patients assessment as of this date. HEAD AND SKULL February 27, 2010: First Assessment Hair was all grey, equally distributed and with fine texture.Scal p was smooth an d a l i ttl e bi t oil y. Hi s scal p appeared cl eanand no lumps or lesions noted. Skull size and contour was normal with no lumps or lesions.Face was wri nkl ed, squ are and semi -symme tri cal i n shape. Hehad a flat facial expression because of depression related to his illness.A l arge vei n prot rude d i n the l eft frontal re gi on of hi s face , ando c c a s i o n a l l y g a v e h i m p a i n t h a t r a d i a t e s b e h i n d h i s l e f t e a r , b u t according to him the pain was tolerable.He was asked t o el evate an d l owe r hi s eye brow s, cl ose hi s eyest i g h t l y , puff his cheeks, smile and show his teeth. Impressively hem a d e t h e s e p r o c e d u r e s w i t h e a s e , d e s p i t e h i s a d v a n c i n g a g e . Symmetric facial movements were also noted. March 07, 2010: Second Assessment No changes in the patients assessment as of this date. OBSERVE HEAD MOVEMENT February 27, 2010: First Assessment The clients head movements were still functioning well. He couldmove his chin to his chest, his chin can points upward, move his headt o w a r d s h i s shoul ders and turned hi s head l eft and ri ght with l e s s effort. March 07, 2010: Second Assessment No changes in the patients assessment as of this date. EYES February 27, 2010: First Assessment The pati ents eyes we re posi ti oned and al i gned symmetri cal l y.E y e b r o w s w e r e g r e y i n c o l o r a n d t h

i n , s y m m e t r i c a l a n d e v e n l y distributed.E y e l a s h e s w e r e s h o r t a n d s t r a i g h t . N o l e s i o n s , s w e l l i n g a n d secre ti ons note d on both eyel i ds, i nner and oute r cantu s. Note d al sowas the pale color of the eyelids, due to GI bleeding. No edema on thel acri mal gl ands al so. Both eyes coul d mov e i n coordi nati on, wi th theouter cantus parallel with the pinna of the ears.T h e p e r i p h e r a l a n d v i s u a l f i e l d t e s t s w e r e a s s e s s e d t o t h e patient, and diminished eye movements and reflexes were noted. Six cardi nal fi eld of gaze was assessed to the patient, a n d h e was asked t o pe rf ormed fu ncti onal vi si on test, l i ght percepti on, handm o v e m e n t s a n d c o u n t i n g f i n g e r s , b u t w i t h o u t s u c c e s s d u e t o t h e patients diminished eye motor reflexes and vision.The pupi l reacti on to l i ght test we re made t o the pati ents, andthe result was both eyes dilated at 3mm diameter.T h e p a t i e n t s p u p i l s w e r e c o l o r g r a y , p o s s i b l y d u e t o c a t a r a c t . The si ze and sh ape were symmet ri cal . The scl era w as col or whi te andno lesions noted.T h e p a t i e n t i n f o r m e d u s t h a t h e h a d a p r o b l e m with his visuala c u i t y . H e w a s n e a r s i g h t e d a n d c a n n o t c l e a r l y s e e f a r o b j e c t s . Understandably this was due to his old age. March 07, 2010: Second Assessment No changes in the patients assessment as of this date,except for hi s eyeli ds whi ch were not so pall or a n y m o r e , d u e t o t h e improvement of his health condition. EARS AND HEARING February 27, 2010: First Assessment Ears were equal in si ze. Col or was the same with that of t h e ski n. No l esi ons, abnorm al i ti es, swel l i ng or tende rne ss w ere found i nthe auricles and earlobes. Tympanic membrane was pearly gray color.Cerumen was visible in the ear canal of both ears.A u d i t o r y a c u i t y t o w h i s p e r e d o r s p o k e n v o i c e w a s a s s e s s e d t o the pati ent, i ncl udi ng watch ti ck test . The resu l t was pati ents heari ngability was slightly diminished. March 07, 2010: Second Assessment No changes in the patients assessment as of this date. NOSE AND SINUSES February 27, 2010: First Assessment Nose w as sl i ghtl y poi nted and sym metri cal . Nasal septum wasn ormal and wi th no si gns of fl ari ng, l esi ons and swel li ng. He was abl eto smell well.

It had the same color with the skin of the face, no tenderness orl e s i o n s n o t e d i n t h e e x t e r n a l n o s e . A i r m o v e s f r e e l y a s t h e c l i e n t breathe s. Th e i nternal nasal cavi ty was norm al , the mucosa was pi nk,a n d h a s c l e a r , w a t e r y di scharge. The sinuses were pal pated and noevi dence of swelling or lumps noted, and no pain felt by the p a t i e n t either. March 07, 2010: Second Assessment No changes in the patients assessment as of this date. MOUTH AND OROPHARYNX February 27, 2010: First Assessment Lips were dry and slightly pale. Both upper and lower teeth wereyellowish and several cavities noted. Hard and soft palates were intact.The gums were slightly dark in color, moist and firm.T h e t o n g u e w a s p a l e i n c o l o r , m o i s t , s l i g h t l y r o u g h , t h i c k a n d had whi ti sh coati ng, and h ad l ateral margi ns and n o l esi ons not ed. Itwas located at the center of the mouth, and was freely movable.Tongue re si stant test was perf ormed by the pati ent and prov ennormal in functioning.I n s p e c t i o n o f t h e o r o p h a r y n x a n d t o n s i l s w e r e m a d e a n d g a g reflex was tested and assessed as functioning well. March 07, 2010: Second Assessment No changes in the patients assessment as of this date. NECK February 27, 2010: First Assessment The muscl es i n the neck we re equ al i n si ze, head was cente red,a n d h a d c o o r d i n a t e d s m o o t h m o v e m e n t s w i t h n o d i s c o m f o r t s f e l t . Head fl exes at 45, hy pe rexten ds at 6 0, head l ateral l y fl exes at 40and head laterally rotates at least 70. Carotid artery was palpable, aswell as the lymph nodes in the left supraclavicular region.The trache a was i n normal pl acement i n the mi dli ne of the neckand spaces were equal on both sides. The thyroid gland was not visibleon inspection. The gland ascends normally during swallowing.

March 07, 2010: Second Assessment Sti ll the same asse ssment on ou r second vi si t, except that thelymph nodes in the left supraclavicular region cannot be felt anymore.It was an indication that the patients condition was improving.C a r o t i d a r t e r y w a s s t i l l p a l p a b l e , a f i n d i n g t h a t n e e d s f u r t h e r assessment, could be a manifestation of a cardiovascular disease. THORAX AND LUNGS February 27, 2010: First Assessment

P a t i e n t h a s a p i g e o n c h e s t , a d e f o r m i t y o f t h e c h e s t characte ri zed by a prot rusi on of thesternumandribs. T h e c h e s t w a s not so symmetrical.T h e s p i n e w a s v e r t i c a l l y a l i g n e d . S p i n a l c o l u m n was strai ght,ri ght and left shoul ders and hi ps are at s a m e h e i g h t . T h e s k i n a n d chest wall are intact, with no tenderness and masses noticed.T a c t i l e f r e m i t u s w a s p e r f o r m e d , f u l l a n d s y m m e t r i c c h e s t expansion was observed.Auscultation of the chest posterior and anterior was done and letthe pati ent say 99 an d say E . It was n ote d that th e sou nd was notc l e a r l y h e a r d . T h e p a t i e n t h a s a s l i g h t m u r m u r , s l i g h t l y f a s t respirations and not so fully symmetrical excursion in his chest. March 07, 2010: Second Assessment No changes in the patients assessment as of this date. PERIPHERAL VASCULAR SYSTEM February 27, 2010: First Assessment Arms and legs were symmetrical, has intact skin, with no edemaor tende rness not ed. Extremi ti es were pal e due t o hi s ill ness and al socold to touch.The pati ents arms and l egs we re sti ll functi oni ng wel l . He evenshowe d us a mi nute of vi gorou s mov ements wi th hi s arm s and l egs,but afterwards, signs of weariness and weakness took over.Buergers test was done but the skin color of the patient did notchange , i t was sti ll pal e. Capi ll ary refi ll test was al so done but sti ll nochanges in skin color.

March 07, 2010: Second Assessment No changes in the patients assessment as of this date. MOTOR FUNCTION February 27, 2010: First Assessment The following Motor Function Tests were performed b y t h e patient: Walking gaitP a t i e n t h a d p o o r p o s t u r e a n d u n s t e a d y i r r e g u l a r staggering gait with wide stance and walks with arm movements Rom berg Tes t The patient showed loss of balance when eyesw e r e c l o s e d , s u g g e s t i n g p o o r p o s i t i o n s e n

a sensory ataxia, that couldnt maintain balance with the eyes shut. Standing on one foot He had mild swaying with this test. Heel t o toe w alkin g Patient could not maintain balance on toesand heels Alternating supination and pronation He performed withs l o w , c l u m s y m o v e m e n t s a n d i r regular timing, had difficultya l t e r n a t i n g f r o m s u p i n a t i o n a n d p r o n a t i o n , i n c o o r d i n a t e d movements and poor position sense Finger to nose test H e m i s s e d t h e n o s e a n d g a v e s l o w respon se. Finger t o fin ger Pati ent move d sl owl y and w as unabl e to tou chfingers consistently. Finger to thumb He couldnt coordinate well and loss focus Heel down, opposite chin He coul dn t pe rf orm , su ggest poorposition sense Light touch sensation He couldnt distinguish the place touched Palm sensation Patient couldnt identify well the letter drawn onthe patients palm with blunt end of a pen. Temperature sensation We did not able to performed Tactile discrimination The client showed diminish sensation ReflexesCorneal Both of patients eyelids fail to respond

se.

He

may

have

Babinski Unresponsive and loss of sensation March 07, 2010: Second Assessment No changes in the patients assessment as of this date.