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PATIENTS DATA MR.

Potenciano Munoz a 76 years old male he grew up in Tayog Pangasinan but now he is currently residing at Malibay, Pasay City. He was born on December 31 1935 he was married and they had 4 children. He lives with his child and grandchildren. He is the oldest child in two siblings of Mr. Bernando Munoz and Juanita Gulla. The chief complain of the patient before the admission is unproductive cough and easy fatigability. He went to the emergency room and all laboratories that needed done to him and he is diagnosed with CAP-MR.

II.MEDICAL HISTORY A. History of Present illness

5 Days prior to admission, the client experience unproductive cough and easy fatigability. In the next few days the client experience same symptoms the client has no consultation and didnt take any drug. Few hours prior to admission the patient still experience the symptoms but he also experience difficulty of breathing. His child decided to take him to Pasay General hospital after assessment in the Emergency room the patient admitted.

B. Past Medical History

The patient has no hospitalization in the past six months, he has no accidents

C. Family Medical History

The family of the patient has a history of hypertension, goiter, asthma and Diabetes Mellitus.

D. Social History / Personal

The client has no known allergy. He drinks alcohol occasionally. Prior to admission the client uses cigarette he consumes a pack of cigarette per day. Every Sunday and Thursday he went to the cockpit arena and spends the whole day there watching a cock fight.

Gordon 11 Typology Health Patterns Health Perception and Health Management The family prefers to have medical check- up and consultation at the health center or hospital nearby. They didnt use any herbal plants for alternative medications. The place where they live is congested and the patient is exposed to cigarette smoke. Their house has only one door and three windows. There are presence of rodents and vectors. The size of the house is appropriate for the size of their family. Nutrition and Metabolism The patient eats 3 times a day. The patient usually eats meat, vegetables, fish, and meat.He can consume 1-2 cups of rice during meal time. The patient usually consumes 7-8 glass of water a day. Elimination Prior to hospitalization, The client use to urinate 6 times a day and he had a bowel movement every day. Activity and Exercise The client walks every morning for his exercise. His activity is to go and spend his leisure time in the cockpit arena. He spend most of the time to his cocks. Cognitive and Perception As its age he perceived his self as he are. He loves hes doing specially when he goes to the cockpit arena.

Sleep and Rest The client usually sleeps for 7-8 hours and takes a nap for 3 hours. Self-Perception and Self-Concept He described herself as a jolly type of person he just want to spend his time in his cocks and sometime he also spend his time to his grandchildren Role/Relationship He lives with his child and his grandchildren. He is a retired government employee. Coping and Stress Tolerance Her way of coping for stress is through divertional activities such going to a cockfight with her friends.

Values and Beliefs Every Sunday, her entire family goes to church. They are Roman Catholic in religion. They have a strong faith that the Almighty has His own will for them.

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