I.

General Data
Name Age Gender Status Date of Birth Nationality Religion Address Occupation Weight Height Admission Date Type of Admission Mode of Admission Hospital # of days in the hospital Discharge Date Informant : : : : : : : : : : : : : : : : : : Mrs. S 38 years old Female Widow 31 March 1975 Filipino Roman Catholic 1656 Kahilom 3 Pandacan, Manila Homemaker 50 kilograms 5 feet 2 inches 09 1330H January 2014 Direct Wheelchair Manila Naval Hospital 6 days 15 1430H January 2014 patient

II. Past and Present Medical History

a. Chief Complaint a. Wound on Left heel b. History of Present Illness a. The condition started 2 months prior to admission. The patient was a typhoon Yolanda victim in Tacloban City. She suffered an injury to her left heel caused by a glass debris. No management was done two days after the injury happened. On the third day, they sought consultation at Ormoc District Hospital and subsequently admitted. She was attended by nurses who only applied a bandage. Four days since admission, a doctor assessed the affected left heel and noticed that the injury was infected with a foul smelling discharge. Wound dressing was done and Cefuroxime was given. Few hours prior to admission, the patient sought consultation at the outpatient department of Manila Naval Hospital with a chief complaint of wound on left heel. She was seen by Dra. Sales, who ordered blood glucose check with a result of 347 mg/dL. She was referred to Col Eclipse who examined the wound and performed a debridement at the ER department. CBC, BT, CT, Chest X-ray AP, and X-ray of the left heel were done. Cloxacillin 500 mg and Mefenamic acid 500 mg were given. She was admitted to Female Medical Ward.

c. Past Medical History The patient has no known allergies. She has a family history of hypertension and diabetes. In year 2002, she complained of vaginal itchiness, where she was diagnosed to have Diabetes Mellitus type 2 and Metformin was prescribed. However, she was non-compliant with her medication and took herbal medicines instead. Last 2007, she was also diagnosed to have Pulmonary Tuberculosis. She stated that she completed the 6 months medication treatment.

III. System Review

13 Areas of Assessment
1. Psychological status Mrs. S. is a 38 year-old widow, who has a 7-year old son. She is a high school graduate. She is a devout Catholic, who believes in faith healing. She doesnt smoke and drink. Since her husband died last 2011, she had been under her parents care. She is the youngest child in their family. She receives financial support from her father and siblings. She is living with her parents and relatives during her stay here in Manila.

2. Mental Status Patient has no problem communicating with others. She is approachable, capable of answering questions, and comprehends instructions. She is oriented to time, place, person, purpose of hospitalization, and physical condition. 3. Environmental Status The patient lives in a house located south of the Pasig River. There is no problem with the water supply. 4. Sensory Status Visual: The patient does not wear any corrective lenses. Her eyes are symmetrical. Pupil dilation is 1-2 mm, responsive to light stimulation. Blurring of vision unremarkable. No palpable mass was noted. Hearing: Ears are symmetrical with same skin colour. Responds to name calling, no sign of deafness. Does not use any corrective devices for hearing. No discharges and lesions noted. Taste: Patient has no problem distinguishing different tastes. There is no difficulty of swallowing. 5. Motor Status The patient narrated that she was unable to move and walk since she had the injury and just used a wheelchair. She gets assistance from her relatives. During hospitalization, she can perform range of motion exercise; but has difficulty moving her left lower extremity because of her left foot injury. She can tolerate sitting position with caution; however, needs assistance during ambulation. 6. Nutritional Status The patient eats at least three times a day. She said that she has no food preference. She eats lots of carbohydrates and meat. She has no known allergies.

During hospitalization, the prescribed diet for her is a diabetic diet high in nutrients, low fat, low sugar, and moderate calories. 7. Elimination Status She noted that she had daily bowel movement with no difficulty. She voids at least 6 times a day. During hospitalization, she also moves her bowel daily and she voids freely at least 5 times a day. 8. Fluid and Electrolyte Status She eats 3 complete meals a day. The patient has no food preference. She drinks at least 1000 to 2000 ml of fluids a day. 9. Circulatory Status The patient was not able to monitor her blood pressure when she was at home. During assessment, her blood pressure is 110/80 mmHg. She has good pulse on her left foot with capillary refill of 3 to 5 seconds when released after pressing nail bed. Pulse rate ranges from 62-81 beats per minute. Pale conjunctiva was noted. 10. Respiratory Status She stated that she experienced common colds and cough which resolved immediately without treatment or medication. During assessment, symmetrical chest expansion was noted. There were no rales or wheezes upon auscultation. Respiratory rate ranges from 17-22 beats per minute. 11. Temperature Status Patient is afebrile after taking her temperature per axilla for 5 minutes ranging from 3636.8 C. 12. Integumentary Status

Good skin turgor except wound at left foot, and fair in color. Hair is black, clean and evenly distributed on the scalp. Dry skin and pallor noted. 13. Comfort And Safety Patient is easily aroused from sleep due to environmental factors and the pain she feels on her left foot. She usually sleeps 2-3 hours within the shift. She uses a wheelchair for transport. Siderails were kept up when asleep.