Past Medical History Had usual childhood illnesses such as measles, mumps, fever, cough and colds.

Has a complete immunization. No known allergy to foods and drugs 1999 The atient was admitted for ! days at "t. #uke$s Hospital due to chest pain. History of Present illness ! years prior to admission %&'11 unrecalled date( the patient first e)perienced non radiating a*dominal pain with a scale of +,1', the patient ver*alized that -kaya ko pang tiisin ang sakit nuon, akala ko #./ lang kaya nagtake ako ng 0iata*s, ayun natatanggal naman yung sakin kaya akala ko normal lang1. "ince then the patient also e)perienced easy fatiga*ility whenever having a 2og, doing se)ual intercourse lifting heavy o*2ects and cleaning his 2eepney. The pain then recurred after ! months since the first recurrence of the non3radiating a*dominal pain. The patient then again e)perienced a non3radiating a*dominal pain with a pain scale of 4,1' thus again self3medicated with 0iata*s and 5akult, the pain su*sided after he took 0iata*s and 5akult thus thought that it was 2ust normal. This non3radiating a*dominal pain was recurring every after !36 months after the first and second recurrence of the pain, he then self3medicate again with 0iata*s and 5akult until last 7an 14, &'16. The patient had constipation on the first week of 7anuary -hindi ako nakatae ng isang lingo pero hindi ko na pinansin dahil nakatae din naman na ako1as ver*alized *y the patient. The patient noticed he discoloration of his eyes on the first week of 7anuary, -nanilaw yung mata ko nung mga 8irst week ng 7anuary pero hindi ko lang pinansin1. #ast 7anuary 14, &'16, the patient was renewing his N.9 clearance in #aguna, around 931' am, after renewing his clearance the patient e)perienced an a*dominal pain radiating to the *ack with a pain scale of 1',1', the patient then sat at his 7eepney while waiting for the pain to su*side, -mga !' mins muna *ago ako nakapag3drive ulit pauwi eh1as ver*alized *y the patient, then the pain recurred and he went to Holy 8amily #aguna hospital, he was then given .uscopan. He was discharged last 7anuary 19, &'16. The patient then stayed at home *ut was asked to have a :T scan. #ast 7anuary &&, &'16 the patient had e)perienced discoloration of his skin, starting from his head up to his feet. #ast 7anuary !', &'16 the patient undergone :T scan at :alam*a /edical :enter with an impression of Hepatic Hilar region mass with associated *iliary o*struction. :onsider neoplastic %klatskin tumor, hepatocellular :;( vs. inflammatory origin. #ast 8e*ruary 14, &'16 the patient was admitted at "t. #uke$s <3road hospital due to a*dominal pain with a pain scale of 1',1' and a complaint of anore)ia -hindi na ako makakain dahil sa sakit ng tyan ko1as ver*alized *y the patient, his 0r. advise him to have an operation, the

patient agreed. He was advised *y his 0r. to transfer at 8<=3N>/8 last 8e*ruary 19, &'16 *ecause the ?> at "t. #uke$s was under maintenance. The patient was admitted at 8<=3N>/8 last 8e*ruary 19, &'16 at !@!&pm with an admitting diagnosis of Alatskin Tumor and a chief complaint of 7aundice. Diagnosis: ;N:><;T9: :;>:9N?/; Personal Data: The patient has *een married since 19BC, with ! children 1 girl, & *oys. He is currently living with his wife and his youngest son. He drinks 1 cup of coffee %&'' ml( every morning. The patient eats +),day, he eats ork ;do*o !),day at their canteen, eats 131 D rice each mealE he drinks 1 litre of water every day. He is currently living in a well3lit, well3ventilated *ungalow house. 0rinking water is distilled and gar*age is separated and collected two times a week. Socio-Economic Status The patient *elongs to a middle class family. The primary source of income is his work as a driver of a =7 since 1999E he drives from Bam39pm every day with a day3off of his choice.

#esionsF all d,t scratching *c itching of his pruritus

Physical Assessment (February 2 ! 2 "#$ Actual %ital Signs >> &' > BC . 3 11',4' &ormal %alues 1&3&' *eats,min. C'31'' *eats,min. 9',C'3 1!',9' mmHg 'nter(retation Normal Normal 3333

Height F +$91 )eight* +, )eight last December 2 "-* ./

0ody Part 4eneral

1echni2ue 3sed 9nspection

&ormal Findings :ooperative, a*le to follow instructions

Actual Findings ;sleep most of the time *ut arousa*le when taking vital signs and giving medications

'nter(retation

%Guantity and Huality of speech( %>elevance and organization of thoughts(

=nderstanda*le , moderate pace #ogical seHuence, moderate paceE clear inflectionE e)hi*its thought association Normocephalic No a*normal mass <venly distri*uted, Thick hair, No infection and infestation "ymmetric to the face, *oth eyes coordinated with parallel alignment.

Head

9nspection alpation

Normocephalic 5aundice No a*normal mass *ald

Hair and Scal(

9nspection

Eyes

9nspection

"ymmetric to the face, *oth eyes coordinated with parallel alignment.

5ellowish sclera %icteric sclera( 0arkened perior*ital area E6ternal eye Structure Eyebro7s 9nspection Hair evenly distri*uted, "kin intact <Hually distri*uted, :urled slightly outward "kin intact, No discharge, No discoloration, #ids close symmetrically No edema or tearing .lack in color, eHual in size normally !34 mm in diameter, >ound, smooth *order, iris flat and round "ymmetrically aligned to the face, firm and not tender with no discharged noted. <venly distri*uted with skin intact <Hually distri*uted, :urled slightly outward "kin intact, no discharge, no discoloration, lids are symmetrical. No edema and tearing .lack in color, eHual in size 6mm in diameter

d,t lack of sleep d,t itching of pruritus

Eyelashes

9nspection

Eyelids

9nspection

8acrimal gland Pu(ils

9nspection

9nspection

Ears

9nspection

ositioned symmetrically to the face, 2aundice dry skin

&ose

9nspection

"ymmetric and straight, no discharges or flaring

"ymmetric and straight, Iith NJT on the >9JHT Nares 7aundice

Mouth 8i(s 9nspection =niform pink in color, soft and moist and smooth Tongue at midline without lesion :omplete, white, shiny tooth enamel, free of de*ris :oordinated , smooth movement with no discomfort No masses, tenderness No masses, tenderness 3((er E6tremities S9in 9nspection inkish in color 2aundice ale, dry

1ongue

9nspection

5ellowish tongue

1eeth

9nspection

:omplete

&ec9

9nspection

:oordinated movement with no discomfort 7aundice

alpation

Iith #esions 0ry

Iith 9K line on >9JHT metacarpal area alpation Normothermia Not warm, not cold to touch, TF!C Normally firm, no contracture, eHual size on *oth sides of *ody 7aundice 0ry Iith lesions

Arms

9nspection

Normally firm, no contracture, no swelling, eHual size on *oth sides of *ody

alpation &ails ;uscultation 9nspection

ulse >ate@ C'3 1'' "mooth, highly vascular and intact epidermis Normal

alpation

:apillary >efill of 13& seconds

:hest and 8ungs

9nspection

"ymmetric chest e)pansion, Huiet, rhythmic and effortless respiration No retraction, no tenderness, no masses Guiet, rhythmic Normal heart rate C'31''*pm =n*lemished skin, uniform in color

"ymmetric chest e)pansion, Huiet, rhythmic and effortless respiration No retraction, no tenderness, no masses Guiet, rhythmic :ardiac rate of BC ;rea of surgery covered with gauze %not soiled( 7aundice

alpation

;uscultation Heart ;uscultation

Abdominal

9nspection

;uscultation

;verage normal *owel sounds +3&+ per minute Tympany

Iith 7 drain N,;

4enitalia

ercussion 9nspection

No lesions, No 0ischarge, No "megma

8o7er E6tremities S9in 9nspection No lesion, can move freely 7aundice 0ry Iith lesions

alpation Muscles

:apillary refill@ 13& seconds <Hual size on *oth sides of the *ody, no contractures, no tremors Normally firm, smooth, coordinated movements <Hual strength on each *ody side

<Hual size on *oth sides of the *ody, no tremors Normally firm, smooth, coordinated movements

0ones

No deformities, no tenderness or swelling

5oints

No swelling, no tenderness, crepitation or nodules 7oints move smoothly

4ordon;s Functional Health Pattern

4ordon;s Functional Health Pattern

0efore Hos(itali<ation

During Hos(itali<ation

'nter(retation and Analysis 9@ atient is health conscious and seeks medical consultation if needed. He avoids involvement with vices and is aware that it is important. He is willing to undergo necessary procedures to *etter his condition. ;@ His perception a*out health is not one of the factors that led to the development of his illness.

A= Health Perce(tion and Management

Has complete N,; immunization of .:J, Hepatitis ., /easles, ? K and 0 T. 0o not use any her*al medicines .uys and takes over the counter medications such as 09;T;.". Kisits the doctor when pain is not tolera*le. -pag hindi ko na talaga kaya saka ako nagpupunta sa doctor1 as ver*alized *y the patient. &>& A8:>H>8':! &>& SM>?E@ Height@ +$91 Ieight *efore 4+ kg <ats + times a day. #oves to eat ;do*o %!) a day(. <ats 131 D cup of rice each meal. -mahilig akong kumain ng matata*ang pagkain lalo na nung *inata pa ako1as ver*alized *y the patient. <ats fruits and vegeta*les :an drink 1 liter of water a day 0rinks coffee once a day No allergies with any food #ast 8e*ruary 14, Jeneral #iHuid

0= &utritionA Metabolism

9@ The client e)perienced rapid weight loss due to his disease condition. rior to admission, patient was eating a diet consisting of meat, rice, vegeta*les and fruits. atient was fond of eating fatty foods since he was young. .ut due to a*dominal pain, was not a*le to eat last 8e*ruary 14. =pon admission, client was advised to *e on full diet with an increase on protein intake. His water intake

&'16, patient cannot eat anything since he is suffering from a*dominal pain.

lessened from 1# to +''m#. 9ntravenous fluid was started 8e*ruary 19, &'16. ;@

:= Elimination

Koids C) a day %1'' cc per urine( BE88>)'SH 0efecates every day %formed, green in color, foul smelling( 8irst week of 7anuary the patient e)perienced constipation -hindi ako nakatae ng isang lingo pero hindi ko na pinansin dahil nakatae din naman na ako %formed, green in color, foul smelling(1as ver*alized *y the patient.

?n 9ndwelling 8oley :atheter with !'cc urine output for B hours

9@ atients voids regularly prior to admission. Then during hospital stay, urine output decreased dramatically with its color changing from yellowish to tea3 colored due to increased *iliru*in. His stools changed from color green to *lack tarry due to *leeding. ;@ ancreatic :arcinoma causes *iliru*in levels in the *lood to go up there*y causing tea3 colored urine. .lack tarry stools indicate *leeding in the upper J9 tract.

D= Hygiene

;*le to *athe himself He takes a *ath regularly, once a day .rushes his teeth & times a day

No *ath since post operation /outhwash with *actidol swa* care off wife

9@ rior to consultation, patient is a*le to maintain good hygiene. The clientLs condition renders him una*le to do ;0#Ls without assistance. ;@ 0ue to his fatigue and weakness, the

patient *ecame dependent to his significant others. He is now una*le to perform his sanitary practices *y himself. The patient usually walks for e)ercise *ut gets tired easily (- BEA@S P@'>@ 1> ADM'SS'>& $ His leisure activities include the following@ >eading the newspaper and watching T.K. The patient lies supine on *ed since post operation 9@ The client$s activities are greatly reduced compared *efore hospitalization. The patient was a*le to walk as an e)ercise though he gets tired easily, and is a*le to accomplish his daily activities. 0uring hospital admission, due to his easy fatiga*ility, he stays in *ed and needs assistance am*ulating. A: His movements were limited *ecause of his weakness and fatigue. /ovement increases o)ygen demand which contri*ute to clientLs fatiga*ility. F= Se6ualityA @e(roductiCe /arried since 19BC 8ather of ! children, 1 girl, & *oys. Has no history of se)ually transmitted disease 0o not use any *irth control "e)ual contact once a month for the last ! years since patient e)perience easy No se)ual intercourse 9@ The patientLs se)ual activity was affected after complaints of easy fatiga*ility. ;@ The fatigue that the client e)periences is due to his illness which renders him una*le to participate in his

E= ActiCityAE6ercis e

fatiga*ility

usual se)ual activities.

4= :ognitiCeA Perce(tual

Iith a !6',!6' vision, with dou*le lens glasses for 6 years. ?riented to people, time and place >esponds to stimuli ver*ally and physically

>esponds to stimuli ver*ally

9@ atientLs cognition and perception is intact and is not affected *y his illness. ;@ His condition does not affect his a*ility to think, his orientation to person, time and place. He is a*le to respond appropriately to stimuli.

H= @olesA @elationshi(

/arried since 19BC #ives with wife and youngest son His parents and si*lings live in the same lot. "topped working since 7anuary &', &'16 Iell supported and loved *y his family

Iell supported *y family "tills plays the role of the father despite condition *y means of reminding important matters to his son

': rior and during hospitalization his family has their full support for the client despite his condition. A: 8amily support often plays a ma2or role in helping client accept and cope from illness. 9@ rior to admission, client is in the state of anger and then later on during admission, with the help of his significant others, is a*le to accept his illness. ;@ The patient is a*le to understand his current situation and s willing to participate in necessary interventions to

'= Self-Perce(tionA The patient was in Self-:once(t state of anger when first learned of his illness -nagagalit nga ako noon %prior to admission( kung *akit ako pa ang nagkasakit dahil sa dami *a naman ng mandaram*ong at manloloko sa mundo ako pa ang *inigyan ng diyos ng ganito1 as ver*alized *y the patient.

n,a

correct his condition. >oman :atholic Joes to church once a month n,a 9@ The patient has a concrete sense of *elief in Jod and is a*le to e)press his faith on a regular *asis. ;@ <)pression of faith is essential in strengthening oneLs core value and *elief. :opes with pro*lem *y talking a*out it with family and finds ways to resolve it together No traumatic events e)perienced *efore ?= :o(ingAStress n,a ': The patient is a*le to cope with stress through ver*alizing his feelings to his family. A: 8amily has a significant role in hospital treatment of patients, since it can provide effective psychological and emotional support to patients undergoing treatment. 9@ 0iscomforts like pruritus can cause distur*ance in sleeping patterns. ': Ihen the patient was admitted to the hospital he was prescri*ed with medicines as a part of treatment. A: He is now receiving additional medications to treat,improve the

5= %alue and 0elief

8= Slee(A@est

M= Medication History

The patient sleeps at The patient is asleep 9,1'pm then wakes most of the time, *ut up at 4 am is arousa*le when taking vital signs and 0oesn$t use any giving medications medication to promote sleep 0iata*s for .ottle MB 0+N"" 1# a*dominal pain regulated N 1''cc,hr on #eft /etacarpal ;rea "0 M1 on #eft /etacarpal ;rea of N"" +''ml O !''mg of Tramadol regulated N &+ugtts,min "0 M& N"" 9'cc O 1''mg of

8urosemide regulated N 1!mg,hr via perfusor on right metacarpal area "0 M! 0+I &+'ml O 1+' NaH:?! regulated N 14cc,hr on >ight metacarpal area

symptoms and to prevent further development of his disease.