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Date of Assessment: August 17, 2011

A. BIOGRAPHIC DATA
Name: A. S. P.
Address: Rosales, Pangasinan
Age: 55 years old
Gender: Male
Birth date: February 11, 1953
Birth place: Tarlac City, Tarlac
Ethnic Group: Pangasinense
Primary Language Spoken: Ilokano
Marital Status: Married
Educational Attainment: College Graduate (BS Nursing, underboard)
Occupation: House Husband
Religious Orientation: Protestant (Methodist)
Attending Physician and Clinic: Dr. Winfredo Fernandez, Pangasinan Medical
Center
Health Care Financing and Usual Source of Medical Care: Within the Family
Income: Monthly income of the family is P18,000 to P22,000
B. PAST HEALTH/MEDICAL HISTORY
Childhood Diseases: Chicken pox and measles when he was in grade school.
Immunizations: Cant be recalled if he completed his childhood
immunizations but recently (last March 2008) he completed 5
shots of anti-rabies vaccination because of a dog bite.
Allergies:
Drugs so far no allergies to drugs
Food - shell foods
Others (insects, dust) no other allergies
Accidents and Injuries: Motorcycle accident when he was in his late 30s
resulting to a right clavicular fracture, according to him it
took three weeks before he can completely move and
rotate his right upper extremity.
Hospitalizations: His last confinement was sometime in July last year due to
slurring of speech, facial asymmetry, and right sided weakness.
He was diagnosed then with Cerebrovascular Accident,
Essential Hypertension and Diabetes Mellitus type 2. As of now,
there are no signs of weaknesses or facial asymmetry.
Medications:
Prescription Amlodipine (5 mgs/tab, 1 tablet once a day) for his
hypertension and Glimepiride (2 mgs/tab, 1 tablet once a day) for
his diabetes.

Self Prescribed Paracetamol, Mefenamic Acid, Diatabs, Loratidine,


Bisacodyl
Foreign Travel: He went to Saudi Arabia when he was in early 30s to work as a
construction worker and lasted for four years.
C. FAMILY HISTORY OF ILLNESS
His father died at the age 70 (year 2000) because of diabetic complications,
hypertension, and pulmonary emphysema. His mother died at the age 77 (year
2007) because of ruptured aneurysm in the brain.
In the family, he is the second child; unfortunately, he and her eldest sister
were diagnosed with hypertension and diabetes mellitus type 2 among the four
siblings. So far, among his children, his immediate nephews, and his immediate
nieces, none of them are experiencing signs and symptoms of hypertension and
diabetes mellitus though they have their annual consultation with their family
physician.
Heredofamilial diseases:
Heart disease (-)
Hypertension (+) father
(+) mother
Tuberculosis (-)
Diabetes Mellitus (+) father DM type 2
(+) eldest sister DM type 2
Mental Illness (-)
Cancer (-)
*Hereditary illnesses
genogram on the last page...
D. HISTORY OF PRESENT ILLNESS
Before he was diagnosed with hypertension and diabetes mellitus, the usual
signs and symptoms he always experiencing were frequent dizziness, occipital
headache, nauseated, leg numbness, frequent thirst, decrease in stamina, cold
sweats, and frequent urination. He told me that to alleviate some of those signs and
symptoms he usually takes a rest when he is tired especially when he is having
dizziness, take multivitamins, take some over-the-counter drugs such as
Paracetamol (analgesic.)
It took three months before he had his very first consultation with a physician
that was July last year, consultation first then advised for admission. He was
admitted then. He was convinced by his wife and by his siblings to have a check-up
with the experts and smilingly claimed that her younger sister stated that, If you
are not going to have your consultation at this moment, you will be the next in line
to be buried six feet under the ground, next to our parents.
After series of laboratory procedures and monitoring during his confinement,
he was then given Amlodipine and Glimepirirde as his maintenance drugs for his
hypertension and diabetes mellitus type2.
E. FUNCTIONAL HEALTH PATTERNS/HEALTH PERCEPTION AND HEALTH
MANAGEMENT PATTERN

During our conversation, it was clearly averred by him that he is much better
now as compared before when he was not yet diagnosed with hypertension and
diabetes mellitus. I showed him a line; in extreme positions, health and illness are
located, I asked him to point where his health is right now. Without a second
thought he quickly pointed on a position near the health side. He considers himself
healthy and satisfied enough if he is not experiencing any pain, no fever, and no
signs of bleeding. He added that these three signs and symptoms are the common
reasons why people go to health institutions.
In his small community, according to the elderly that if you feel any
headache, dizziness related to hypertension, the only answer is to take in orally a
clove of garlic. And if they think that you have diabetes, just lessen your intake of
rice and sweets like chocolates, soda drinks, and eat high amount of bitter melon
(ampalaya.) He admitted that in their small village, self-diagnosing and selfmedicating is very obvious without having a consultation to a health specialist.
After the hospitalization, he committed to himself to have his check-up biyearly. The last consultation he had was last July 2008 and the physician said to him
to continue his maintenance medications. I asked him if he is performing self
testicular examination after a warm bath, he answered no. He seeks consultation
whenever he feels occipital headache, dizziness, cold sweats, and vomiting. In the
last six months, he visited his physician once for follow-up check-up only.
Sometimes, he had hard time to follow suggestions from the physicians or even
from the nurses because they dont explain it to him clearly what the benefits of
what they teaching to him are.
Safety practices he follows to control his blood sugar and hypertension is
watch out foods that are rich in carbohydrates and foods that are rich in fats and
cholesterol. He said that to be healthy is difficult, it needs an effort to attain healthy
body and mind. It needs self-discipline and compliance.
About his personal hygiene, during our interaction, I noticed him wellgroomed, clothes are ironed, well-combed hair, no distinctive odor, fingernails are
clean, and toenails are also clean, skin is dry and with some corns and calluses
(ventral part of his feet.) I asked him how he does his hygienic practices; he
answered me, I usually take my bath mid-early in the morning at least once a day
and having a shower before going to bed at night. I washed my hands every time I
will hold things that I think that are filthy. I am very cautious enough when it comes
to my feet, because according to my health providers it is very precarious if I am
not going to take care of it that it might lead to amputation. The problem is; the
only things I know are to wear socks, wear slippers as much as possible, and clean
my feet properly. I dont use deodorants or even cologne because my wife hates it. I
brush my teeth every after meal or at least three times a day and have my dental
check-up whenever I feel toothaches. I use toothpicks instead of dental floss.
About substance use, he is a heavy alcoholic drinker before and now he limits
himself to at least three bottles (330ml) in a week. I suggested to him that it is
better to stop drinking alcoholic beverages and he answered me, once in awhile
our body needs alcohol. He never tried to puff a cigarette nor use highly-abused
drugs such as ampethamines, marijuana, and the like.
Upon visiting their home, I can say that there is a good ventilation and good
lighting especially at the living room area. There water supply is from a manual
pump which is used for laundry, watering the plants, and for cleaning. The source of
their potable water is from water deliveries/water stations (bottled water.) They are
using water-sealed toilet, they bury their garbage under the ground (except non-

biodegradable waste) to be used as their fertilizer to their mini nursery-garden, they


practice hand washing before handling food and their wash room is far from their
kitchen and dining area (at least 5 to 6 meters away), they always clean their
backyards and surroundings everyday, and they dont keep stagnant water near
their house to prevent certain diseases such as dengue fever.
F. NUTRITIONAL AND METABOLIC PATTERN
Food intake for the last three days:
Sunday (August 03, 2008)
Breakfast: 1 boiled egg, 2 longganisa, 1 cup of rice, and 1 cup of
tea
Snack: (-)
Lunch: 1 medium-sized bowl of lentil, 2 cups of rice, and 3
glasses of water
Snack: 2 apples
Dinner: medium-sized bowl of lentil, 2 fried fish (2 belly part
of milkfish), and 3 glasses of water
Monday (August 04, 2008)
Breakfast: 1 boiled egg, 2 hotdogs, 3 slices of bread, and 1 cup
of coffee
Snack: (-)
Lunch: 1 medium-sized bowl vegetable (pinakbet), 1 fried fish,
1 cup of rice, and 3 glasses of water
Snack: 2 apples
Dinner: 1 medium-sized bowl of chopsuey, 1 cup of rice, and 3
glasses of water
Tuesday (August 05, 2008)
Breakfast: 1 boiled egg, 1 large-sized bowl of arrozcaldo, and 1
cup of coffee
Snack: (-)
Lunch: 1 medium-sized of chocolate meat (dinuguan), 1 cup
of rice, and three glasses of water
Snack: 2 apples
Dinner: medium-sized bowl of chocolate meat (dinuguan), 1
steamed pork chop, 1 cup of rice, and 3 glasses
of water
His fluid intake is at least 1800 ml to 2200 ml a day, mostly water. His
knowledge regarding proper nutrition is eating the right amount of food at the right
time. He is now more on vegetables and fruits after he was diagnosed of having
hypertension and diabetes mellitus and he cant deny that sometimes he is still
craving for meat products which is his favourite before. His wife usually prepares
their food with some help of his children and they sees to it that it is prepared
hygienically. He is not fond of eating at restaurants or even at fast food chains, he
preferred home-prepared foods because he stated that he is 100% sure regarding
its cleanliness. Before, they eat together as a family, due to inevitable growth and
development of his children, his eldest son has his own family already and living

separately, his second child was hired to work outside the Philippines; his third child
is working as a nurse outside their hometown as well as his fourth child who is in
college. His youngest little girl is the only one was left close to them who is in grade
school, so right now they are eating their meals as if they are starting a new family
again. He and his wife are eating their meals together with their youngest child.
His wife is the one responsible in food budgeting. Regarding his weight, as
compared a year ago he lost approximately 15 pounds. As of now, he is in good
appetite though there are some restrictions on his diet. He should limit his intake on
sweets, fatty, and high in cholesterol foods. There are no obvious skin problems
though some parts of his skin especially on his both lower extremities are dry. No
dental problems and no dentures (false teeth.)
G. ELIMINATION PATTERN
He defecates once a day usually in the morning. The colour of his stool is
yellow brown and soft in consistency as described. There are no discomforts or pain
felt during moving his bowel. If he feels and thinks that he is a bit constipated, he
takes one tablet of Bisacodyl (Dlucolax) at night and it is expected to move his
bowel the following morning which affording relief.
He voids at least 8 to 10 times a day, in every urination he approximated that
he is voiding at least 200 ml of urine, yellow in colour, not that musty in odor, and
clear.
He perspires excessively when he is hungry and tired after physical exertion
(exercise.)

H. ACTIVITY-EXERCISE PATTERN
Every morning of weekdays he goes at the sports complex which is 2
kilometres away from their home to have his jogging exercise for at least an hour.
Every afternoon of weekdays including Saturdays, he is cleaning their home, doing
some household tasks, and cleaning his mini nursery-garden. After each activity he
felt satisfied and relaxed because according to him, your body needs to move to
lessen at least some stresses in life. Every Sunday is a worship day with his family
(he, his wife, and their youngest child); they go to church to listen the homily of the
celebrant.
He is a house husband. Sometimes in doing heavy tasks, he needs sufficient
energy to do so but due to his present condition it needs time to accomplish a
certain task. Doing his favourite tasks which are gardening and jogging gives him a
contentment and pleasure in everyday life.
I. SLEEP-REST PATTERN
He usually sleeps at 9:30 in the evening after teaching and guiding his
youngest child in doing her home works and wakes up around 5:00 in the morning
to help his wife in preparing their breakfast and to prepare himself for his daily
jogging exercise. In average, he sleeps at least 7 to 8 hours without any
interruptions every night. Sometimes he wakes up at night to void and to drink
water. He is very satisfied every time he wakes up because he is well-rested and
added that a new day will smile again to him and to his family. Their bedroom is

very conducive for resting, no televisions, no radios, or any other things that can be
a source of noise. No problems in their sleeping environment.
It is a routine in the family that before going to sleep, they have to drink one
glass of warm fresh milk, which he added that it will help them to sleep easily. He
easily gets sleep especially when he is tired. Neither aiding devices nor medications
(sleeping pills) are needed just to help him fall asleep. He usually takes his nap
around 2:00 in the afternoon to 3:30 in the afternoon before hitching-up his
daughter in school. He listens to instrumental slow music every afternoon before
taking his nap, reading broadsheets, and gardening are the things he does to relax.
J.

COGNITIVE-PERCEPTUAL PATTERN
There are no difficulties in reading or writing. There are no sensorineural or
conductive hearing losses. No eyeglasses worn during the interview and no history
of wearing eyeglasses. He reads newspaper at least a foot away from his eyes. He
has a very vivid memory. He had some hard time to learn new things especially if its
computer related topics.
He is able to distinguish foods that are sweets, salty, sour, and bitter. He has
a good olfactory sense able to identify alcohol, coffee, and vinegar while his eyes
are closed.

K. SELF-PERCEPTION AND SELF-CONCEPT PATTERN


He described himself as a worthy man with principles in life, though he is not
that lucky in terms of job at least he has a very happy, simple family. Physically, he
told me that he is getting older, his baldness is very obvious now, he is getting
shorter, and his stamina is decreasing, and having white hair. Smilingly, he inserted,
thats the process of life, its part of aging, and it is unavoidable. He admitted that
at first, when he noticed some changes of his physical appearance he thought and
said to himself that, this is not me, but after sometime he accepted the reality and
tried to inculcate in his mind that everybody will go to this process not only him. His
relationship with others during this phase of physical changes affects his
interpersonal bond but only lasted for few months with the support of his family and
relatives.
He is an ordinary man who doesnt want to compare himself to others or to
be compared to others because everybody has differences. He merely expresses his
thoughts and feelings to others by conversing. His goal for the next five years is to
see all his children in their peak of success in every aspects of life. I asked him,
What are your plans to achieve that goal? He simply answered me, By taking
good care of myself is good enough to achieve that goal.
He admired his father very much because his father is a man with words and
principles and he can see his father to himself. You can see him very pleasant and
happy because one of his philosophies in life is, Living in a very positive way will
make you younger and healthier. He is a very optimistic man. When he is mad or
angry (superficial or mild cases), he keeps his temper to himself and the only way to
get rid of it is to be happy. But if you made him anger to the extent of his patience,
you will hear him shouting.
He is very gratified with his mood as of now, he is happy and no worries.

L. ROLE-RELATIONSHIP PATTERN
He is living with his wife and with his youngest child. The structure of their
family is a nuclear-typed Family which comprises father, mother, and children.
Significant people in his life are his families, relatives, and friends. Each member of
the family is very close to one another. He is the father of the family but again due
to his present condition he is jobless, the one supporting their family is his three
children and his wife. As of now, no problem arises. They usually handle problems
by conversing to one another and solving the predicaments right then and then
without prolonging it to a week.
Voicing out opinions or open communication to each member of the family is
a good help or way to alleviate some weight of a certain problem. His wife usually
initiates activities within the family and sometimes their children, especially the
third child their eldest daughter. A usual activity of the family is going to church
every Sunday to worship as one family. And every holiday, they spend their time
together on a three day out-of-town vacation. He doesnt involve himself socially
that much. Hes contented interacting with his family, immediate relatives, and
friends. Every afternoon, he and his relatives play cards as means of socializing and
sometimes drinking alcoholic beverages with them.
Their monthly income is adequate to their physiological needs but it requires
budgeting wisely because his maintenance medications are expensive. They are
living in an open compound community.
M. SEXUALITY-REPRODUCTIVE PATTERN
As a man, he is the father of five children. He is very confident on how he
expresses his sexuality though he admits that he is now aging, there is a hard time
maintaining his penile erection. He is not that affectionate, he doesnt want to show
his feelings especially in the public. He shows his affection inside the family. With his
age, there are no concerns regarding fertility because he is contented with his five
children but during his sexually active years, he claimed that he used condoms,
withdrawal, and contraceptive pills (for his wife) as means of contraception.
When I asked him if he engaged himself to high risk sexual practices and any
changes or problems in sexual relations, he evoked his privacy.
N. COPING-STRESS TOLERANCE PATTERN
One of the most stressful events happened in his life was when he was
diagnosed having hypertension and diabetes mellitus July last year. Fortunately, his
wife and family are very supportive and very willing to help just to assuage its
complications. The support from his significant others are very effective in coping
during that situation.
His wife is his best friend; she is always there to support him all the way. No
significant changes happened in his life in the last year or two.
O. VALUE-BELIEF PATTERN
According to him, eating nutritious foods and balance healthy lifestyle makes
a person healthy. Health is important to him because it is the basic groundwork of
life. There are no spiritual or religious practices in relation with health.

Religion is important to him because it gives him more reasons to be good


and gives something to believe in when all else fails. With his experiences, he said
that it helps to lessen some difficulties and trials in life, both emotionally and
psychologically.
He was raised in a very conservative and traditional family and still fresh in
his mind what his mother told to him that you have to respect and love your
fellowmen no matter who they are and what they are, and the Golden Rule.
P. OTHERS
None

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