Patients profile

Patient x is a female, 29 y.o. Single and currently working as a sales lady. She’s a
Filipino citizen and presently residing at Langihan Butuan City.

My patient is an occasional drinker. She eats at least three times a day. Part of her diet
was eating street foods particular barbecues. She sleeps between 11-12am and wakes
at or 5am and prepares to go to work. She works from 6am up to 7pm daily.

She has no history of any hospital admissions or any acute illnesses.

Prior to admission she was experiencing abdominal pain and discomfort that soon
becomes more severe, particular at the left lower quadrant of abdomen. According to
her, she was experiencing these symptoms for a year now but seeks no medical
advice. Just two months ago her condition worsens affecting her daily activities and
work. Last April 3, 2007 she has decided to have a check-up at Butuan Doctors'
Hospital her attending physician is Dr. Gambe. She underwent a series of laboratory
examinations and procedure such as colonoscopy and after that she was told to went
home and wait for the result to be analyzed and diagnosed. the Doctor advised her to
be back after a month or two if her condition does not subside. Unexpectedly the result
took long and now she’s having more and severe symptoms including bowel difficulty,
loss of appetite and sudden weight loss. Prior to this manifestations she has decided
to be admitted at Butuan Doctors’ Hospital due to worsening of her condition. Patients
vital signs upon admission were, Temperature – 36.6*C, Heart rate – 20 cpm., Pulse rate
– 72 bpm and Blood Pressure of120/60 mmHg

She decided to be admitted to have a proper management of her condition. It was on

June 23, 2007 (Friday). She was attended by Dr. Gambe. Chief complaints were,
abdominal pain and cramping particular at the left lower quadrant, loss of appetite and
sudden weight loss, bowel difficulty and body malaise. The doctor review here
previews laboratory results and procedures. Pre-operative diagnosis was Sigmoid CA.
It was also found out that the patient is infected by a parasite Schistosoma japonicum
that causes Schistosomisais and additional symptoms.

On June 25, 2007 patient was scheduled for explorative laparotomy. Attended by Dr.
Jugao her surgeon, Dr. Gambe and Dr. Oclarit her anesthesiologist. The operation
performed were, sigmoidectomy, epigastric and umbilical incision, midline incision,
peritonium and sigmoid resection was done.

Patient was received at June 26, 2007 at 8:00am post-operative after surgery and was
on NPO. She was lying on bed awake, with IVF #6 D5NM 1 ltr. infusing well at the left
cephalic vein and with Foley Bag Catheter insertion; draining well.

Patient was in good grooming but weak looking. She was complaining of moderate
pain at post-operative site.

Initial Vital Signs taken and recorded, she was afebrile. Temp – 32*C, PR – 76 bpm., HR
– 17 cpm and BP – 120/80 mmHg.
Thirteen areas of assessment

Social status

Patient x is a female 29 y.o. single. She’s currently working as a sales lady at Ribsons-
Marketing Butuan City.
Before hospitalization she was working at regular time and schedule, was active on her
work and friends.
Upon admission, her social interaction with friends and family is hindered, she’s
unable to work, meet with friends or do her usual and daily activities due to her
condition.

Emotional Status

She was likely a joyful type of person as she would described herself.
Upon admission, she was anxious of her condition on the possible outcomes of her
hospitalization and procedures to be done.
During hospitalization, patient was depressed upon interaction, she was thinking of
her physical condition, about her family and friends and most particularly on their
expenses. Pt. was buying time to accept her present condition physically and
emotionally.

Cognitive Status

She was responsive and coherent upon interaction. She was oriented on the time, date,
place and on her present condition.
She was a college level and very much a good listener, she was somewhat
knowledgeable on the reason of her admission.

Body Temperature

Upon admission patient temp was 36.6*C.

Prior to her condition she was experiencing a sudden uplift of temp. of 38.2*C, as was
having an episode of fever during hospitalization, post- operatively.

Circulatory Status

Upon admission patient has a normal circulatory rate of 72bpm.

During hospitalization patients circulatory status is likely higher than normal level but
without any signs of impeding blood supply or vein distension. Prior to her condition
she has a pulse rate of 92 bpm, taken when patient is relaxed.

Respiratory Status

Upon admission pt has a normal respiratory rate of 20 cpm.

During hospitalization pt breathing patterns is likely increased or higher than normal
rate. She has a respiratory rate of 24 cpm, it was shallow and fast, taken when patient
is relaxed.
Nutritional Status

Before hospitalization she has a good appetite and eats regularly at least 3x a day. She
likes to eat street foods particularly barbecue . She prefers to eat it because its
available always on their place. She has toleration in her diet and also she’s an
occasional drinker.
Upon admission she is on NPO. The doctor orders the patient to be on soft liquid diet
when she’s able to eat. It was expected that she will need to have a new balance and
supervised diet plans suited to her condition. Patients BMI shows that she’s
underweight., based on her height and possible weight.

Elimination Status

According to her, she usually eliminates at least 2 or 3x a day.

Before admission, pt had bowel difficulties or having only a scanty and watery feces
and sometimes with the present of blood.
When confined, she was on NPO without bathroom privileges and was on Foley
Catheter with usual urine output or 400-500 cc.

Reproductive Status

She’s single and claimed of no or any abnormalities.

After her hospitalization, patient was expecting that it would maybe take longer time
before she can resume to her usual sexual activities.

Perception and Coordination

She has a clear vision and doesn’t use any eyeglasses. Without any abnormal
discharges from ears, nose and mouth. She has a good sense of smell and can
distinguish the smell of rubbing alcohol when tested. She can hear even at the
distance of 3 meters or more when ask. Skin sensation is normal.
She was complaining of ,moderate pain at post-operative site, she was able to move
her both upper and lower extremities but has difficulty ambulating due to body
malaise.

Rest and Sleep

Patient’s normal sleep pattern was around 11-12am and wakes up at 4-5am.
Before admission, she was having difficulty sleeping and almost not able to have
enough rest due to her to her condition.
During hospitalization, she was able to have some rest but most of the time wakes up
because of environmental noises.
State of skin and Appearance

Pt has brown skin complexion, long wavy hair at shoulder level and almond shaped
brown eyes. She stands about 5’3’’ in height and weights about 45 kilos.
During hospitalization she is weak looking and having an excessive sweating. Pt has
marks and bruises on her upper right and left arms.
She has a break on the skin related to post-operative incision at abdominal area, but
without any abnormal discharges and with good circulation on the area.

State of Mobility and Activity Patterns

Before patient as active on her activities of the daily living and was able to work and
coordinate with her colleagues properly.
Prior to admission, she was experiencing body malaise and with altered activity
patterns related to her condition thus unable to perform her work.
After hospitalization, she would be expected to minimize her daily activities and works
at reasonable time considering her condition and status. Her activity patterns will need
to be changed prior to her condition for early recovery and to prevent complications.