A.

Review of Systems (-) Weight Loss (-) Fatigue (-) Chest pain (+) Cough and colds (-) Weakness (-) Difficulty of breathing (-) Diarrhea

1. Regional Examination August (?) , 2013 System General Actual Findings Concious, coherent, and not in cardiorespiratory distress BP: 120/80 mmHg PR: 82 bpm RR: 20 cpm T: 36.4 Wt: 46 kg. Slightly icteric sclerae, pink palpebral cojunctivae, moist oral mucosa, no nasoaural discharge, no CLAD, no TPC Symmetric chest expansion, clear breath sounds, (-) crackles, wheezes, or rales Adynamic precordium, normal rate, regular rhythm, no murmurs, heaves or thrills Hypoactive bowel sounds, (+) guarding, (+) tenderness, no palpables masses, no organomegaly, (-) direct tenderness on the RUQ, (-) Murphys Full and equal pulses, (-) bilateral knees non-tender, no swelling, no erythema at the time of examination, no cyanosis, CRT <2 seconds, (-) edema GCS15

Vital signs:

HEENT

Chest and Lungs

Heart

Abdomen

Extremities

Neurologic

2. Laboratory Studies / Diagnostics

Procedure Date

Indication

Normal Findings / Values (

Actual Findings

Significance / Interpretation Explanations of the Findings (as too High or Low)

Hematology

To aid in diagnosing anemia and to monitor blood loss and infection Hgb The oxygen-carrying pigment of red blood cells that gives them their red color and serves to convey oxygen to the tissues

12.0 - 16.0 (g/L)

13.8 (g/dL)

August (?), 2013

Hct A measure of the packed cell volume of red cells, express as a percentage of the total blood volume. WBC This is used to determine if there is infection present.

0.37 0.47%

.38 %

5.00 10.00

12

Slightly increased WBC may indicate Infection.

Urinalysis

A urinalysis consists of a number of physical, chemical and microscopic tests of a urine sample as part of a checkup to help diagnose a urinary tract or metabolic disease. Doctors also use urinalysis as a general health screen. MACROSCOPIC Light Yellow Color MICROSCOPIC 5-10 WBC White Blood Cells Red Blood Cells Epithelial Cells Crystals: Eurates/Phosphates 0-1 RBC Many Few

August 24, 2013

Transparency Sugar Protein

Slightly turbid Negative Negative

FUNCTIONAL ASSESSMENT (Pre-hospitalization) * Health Perception and Health Management The client feel good about herself. She also finds it easy to socialize with the people around her and interact naturally; she sleeps an average of eight to ten hours; has allergy to chicken; has a healthy appetite, she claims that she consumes a lot of food, mostly rice and meat, shows a preference of meats over some fish and vegetables; does not have a hard time with urination or bowel movement, if ever she does have problems, she claims it is usually solved through increasing fluid intake and eating foods high in fiber. * Nutritional and Metabolic Pattern The patient is having her diet as diet as tolerated during her confinement in the hospital except for dark-colored foods. * Elimination pattern Patient usually defecates once a day, brown in color with no other problems during defecations. She urinates approximately 4-6 times a day, yellowish in color, also with no other problems in voiding process. * Activities of daily living (ADL) The patient verbalized that she can eat independently and can dress herself properly without a need of any assistance as well as in bathing. She usually sleeps around 9 oclock in the evening and awake at 11 oclock in the morning. * Values Belief Pattern The client is a Roman Catholic. She verbalized that the family does not always attend worship sessions. They dont actively participate in the activities in their church. (While confined) * Self-perception and self-concept pattern The patient had a fighting spirit that she will overcome all the trials that may come to her life. She had an overviewed that she will get well soon. * Activities Tolerance-Exercise pattern Patient was able to ambulate around and able to make walking exercises, she was able to dress and eat on her own and walk without any assistance on her side not until after the surgery that somebody has to assist her. * Sleep rest pattern

The client doesnt have a difficulty in sleeping. The patient also verbalized that the environment is not soothing for her but after a day she was able to adjust and adapt gradually in the environment. * Cognitive-Perception The patient can speak fluently and understand fully in Tagalog and English. She is oriented with the time, people that surround her and place. Her memory is good and answers the question that was given to her. * Role-Relationship Pattern (while confined) The client is nice and easy to get along with but sometimes gets easily annoyed to her 2 siblings because she doesnt want to be bothered.