OUTCOME PRESENT STATE MODEL

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 CLIENT IN CONTEXT PRESENT STATE INTERVENTIONS EVALUATION

CLIENT IN CONTEXT EMERGENCY ROOM BLOTTER:

L.R.Q., 63 years old, married, currently Time in: 1:10 PM
residing at Cawayan, Dalaguete, Cebu, born Time out: 5:20 PM
on June 24, 1946, was admitted for the first BP: 110/70 mmHg
time at Cebu Velez General Hospital on PR: 84bpm
August 24, 2009 at 5:20 PM per taxi RR: 24cpm
accompanied by his wife, for complains of Temperature:36.0 C/ axilla
presence of adenomatous polyp, rectum, Weight: 56 kilograms
under the service of Dr. Donaldo of the
Department of Internal Medicine, was co- Problem:
managed of surgery on August 25 2009 1. Adenomatous polyp, rectum
under the service of Dr. Stephen Bullo, with
the case number of 05945, room number
404a at PPW 4th floor. PHYSICAL EXAMINATION
General Measurements:
HISTORY OF PRESENT ILLNESS Height: 5’3”
2 years PTA, patient noted onset of Weight: 56 kgs
yellowish stool lasting for months thus sought Ideal Body Weight: 54kilograms
consult and given unrecalled medicines.
4 months PTA, patient noted decreased in General Appearance:
stool, less than ½ cup, soft, watery, yellow, August 27, 2009(Thursday)
blood-streaked, caliber stool, 2 episodes per Time: 5:10 pm
day, with positive passage of flatus, with
occasional tenesmus, no associated anorexia, Examined Patient lying on bed awake, conscious,
body malaise, light headedness or changes in coherent, afebrile with IVF PL148 infusing well at
urinary habits. Patient complained for right arm 30 drops per minute with the following
abdominal pain in the RLQ, pinching in vital signs
character with a pain scale of 5/10, being 10 BP = 150/100mmHg, PR = 90bpm, RR = 17cpm, T
as the highest and 1 as the lowest, localized = 37°C,BMI = 22.5
with passage of flatus. Patient’s condition
was tolerated and no medications taken and Skin:
no consultation was done. Brown complexion, warm to touch, senile skin
3 months PTA, due to persistence of the turgor, decreased elasticity, incision length of 9
condition, patient sought for consult. Patient inches, gauze was dry with no putrid smell to be
undergone a colonoscopy and biopsy at noted, no swelling, no redness, large birthmark on
Visayas Community Medical Center. right side of the chest, scar on right leg near the
Colonoscopy revealed (+) mass at 10 cm shin
from anal area, soft, attached to the wall
occupying about ¼ at the lumen at the rectal Nails:
area with tiny ulcers seems scattered Pale nail beds, no nail clubbing, CRT<2 seconds,
surrounded with erythema and (+) mucosal thickened and smooth, firm
invagination at the descending colon. Biopsy
revealed presence of an adenomatous polyp. Hair:
Patient was advised by the doctor for surgical Black with thick strands, evenly distributed, no
removal and was prescribed with unrecalled presence of parasite or dandruff
medication to be taken for 1 month with good
compliance. Patient claimed improvement of Head and Scalp:
condition. Normocephalic, can flex and turn head up, down
3 weeks PTA, patient noted decreased and to both sides, no lesions on scalp, smooth, no 16
amount of stool, less than ½ cup, watery, pain noted during movement
yellow, non-blood streaked associated with
RLQ abdominal pain, 5/10, being 10 as the Face:
APPENDICES

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