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Myoma pathophysio, gordon's ncp

Myoma pathophysio, gordon's ncp

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Published by icesexy
Pathophysiology by Irish C. Edombingo
Pathophysiology by Irish C. Edombingo

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Published by: icesexy on Mar 14, 2010
Copyright:Attribution Non-commercial

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08/23/2012

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PATIENT’S PROFILE
NAME:
Patient “x”
ADDRESS:
Alano extension, Pagadian City
SEX:
Female
BIRTHDATE:
May 18, 1968
AGE
: 41 y/o
BIRTHPLACE:
Davao del Sur 
NATIONALITY:
Filipino
RELIGION:
Roman Catholic
CIVIL STATUS:
single
FATHER’S NAME:
Juanito Pantullana
MOTHER’S NAME:
Remedios Pantullana
ADMISSION: DATE
: February 28, 2010 
TIME:
10:40 am
Room/Ward:
OB-WARD
Chief complain:
Hypogastric pain
ADMISSION DIAGNOSIS:
Uterine Myoma
ATTENDING PHYSICIAN:
Dr. Chandra Salvador 
HISTORY OF PAST ILLNESS:
The patient was never been hospitalizedbefore and had not experienced any kind of diseases. She onlyhad mild illness such as cough, fever and headache. She alsoexperienced dysmenorrhea in the 1
st
– 2
nd
day of her menstruation.
HISTORY OF PRESENT ILLNESS:
3 years prior to admission, the patientnoticed a mass on hypogastric area of her abdomen. She thoughtthat it was only due to her loaded works and stress and so, sheonly consulted a “hilot”. She didn’t mind to have a consultation ona doctor because of lack of financial budget.1 year prior to admission, the patient hadundergone free medical check up from the company where shewas working with and so, the UTZ’s result found out that she hadan enlarged uterus with intramural myoma uterine.
PHYSICAL ASSESSMENT
 
GENERAL SURVEY:
Received lying on bed conscious and coherent without IVF. Patient isconscious and coherent, and also responsive to certain questions andinstructions given to her. Tension and increased alertness was noted on thepatient upon receiving her.
VITAL SIGNS:
T = 36.3oCP = 70 bpmR = 26 cpmBP = 120/70 mmHg
 
SKIN
warm to touch on upper extremities like in the palm of her hands
cold temperature on the sole of the client
Fair skin and brown in color
Has a good skin turgor upon palpation
Presence of scars on both upper and lower extremities
HAIR
Equally distributed hair
Black with some white hair in color
Slightly coarse
No nodules, lumps and tenderness noted upon palpation
Absence of lice and dandruff 
NAILS
Nail beds are pinkish in color
Smooth texture
short nails with dirt noted
good capillary refill, less than 2 seconds
EYES
symmetrical
pupils are equally round and reactive to light accommodation
pupils are black in color
sclera is white
eyebrows and eyelashes are equally distributed
 
eyelashes are slightly curve
pupils constricts symmetrically when lighted with a penlight
Blurred vision on her both eyes
EARS
no deformities
symmetrical
no cerumen and dirt noted
uniform in color
no discharges noted
mobile, firm, and not tender upon palpation
helix of ears are in line with the outer canthus of the eye
NOSE AND SINUSES
nose is located in the midline of the face
symmetrical
proportionate to the face
absence of discharges
no nasal flaring
uniform in color
no skin breakdown
nasal septum intact
nasal hairs are evenly distributed
no tenderness and pain upon palpation on facial sinuses
MOUTH
dry lips
pinkish colored gums
uvula is located at the midline of the soft palate

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