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II. Assessment A. General Assessment Tool I. GENERAL INFORMATION Name: E.M. Age: 30 yrs.

old Birthday: December 21, 1979 Sex: Male Civil Status: Single Religion: Roman Catholic Occupation: Farmer Address: Rizal, Claveria, Misamis Oriental Informant: M.V. and E.M. Relation: elder sister and patient himself Admission Date: July 13, 2010 (Tuesday) Time of Admission: 11:00 PM Chief Complaint: Change in sensorium Attending Physician: Dr. Sarmiento Diagnosis/ Impression: Hepatic Encephalopathy secondary to hepatitis B Infection History of Present Illness: Last July 1, 2010, patient complained of intermittent epigastric pain with a pain level of 7/10 with 10 as the most painful and loss of appetite but tolerated his condition. On July 5, 2010, he still complained of loss of appetite, and on and off epigastric pain that radiated to the right upper quadrant as well as hematemesis. Patients elder sister administered antacids (Kremil-S, 1 tab, 500 mg) since she suspected that the patient might be suffering from hyperacidity. His wife also applied efficascent oil all over his back and his abdomen after suspecting that the patient has panuhot. On July 9, patient still suffered from the same complaints which prompted them to seek medical advice in Claveria Public Hospital. He was told by the physician that he might be suffering from ulcer and that he needed further evaluation and follow-up visits in the hospital. He was given cimetidine and antacids (Al (OH) 3) and was allowed to rest at home. On July 12, he complained of feeling worse, as he experienced blurred vision and tends to forget the things that he is doing (e.g. why he is opening the door, why he is holding a paper). According to his wife and sister, the patients affect became flat and appeared clueless of what he was saying or doing. 1 day P.T.A., his epigastric pain worsened and chose not to eat the whole day. He then vomited in the evening; vomitus was brownish with blood streaks and was approximately 60 cc. In the morning of July 13, his wife tried to get him up from bed but he was too weak to do so and he felt nauseated and dizzy. They rushed him to Claveria Public Hospital but the physician was unable to diagnose the patients

condition due to inadequate resources. He was referred to Northern Mindanao Medical Center, hence, their current admission. Food and Drug Allergy, please specify: No known drug or food allergies Past Major Illness, Operation, and Hospitalization: Last November 2008, patient was hospitalized in Claveria Public Hospital with a chief complaint of high grade fever and was diagnosed with Urinary Tract Infection. Vital signs: July 14, 2010 HR- 86 bpm RR- 16 cpm Temp36.3 0C BP120/80 mmHg July 15, 2010 HR- 61 bpm RR- 16 cpm Temp36.6 0C BP120/80 mmHg July 16, 2010 HR- 73 bpm RR- 15 cpm Temp37 0C BP130/80 mmHg July 17, 2010 HR- 90 bpm RR- 21 cpm Temp37 0C BP130/80 mmHg September 3, 2010 HR- 80 bpm RR- 18 cpm Temp 37 0C BP120/80 mmHg

July 14, 2010 Weight: 50kg Height: 56 II. ACTIVITY/REST Usual activities:

July 17, 2010 Weight: 52kg Height: 56

September 3, 2010 Weight: 59kg Height: 56

July 14, 2010 Magdaro, manigway. Magsige ra gyud na siya og trabaho. as verbalized by S.O.

July 17,2010 Halos naa rako sa uma gatrabaho tibuok adlaw. Diri sad sa ospital kay sige ra ug higda ug lingcod. as verbalized by patient.

September 3, 2010 Ga-stand by rako diri balay pagka-uli gikan ospital. Mga isa ka semana ayha ko naka joggingjogging ug baklaybaklay sa gawas sa balay. Ug human sa tulo ka semana kay nakahinay-hinay nako og sugod sa trabaho. Karon kay nakabalik na gyud ko sa akong mga 7

Usual leisure time activities:

Hilig na siya og magbasketball, maglaag, magtanaw og tv. as verbalized by S.O.

Limitations imposed by condition:

Dili na siya makahimo sa iyang trabaho kay pirme nalang mag-lain iyang ginhawa. as verbalized by S.O.

Usual sleep pattern:

Sa una mga alasdyes na siya matulog sa gabii ug mumata dayun mga alas singko para magtrabaho na dayun. Pero tong lain na iyang

Ay, maglaag-laag, basketball og standby sa balay kung way himuon Diri sa ospital, magsturya2x lang sa mga parente kay wala gyuy lain lingaw as verbalized by patient. Gatrabaho pa man hinuon ko tong sakit akong tiyan pero atong dominggo nga gahanap-hanap na akong panan-aw og dali nako makalimot, wala na gyud ko naka-adto ug uma ug wala nako kabalo ug unsa na akong mga gipanghimo. Na hospital pa gyud ko samot nga wala gyud ko nakatrabaho. Pirme rako diri sa katri kay nakacatheter pa man ko og medyo luya pasad ko. as verbalized by patient. Ga sige rako ug tulog diri sa hospital kay medyo luya pasad akong pamati. Mga alassyete tulog nako ug maka-mata rako pag magkuha napud

kasagara na trabaho sa umahan. as verbalized by patient. Basketball2x gihapon usahay ug magtan-aw t.v sa gabii. as verbalized by patient.

Okay naman ko makatrabaho nako balik ug tarong ug makalaag-laag nasad ko. Pero dili sad ko gapalabi kay mahadlok sad ko nga basin ma-unsa pa lang ko as verbalized by patient.

Wala man pud koy problema sa akong pagtulog karun. Matulog ko mga alas otso dayun mumata mga alas kwatro o alas singko. as 8

Naps:

ginabati-on mga alas syete pa lang tulog na ug mumata mga alas otso sa buntag. as verbalized by SO. Na mag sige ra gyud ug tulog sa udto katong nagsakit na siya. as verbalized by SO.

ug bp or maghatag tambal. as verbalized by patient. Sa una tong wala pako nagsakit usahay rako makatulog sa udto o hapon pero karun sa ospital mag sige ra gyud ko ug tulog. Ganiha buntag mga duha or tulo ka oras dayun mata-mata nasad... taud2x balik nasad ug tulog. as verbalized by patient. Wala man. as verbalized by patient. Wala man sad. as verbalized by patient.

verbalized by patient.

Tibuok adlaw naa man ko sa uma. Makauli ko sa balay mga alas unsi. Usahay makatulog gamay ug mga usa ka oras dayon balik nasad sa uma. as verbalized by patient.

Aids:

Difficulty sleeping:

Feeling on awakening:

Wala man, makatulog mana diretso. as verbalized by SO. Wala man pud na siya nagreklamo nga lisod itulog. Mag sige naman hinuon ug tulog. as verbalized by SO. Dili sad gyud ko kaingun pero murag gikapoy man gihapon. as verbalized by SO.

Wala man. as verbalized by patient. Wala man. as verbalized by patient.

Okay ra pero luyaluya gamay. as verbalized by patient.

Maayo man akong pamati. Wala man pud koy lain nga gabation. as verbalized by patient.

Objective: July 14 & 15, 2010 Observed response to activity: Patient was not able to perform any activity. Posture: Patient was unable to stand as he remained in bed. Others/Comments: Patient was stuporous and responds in vigorous and painful stimuli (e.g. pin prick, face tapping). Upon waking up, patient stares blankly in one direction and does not follow verbal instructions (e.g. follow the light with the eyes, raise arms, and flex legs). Patient does not respond verbally to questions or instructions. 9

July 17, 2010 Observed response to activity: Patient was able to perform activities such as active range of motion exercises and was able to sit up on bed. Posture: Patient was slouching. Others/Comments: Patient moved slowly. He responded to certain stimuli such as follow the light with the eyes, raise arms, and flex legs. September 3, 2010 (home visit) Observed response to activity: Patient able to walk 10-12 ft. away from S.N. HR, RR & BP remained the same & remained stable. Posture: Pt. able to stand & sit erect. III. CIRCULATION July 14, 2010 History of hypertension September 03, 2010 Wala pud ko Sukad2x sa Katong naa pa kabalo kung akong pagkabata ko sa ospital nahigh blood wala man pud ko usahay ingnan ko naba ni siya. gi-high blood. as sa mga nurse as verbalized by verbalized by nga taas akong S.O. patient. B.P. dayun munaog napud. As verbalized by patient. Wala man sad Wala man. as Wala man sad na siya verbalized by nagsakit akong nagreklamo. as patient. dughan. as verbalized by verbalized by S.O. patient. Wala man sad ko nakamatikod nga nanghupong siya. as verbalized by S.O. Murag medyo ni dako akong duha ka tiil. Karun pa sad ni nabantayan sa akong igsoon as verbalized by patient. Pag-gawas namo sa hospital pareha ra kadako atong ulahi ninyong adto pero pag-abot namu diri sa balay mas gidako siya ug nagdako pud akong tiyan as verbalized by 10 July 17, 2010

Heart trouble

Ankle/leg edema

patient. Slow healing Wala man pud. as verbalized by the S.O. Wala man sad ko nakamatikod nga dugay maayo akong samad. as verbalized by patient. Wala man pud as verbalized by patient. Wala man pud ko gi-ubo karun as verbalized by patient. Wala pasad ko nasamad pag-uli nako diri sa balay as verbalized by patient. Wala gihapon verbalized patient. man as by

Claudication

Cough/hemoptysis

Extremities/numbnes s

Wala man pud siya nag-ingun o nag- reklamo. as verbalized by the S.O. Wala man sad siya gi-ubo. Wala pasad na siya nagreklamo nga dunay dugo iyang ubo as verbalized by the S.O. Wala man pud. as verbalized by the S.O.

Wala man sad koy ubo as verbalized by patient.

Wala man sad Wala man pud maminhod akong as verbalized by kamot ug tiil. as patient. verbalized by patient.

Objective: July 14, 2010 Blood Pressure Lying L-120/80 mmHg Sitting Not assessed Standing Not assessed

July 15, 2010 Blood Pressure Lying L-120/80 mmHg Sitting Not assessed Standing Not assessed

July 16, 2010 Blood Pressure Lying L-130/80 mmHg

July 17, 2010 Blood Pressure Lying L-130/80 mmHg

September 3, 2010 Blood Pressure Lying R- 120/90 mmHg SittingL-120/90 mmHg Standing R-120/90 mmHg 11

Sitting Sitting L120/80 LmmHg 130/80mmHg Standing Not assessed Standing L120/80mmHg

Pulse Pressure: 4050 mmHg PMI: 5th ICS, left sternal border, midclavicular line

Pulse Pressure: 4050 mmHg PMI: 5th ICS, left sternal border, midclavicular line

Pulse Pressure: 4050 mmHg PMI: 5th ICS, left sternal border, midclavicular line

Pulse Pulse Pressure: 40- Pressure: 40 50 mmHg mmHg PMI: 5th ICS, PMI: 5th ICS, left sternal left sternal border, border, midclavicular midclavicular line line

Objective Data Heart Rate Sounds Rhythm Pulse Site Carotid Brachial Radial Dorsalis Pedis Popliteal Temporal

July 14, 2010 87 bpm S1 S 2 noted Regular July 14, 2010 87 bpm 85 bpm 86 bpm 82 bpm 83 bpm 86 bpm

July 15, 2010 66 bpm S1 S 2 noted Regular July 15, 2010 66 bpm 63 bpm 61 bpm 58 bpm 58 bpm 60 bpm

July 16, 2010 73 bpm S1 S 2 noted Regular July 16, 2010 73 bpm 69 bpm 73 bpm 69 bpm 71 bpm 73 bpm

July 17, 2010 90 bpm S1 S 2 noted Regular July 17, 2010 90 bpm 91 bpm 90 bpm 88 bpm 89 bpm 90 bpm

Sept 3, 2010 80 bpm S1 S 2 noted Regular Sept 3, 2010 80 bpm 81 bpm 80 bpm 79 bpm 80 bpm 81 bpm

Breath Sounds: July 14, 2010 July 15, 2010 Clear Breath Clear Breath Sounds Sounds

July 16, 2010 Clear Breath Sounds

July 17, 2010 Clear Breath Sounds

Sept 3,2010 Clear Breath sounds

Jugular vein distention: none noted Extremities: Temperature: Warm to touch July 14, 2010 July 15, 2010 Temp - 36.3 0C Temp - 36.6 0C Objective Data Capillary Refill: July 14, 2010 <2 seconds

Color: Brown July 17, 2010 Temp - 37 0C July 17, 2010 <2 seconds Sept 3, 2010 Temp-37 0C Sept 3, 2010 4 seconds

July 16, 2010 Temp - 37 0C

July 15, 2010 <2 seconds

July 16, 2010 <2 seconds

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Vascular Bruit: Homans Sign: Varicosities: Color of Nail Beds: Lips: Oral Mucous Membranes:

None noted (-) No varicositie s noted Yellow Pale and dry Moist, intact, color of membrane s under the tongue is yellowish Icteric

None noted (-) No varicosities noted Yellow Pale and dry

None noted (-) No varicosities noted Yellow Pale and dry

None noted (-) No varicosities noted Yellow Pale and dry

None noted (-) No varicosities noted Yellow Pale and dry Moist, intact, color of membranes under the tongue is yellowish Icteric

Moist, Moist, Moist, intact, color intact, color intact, color of of of membranes membranes membranes under the under the under the tongue is tongue is tongue is yellowish yellowish yellowish Icteric Icteric Icteric

Sclera:

IV. EGO INTEGRITY July 14, 2010 July 17, 2010 Usahay maproblema sa atong kapobrehon samot na karun nga na ospital pajud.. As verbalized by patient. Lingaw-lingaw uban ang pamilya isturya-isturya. Pasalamat sad gyud ko kay gatabang sa ako akong mga igsoon As verbalized by patient. September 3, 2010 Mahadlok kog huna-huna nga niingon ang doctor nga wala na ni kaayuhan akong sakit pero okay raman gihapon, salamat sa Diyos. As verbalized by patient. Dili nalang hunahunaon ug padayon og ginhawa. As verbalized by patient.

Report of stress factors:

Kwarta ramay permi gaproblemahon ana. As verbalized by S.O.

Ways of handling stress:

Magjoke2x rana. Wala gyud na siyay libog, magkatawa2x rana permi, iya nalang dayun idala sa katawa bah. As verbalized by S.O.

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Financial concerns:

Relationship status:

Na problema gyud na. Ambot aha pa gani mi mangita ug pangbayad diri. Perti gyung lisuda biya namo mam. Naa pa iyang pamilya nabiyaan didto sa Claveria As verbalized by S.O. Buotan man kaayu na siya, wala gyud na siyay problema sa iyang asawa, pamilya ug mga igsoon. Wala pud na siyay kaaway. Si-aw man gud kaayu na siya ug jokeron bah. As verbalized by S.O. Aktibo gyud kay sige raman na ug trabaho ug lakaw As verbalized by S.O. Medyo na laylo lang gyud siya sa iyang mga gapangbuhaton tungod sa iyang sakit As verbalized by S.O.

Galisod gyud mi karon. Wa gyud mi ikapalit aning gipangresita nga tambal. As verbalized by patient.

Igo-igo ra gyud makakaon sa tulo ka adlaw ug gapaningkamot gyud og trabaho karon kay wala gyuy lain magbuhi sa akong pamilya. As verbalized by patient.

Okay ra man sad akong relasyon sa akong pamilya. Wala man sad koy kaaway. Mas na close na hinuon gyud ko karun sa akong mga igsoon. As verbalized by patient. Karun kay naa ra gyud ko pirme sa katri gahigdahigda, lingkod2x. As verbalized by patient. Sa una kay lihok gyud kayo ko. Karon sige ra og higda ug naa ra gyud sa katri. As verbalized by patient.

Okay ra man. Pasalamat lang gyud ko nga naa akong pamilya gasuporta og gasabot sa akong kahimtang. As verbalized by patient. Dili ko mahimutang kung wala koy buhaton. Medyo lihok gyud ko. As verbalized by patient. makabalik nako sa akong trabaho pero gabantay gyud gihapon ko kay basin magdaot nasad ko. As verbalized by patient. Wala pud. Gasalig lang gyud ko sa Ginoo nga matas-an pa gyud akong kinabuhi. As verbalized by patient. Wala man. As 14

Lifestyle:

Recent Changes:

Feelings of Helplessness/ Hopelessness: Powerlessness:

Wala man pud. As verbalized by S.O. Wala. As

Wala man. As verbalized by patient. Wala man. As

verbalized by S.O.

verbalized by patient.

verbalized by patient.

Objective: Emotional Status Objective July 14, Data 2010 Observed Physiologic Response: Not assessed (patient was Stuporous) July 15, 2010 Not assessed (patient was Stuporous) July 16, 2010 Calm July 17, 2010 Calm Sept 3. 2010 Calm

Other comments: Upon first day of assessment patient most of the time was asleep and when aroused by vigorous stimuli, he cannot respond verbally and does not obey command/ instructions. Assessment was done through interviewing the family members during the first day. V. ELIMINATION July 14, 2010 Kada-adlaw na siya gakalibang. As verbalized by S.O. Usual bowel pattern: July 17, 2010 Dili man pareha maam. Usahay ikaisa, ika-duha usahay pud, dili ko kalibang sa usa ka adlaw. Pero diri sa ospital wala pako kalibang gikan kagahapon. As verbalized by patient. Tong wala pako na-ospital. Brown dili pud gahi kaayu og dili pud basa. As verbalized by patient. Nah,wala nako nakahinumdum maam. As verbalized by September 3, 2010 Mga ka isa o kaduha sa usa ka adlaw. Dili man pareha adlawadlaw. As verbalized by patient.

Usual character of stool: Last Bowel Movement:

Brown, tibuok man As verbalized by S.O.

Ay, okay ra man. Brown ug dili gahi og dili pud basa. As verbalized by patient. Kagahapon. As verbalized by patient. (referring to 15

Ingun sa iyang asawa kay atong dominggo pana siya nakalibang kay

Laxative use:

History of bleeding: Hemorrhoids:

Constipation:

Diarrhea:

Usual voiding pattern:

Incontinence:

Wala man. As verbalized by patient. Wala pud siya Wala. As nagreklamo As verbalized by verbalized by S.O. patient. Ingun sa iyang Wala pa ko asawa kay atong kalibang sugod tong dominggo pana siya Nakamata ko nakalibang kay gahapon. As halos wala naman verbalized by pud lagiy patient. gakaonon. As verbalized by S.O. Wala sad. As Wala man. As verbalized by S.O. verbalized by patient. Wala man pud siya Usahay kaduha sa nagreklamo nga buntag og sa lisud iihi o sakit iihi. hapon, katulo Katong una dayon sa gabi.i namong pero diri sa ospital pagpacheck-up sa kay nakacatheter Claveria, yellow ang man ko. As color sa iyang ihi ug verbalized by sakto ra man sad patient. daw kadaghanon, As verbalized by S.O. Wala. As Wala. As verbalized by S.O. verbalized by

halos wala naman pud lagiy gakaonon. As verbalized by S.O. Wala man siya gagamit. As verbalized by S.O.; Laxative aid was ordered and administered on July 14, 2010 (Lactulose, 30 mL every 2 hours, restart with BM then 30 mL TID) Wala man pud. As verbalized by S.O.

patient.

September 2)

Wala pa sad ko sukad-sukad naka tumar. As verbalized by patient.

Wala man. As verbalized by patient.

Wala. As verbalized by patient. Wala man sad As verbalized by patient. Makalibang na ko ug tarong karon. As verbalized by patient.

Wala. As verbalized by patient. Dili pareha usahay mga ika pito sa usa ka adlaw, usahay ikawalo. As verbalized by patient.

Wala. As verbalized by 16

Urgency: Retention: Pain/Burning/Di fficulty in voiding:

Wala. As verbalized by S.O. Wala. As verbalized by S.O. Wala man pud daw sakit. As verbalized by S.O.

patient. Wala. As verbalized by patient. Wala. As verbalized by patient. Wala. As verbalized by patient.

patient. Wala. As verbalized by patient. Wala. As verbalized by patient. Wala. As verbalized by patient.

History of kidney/bladder disease: Na-admit siya sa 2008 kay gi U.T.I. pero kasa rasad to.(And there were no verbalizations regarding treatment.) Objective: Abdomen Tender: Palpable mass: Soft/Firm: Size/Girth: Bowel Sounds: Bladder palpable: Distension of Bladder: July 14, 2010 non tender none Firm 27 inches Hypoactive, irregular, gurgling sounds; (UR: 6, UL: 5, LR: 4, LL:4) Bladder not palpable Not Distended July 17, 2010 non tender None Firm 27 inches Hypoactive, irregular, gurgling sounds; (UR: 6, UL: 5, LR: 4, LL:4) Bladder not palpable Not Distended September 3, 2010 non tender None Firm 30 inches Normal, high pitched gurgling noises; ((UR: 16, UL: 15, LR: 15, LL:20) Bladder not palpable Not Distended

Others/Comments: Patient has a condom catheter attached to a urobag and is draining well to an amber-colored urine at 450 cc level (Inserted by Dr. Echalico on 07/13/10; 11:30 pm) upon first day of assessment up to last day of assessment and still had the condom catheter until July 18, 2010 Patient verbalized during home visit that he was only able to defecate on July 18, 2010 VI. FOOD/FLUID July 14, 2010 July 17, 2010 September 3, 2010 17

Usual diet (type):

S.O. verbalized, kasagara gakan-on niya kay bulad, isda ug mga utan. Kung makakaon ug karne usahay rasad kaayo kay mahal sad. . S.O. verbalized, katulo sa isa ka adlaw

Ginapa-agi raman ang murag lugaw diri sa akong ilong. Pero ingun man to si doctor nga puede na ni tantangon. As verbalized by patient Murag isa man tingali sa buntag dayun isa sa gabii gahapon diri gi-agi sa tubo sa akong ilong. Nakalimot man ko. As verbalized by the patient Lugaw ganiha buntag As verbalized by patient

Halos gulay gyud o mga de lata nga sud-an ug kan.on akong gakan-on. Makakaon usahay ug karne kung naa. As verbalized by patient Katulo sa isa ka adlaw. Usahay makasnak2x ginagmay sa hapon As verbalized by patient Ganiha pani-udto kay kan.on ug de lata nga sardinas. As verbalized by patient Wala naman hinuon, nibalik naman akong gana sa pagkaon As verbalized by patient

Number of meals daily:

Last meal /intake:

Katong gipa-agi sa iyang ilong nga murag lugaw pero gisuka rasad lagi niya as verbalized by the S.O. Mga sugod atong July permi rana siya walay gana. Ug ato laging mga lunes ug martes kay halos wala nay gakaonon kay sakit daw iyang tiyan ug ginasuka ra pud niya. Atong lunes nagsuka na siya sa balay ug nagreklamo siya sa buntag sa martes nga kasuka-on daw siya as verbalized by S.O. S.O. verbalized, wala man siyay

Loss of appetite:

Katong wala pako na-ospital permi rako walay gana pero karun akong pamati gyud kay perting gutoma As verbalized by patient

Nausea/ Vomiting:

Wala naman hinuon ko nagsuka ug dili naman sad ko kasuka-on As verbalized by patient Wala. As verbalized by

Wala naman ko nagsuka, ug dili na pud ko makafeel ug kasukaon As verbalized by patient Wala. As verbalized by 18

Dentures:

pustiso Allergy/ Food Intolerance: S.O. verbalized, wala man Permi na siya magreklamo nga sakit iyang kutokuto, tingali sad kay permi siya walay gana ug halos wala nay kaonon As S.O. verbalized

patient. Wala. As verbalized by patient. Medyo ga-lain akong kuto2x, tingali tungod kay paminaw nako gutom kaayo ko. As verbalized by patient.

patient. Wala. As verbalized by patient. Usahay maglain akong tiyan ug kuto2x labi na gikan ko magtrabaho o tunga2x sa akong pagtrabaho. Mawala raman sad pagmakapahuway na ug matrapuhan ang akong singot As verbalized by patient. Wala man. As verbalized by patient. Pag-abot nako diri sa balay gikan ospital, nitambok gyud ko kay nanghupong man sad ko sa akong kamot ug tiil. Mga 64 kg ko tong nagpacheck-up ko sa ospital diri sa claveria As verbalized by patient. Naginom ko atong Lasix kay nagdako akong tiyan, ni 36 inches gud to kadako pag-abot diri balay pero nawala ra dayun mga ikatulong semana sa agosto As verbalized by patient.

Heartburn/ Indigestion:

Mastication/ swallowing problems: Changes in weight:

S.O. verbalized, wala man Nagniwang na siya karun. Katong wala pa na siyay gibati tambok2x pana siya. Dili lang sad gyud ko kaingun kung unsa siya kabug-at sa una. As S.O. verbalized

Wala man. As verbalized by patient. Medyo nagniwang ko karun pero sa una mga 55 kilos gyud ko As verbalized by patient.

Diuretic use:

S.O. verbalized, wala man.

Wala man ko gagamit As verbalized by patient.

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Others/Comments: Upon first day of assessment, Patient has an NGT(French 16) at his left nostril (Inserted by Dr. Echalico on 07/14/10; 12:05 AM) Physician ordered on July 14, 2010: 0F- 2200 kcal (110 gm CHON, 275 carbohydrates, 73 gm fat, 4 gm NaCl) in 4 equal feedings Patient vomited thrice upon first day of assessment - Patient vomited right after being fed via NGT; vomitus was yellowish in color; approximately amounting to 240 cc. - Patient vomited right after being transferred from the E.R. to the Male Medical Ward; vomitus was greenish in color with blood streaks approximately amounting to 180 cc. - Patient vomited for the third time after being given second feeding via NGT; vomitus was yellowish in color approximately amounting to 240 cc. Patient able to progress to soft diet on July 18, 2010 Patient able to resume usual diet pattern upon arriving at home

Objective Data Skin turgor: Mucous membranes: Edema: Thyroid enlarged: Halitosis: Appearance of tongue: Height: 56

July 14, 2010 Good and resilient moist, intact but yellowish in color none Not Enlarged Bad odor noted moist, pinkintact

July 15, 2010 Good and resilient moist, intact but yellowish in color none Not Enlarged Bad odor noted moist, pinkintact

July 16, 2010 Good and resilient moist, intact but yellowish in color Mild edema (+1) on both feet Not Enlarged Bad odor noted moist, pinkintact

July 17, 2010 Good and resilient moist, intact but yellowish in color Mild edema (+1) on both feet Not Enlarged Bad odor noted moist, pinkintact

September 3, 2010 Good and resilient moist, intact but yellowish in color Bipedal pitting edema Not Enlarged Mild odor noted moist, pinkintact

July 14, 2010 BMI: 17.79; classified as underweight

July 17, 2010 18.5; within normal range for BMI

September 3, 2010 20.99; within normal range for BMI 20

Body Build: Hernia/ masses:

ectomorph; decreased amount of fat and muscles None Patient has a set of complete teeth most are yellowish in color. The gums are pinkish, intact and without lesions. The back of the tongue is yellowish and bad odor noted from the mouth.

ectomorph; decreased amount of fat and muscles None Patient has a set of complete teeth most are yellowish in color. The gums are pinkish, intact and without lesions. The back of the tongue is yellowish and mild odor noted from the mouth.

Endomorph None Patient has a set of complete teeth most are yellowish in color. The gums are pinkish, intact and without lesions. The back of the tongue is yellowish and mild odor noted from the mouth.

Condition of teeth/gums:

Intake and Output Record: (Refer please to appendices) VII. HYGIENE July 14, 2010 Activities of Daily Living (Independent/ Dependent): Equipment/ prosthetic devices required: Assistance provided by: July 17, 2010 September 3, 2010 Independent None Assistance may be provided by his wife Patient is already able to perform activities of daily living independently

Dependent None Elder sisters and elder brother

Dependent None Elder sisters and elder brother Patient is fully conscious but still needs assistance as he has not regained his full normal strength

Others/Comments: Upon assessment, patient is stuporous responds to vigorous stimuli but not able to talk and make movements purposefully. Patient is not able

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to feed, dress and take care of himself as he laid in bed all through out the day.

Objective: Objective Data

July 14, 2010 unkempt, with long dirty nails, General dry and Appearance: cracked soles Manner of Dress: Body Odor: Condition of Scalp: Presence of Vermin: Others/Com ments: Appropriat e; wore tshirt and shorts Has some body odor With dandruff but no lesions noted No infestations noted Patient was not able to take a bath due to his condition but assisted by his family members and student nurses with

July 15, 2010 unkempt, with long dirty nails, dry and cracked soles Appropriat e; wore tshirt and shorts Has some body odor With dandruff but no lesions noted No infestations noted Patient still not able to take a bath but assisted by his SO with hygienic measures such as sponge bath

July 16, 2010 Well-kept with short clean nails; able to endure some activities Appropriate ; wore tshirt and shorts Less body odor

July 17, 2010 Well-kept with short clean nails; able to endure ambulating

Appropriate ; wore tshirt and shorts No body odor With With dandruff but dandruff but no lesions no lesions noted noted No infestations noted Patient still not able to take a bath but assisted by his SO with hygienic measures such as sponge bath No infestations noted Patient still not able to take a bath independen tly but assisted by his SO with hygienic measures such as sponge bath

Sept. 3, 2010 Untidy with long dirty nails as he came from a heavy days work in the farm Appropriate; wore t-shirt and shorts Some body odor With dandruff but no lesions noted No infestations noted Patient takes a bath everyday and is able to change his clothes independently

22

hygienic measures such as changing of clothes as necessary VIII. NEUROSENSORY July 14, 2010 S.O. verbalized, nagreklamo lagi siya nga gakalipong daw siya atong martes (July 13, 2010 pero dili mana siya permi gyud gakalipong sa una. wala man, gakalipong lang siya. As verbalized by S.O. nagluya gyud siya sugod atong mga lunes (july 12, 2010), murag tibuok lawas niya dili niya ma-alsa. Maayo karun kay murag sige siya ug tulog diri sa hospital pero gakabalaka sad mi kay dili man pud makamata ug sturya ug tarong As verbalized by S.O. nagreklamo to siya nga hanap2x daw iyang panan-aw. July 17, 2010 Dependent Usahay malipong ko kung kali kot mutindog as verbalized by patient September 3, 2010 Independent wala man ko gakalipong diri sa balay.. as verbalized by patient

Fainting spells/ dizziness:

Headache:

wala man koy gibati na labad sa ulo as verbalized by patient luya pa gyud akong gibati ug dili pa nayo malihok ug tarong akong lawas as verbalized by patient

wala napud nagsakit akong ulo as verbalized by patient mga tulo ka semana human ko gi gawas sa ospital pa gyud ko ayha nabaskog balik.. wala naman hinuon ko nagluya karon as verbalized by patient

Weakness (location):

Eyes: Vision loss: Right/Left:

makakita nako pero dapat kanang naa sa duol lang

atong wa pako nagdaot, makaklaro man gyud ko sa 23

Wala sad mi kabalo nganu to, nikalit raman As verbalized by S.O. S.O. verbalized, sukad wala pasad mi nakapacheck-up sa iyang mata S.O. verbalized, wala man pud siyay glaucoma. S.O. verbalized, wala man pud na siyay cataract. S.O. verbalized, okay raman sad tingali kay wala man siyay gireklamo nga dili siya isimhot. S.O. verbalized, wala pasad sukad nagsunggo.

kay hanaphanap na kung mga upat ka metro ang ka layo as verbalized by patient wala pako sukad naka pa check-up as verbalized by patient wala man koy glaucoma as verbalized by patient wala man pud koy cataract as verbalized by patient okay raman as verbalized by patient

layo pero karon kay maglisod nako as verbalized by patient plano nako mapatan-aw sa doctor puhon unta as verbalized by patient wala as verbalized by patient wala man as verbalized by patient wala may problema as verbalized by patient wala man as verbalized by patient

Last examination:

Glaucoma:

Cataract:

Sense of smell:

Epistaxis:

wala man as verbalized by patient

Others/Comments: S.O. verbalized, Limtanon nasad kaayu siya ug murag wala siya sa iyang kaugalinon bah Kung magsturya mi usahay kay mawala siya sa passing (out of topic). (referring to patients status prior to admission) Patient verbalized upon home visit usahay makalimot ko sa ginagmay na butang pero pagkadugayan mahidomdoman rasad nko balik. Objective: Objective Data Mental Status: July 14, 2010 Stuporous; Not oriented to time, place, and person July 15, 2010 Stuporous; Not oriented to time, place, and person July 16, 2010 Drowsy; but oriented to time and place and person July 17, 2010 Alert and fully conscious; Oriented to time, place September 3, 2010 Alert and fully conscious; Oriented to time, place 24

Affect: Delusions: Hallucinations:

Flat No delusions reported No hallucinations reported

Flat No delusions reported No hallucinations reported

Appropriate No delusions reported No hallucinations reported

Memory:

Recent: Not Accessible Remote: Not Accessible

Recent: Not Accessible Remote: Not Accessible

Recent: Accessible (able to remember who visited him in the afternoon) Remote: Not accessible

Speech Pattern:

Patient unable to verbally communicate

Patient unable to verbally communicate

Slurred (inaudible and difficult to understand) Congruent in content and context (although it took time to fully understand his words) OS and OD: 2mm, pupil equally round and reactive to light and accommodation

and person Appropriate No delusions reported No hallucinations reported Recent: Accessible (able to remember student nurse who took care of him in the morning) Remote: Accessible (able to remember his own birthday) Understandable; clear; spontaneous And loud enough to hear Congruent in content and context

and person Appropriate No delusions reported No hallucinations reported Recent: Accessible (able to remember what his lunch was) Remote: Accessible (able to recall wifes birthday Understandable; clear; spontaneous And loud enough to hear Congruent in content and context

Congruence:

Patient unable to verbally communicate OS and OD: 2mm, pupil equally round and reactive to light and accommodation

Patient unable to verbally communicate OS and OD: 2mm, pupil equally round and reactive to light and accommodation

Pupil Size/ Reaction:

OS and OD: 2mm, pupil equally round and reactive to light and accommodation

OS and OD: 2mm, pupil equally round and reactive to light and accommodation

25

Facial Droop:

None noted Swallowing is not impaired but strict aspiration precaution due to altered mental status. Patient not able to perform handgrip Not able to stand/sit No paralysis noted

None noted Swallowing is not impaired but strict aspiration precaution due to altered mental status. Patient not able to perform handgrip Not able to stand/ sit No paralysis noted

None noted

None noted

None noted

Swa llowing:

No difficulty in swallowing noted

No difficulty in swallowing noted

No difficulty in swallowing noted

Handgrip/ Release: Posturing: Paralysis:

Left: weak handgrip Right: weak handgrip Slouching No paralysis noted

Left: strong handgrip Right: strong handgrip Slouching No paralysis noted

Left: strong handgrip Right: strong handgrip Erect No paralysis noted

Glasses: None prescribed. Contacts: None Hearing aids: None Others/Comments: Patient is stuporous and responds in vigorous and painful stimuli (e.g. pin prick, tapping his face). Last July 14, 2010. Upon waking up, patient stares blankly in one direction and does not follow verbal instructions (e.g. follow the light with the eyes, raise arms, and flex legs). Last July 14, 2010. Patient does not respond verbally to questions or instructions but after physicians assessment in the E.R., patient suddenly made a moan-like sound for about 30 seconds. Further assessment was done by the physician patient but he did not respond and continued to stare blankly in one direction. Babinski Reflex: Kernigs sign: Brudzinkis reflex: Deep Tendon Reflex: July 14, 2010 (-) (-) (-) July 17, 2010 (-) (-) (-) September 3, 2010 (-) (-) (-)

+2 +2 +2

+2

26

+2

+2

+2 +2 +2

+2

*test for DTR was done by the physician on July 14, 2010 as observed by SN in the ER. *DTR of July 17, 2010 is equal to +2 in both elbows and patella. July 17, 2010 positive September 3, 2010 negative

Aterexis Glascow Coma Scale:

Motor Response: Verbal Response: EyeOpening: Total: SPERM: DATE July 14 July 15 July 16

July 14, July 15, 2010 July 16, 2010 2010 5 5 6 (localizes (localizes (obeys simple painful painful response) stimuli) stimuli) 2 1 5 (incompreh (no verbal (oriented) ensible response) sounds) 2 2 3 (in (in response (in response response to pain) to sound) to pain) 9 8 14

July 17, 2010 6 (obeys simple response) 5 (oriented) 4 (spontaneous) 15

September 3, 2010 6 (obeys simple response) 5 (oriented) 4 (spontaneous) 15

Sensorium Stuporous Stuporous Drowsy

Pupil 2mm 2mm 2mm

Eye movement 2 (in response to pain) 2 (in response to pain) 3 (in response to sound)

Respiration 16cpm 16cpm 15cpm

Motor response 5(localizes painful stimuli) 5(localizes painful stimuli) 6(obeys simple commands) 27

July 17 September 3

Alert and fully conscious Alert and fully conscious

2mm 2mm

4 (spontaneous) 4 (spontaneous)

21cpm 18cpm

6(obeys simple commands) 6(obeys simple commands)

Handwriting:

Signature on July 16, 2010

Signature on July 17, 2010

Signature on September 3, 2010 *Patient verbalized on July 16, 2010, Hala, dili ko kasulat ug tarung Ambot nganu... Murag gakurog akong kamot, dili ko kasabot 28

*Patient verbalized on July 17, 2010, Arang-arang na akong pagsulat Inani gyud ang dapat itsura gahapon sa akong signature *Patient verbalized on Sept. 3, 2010, Okay na akong pagsulat karun, dili na maghiwi2x IX. PAIN/COMFORT Others/Comments: Assessment for pain was not done as patient was not able to verbalize any discomfort. Patient was not able to respond purposefully upon assessment. Patients vital signs were within normal range upon assessment. Patient did not complain of pain in the third and fourth day of assessment where he was already able to verbally communicate. Patient did not complainof any experience of pain upon assessment on July 17, 2010. There were no complaints of pain upon home visit. X. RESPIRATION Subjective July 14, 2010 S.O. verbalized, wala man sad siya gi-ubo. Wala pasad na siya nagreklamo nga dunay dugo iyang ubo July 17, 2010 wala man ko giubo as verbalized by patient. nay adlaw nga tulo ka stick naa puy adlaw nga isa ka kaha akong mahurot.. pero karung semanaha wala ko naka panigarilyo. As verbalized by patient. dili permanente pero naay mga adlaw nga maka hurot kog isa. mga 3 tingali ka adlaw sa isa ka semana September 3, 2010 wala man koy ubo As verbalized by patient.

Cough/sputum:

Smoker:

Panalagsa raman kaayu as verbalized by SO

mga isa o duha ka stick nalang ug ginaantus nako nga sa isa ka adlaw dili gyud manigarilyo. As verbalized by patient. dili na gaabot ug isa ka kaha karon As verbalized by patient.

Pack per day:

S.O. verbalized, mga isa raman o duha ka kaha sa isa ka adlaw

29

Brand:

S.O. verbalized, Philip, Champion, Hope... Bisan unsa man

Number of years:

adtong dise otso pa siya as verbalized by S.O. naa siyay oxygen. As verbalized by S.O.

As verbalized by patient. kasagara fortune nga red pero kung walay fortune bisan unsa raman. As verbalized by patient. nagsugod kog sigarilyo tong namatay si papa mga disi otso ko As verbalized by patient. kaning oxygen sa akong ilong As verbalized by patient.

fortune nga pula ug kung wala, mark nalang As verbalized by patient. mga 12 na ka tuig As verbalized by patient. wala na naman koy gamit2x anang oxygen As verbalized by patient.

Use of respiratory aids:

Others/Comments: Objective Objective Data Respiratory Rate: Depth: Symmetry: Use of Accessory Muscles: Nasal Flaring: July 14, 2010 16 cpm Equal Bilateral Chest Expansion; Deep Symmetric Yes, abdominal muscles Mild nasal flaring noted July 15, 2010 16 cpm Equal Bilateral Chest Expansion; Deep Symmetric Yes, abdominal muscles Mild nasal flaring noted July 16, 2010 15 cpm July 17, 2010 21 cpm September 3, 2010 18 cpm Equal Bilateral Chest Expansion; Deep Symmetric Yes, abdominal muscles No nasal flaring noted Tactile fremitus noted on both lung fields

Equal Equal Bilateral Bilateral Chest Chest Expansion; Expansion; Deep Deep Symmetric Symmetric Yes, Yes, abdominal abdominal muscles muscles Mild nasal Mild nasal flaring flaring noted noted Tactile fremitus noted on both lung fields Tactile fremitus noted on both lung fields

Fremitus:

Not Not assessed as assessed as patient not patient not able to able to verbally verbally communicate communicate

30

Breath Sounds: Cyanosis: Clubbing of Fingers: Sputum Characteristics:

Clear, vesicular lung fields Acyanotic None None

Clear, vesicular lung fields Acyanotic None None

Clear, vesicular lung fields Acyanotic None None

Clear, vesicular lung fields Acyanotic None None

Clear, vesicular lung fields Acyanotic None None

XI. SAFETY July 14, 2010 Allergies/ sensitivity: S.O. verbalized, wala mana siyay allergy. July 17, 2010 Patient verbalized, wala man pud koy nahibal-an na allergic ko Patient verbalized, wala man pud ko na-abunuhan ug dugo. September 3, 2010 Patient verbalized, wala man. Patient verbalized, sukad2x wala gyud ko kabalo nga naakoy hep B. Ingun ang doctor pwede daw nako ni makuha sa pakighilawas Patient verbalized, wala man.

History of STD (date/type):

S.O. verbalized, wala man.

Blood transfusion/number:

S.O verbalized, wala paman sad na siya sukad naabunuhan ug dugo S.O. verbalized, nahulog to siya sa kabayo sa una pero wala raman siya na-unsa. Naligyas sad daw na siya pagdula ug basketball tong mga unang semana sa july. S.O. verbalized, wala man pud.

Patient verbalized, wala man. Patient verbalized, sa una nahulog ko sa kabayo pero bata pako ato..mga 12 pako. napi-ang ko ato sa kamot pero gipahilot ra dayon. Wala man pud ko naligyas tong nagbasketball ko. Patient verbalized, wala.

History of accidental injuries:

Patient verbalized, wala man gikan tong na-ospital ko.

Fractures/ dislocations

Patient verbalized, wala. 31

Arthritis/ unstable joints Back problems

S.O. verbalized, wala man na siyay arthritis. S.O. verbalized, wala pud man siya nagreklamo wala mi ka matikod. S.O. verbalized, wala man sad. S.O. verbalized, wala man sad. S.O. verbalized, dili man siya gasungkod.

Patient verbalized, wala man pud koy arthritis. Patient verbalized, wala may sakit akong likod. Patient verbalized, wala ko kabantay. Patient verbalized, wala man koy namatikdan nga gilusayan ko. Patient verbalized, wala. Patient verbalized, dili man ko gasungkod.

Patient verbalized, wala man. Patient verbalized, wala man koy nabatian nga na sakit akong likod. Patient verbalized, wala. Patient verbalized, wala man ko nalusayan. Patient verbalized, wala. Patient verbalized, dili man ko kailangan ug sungkod.

Change in moles

Enlarged nodes Prosthesis Ambulatory device

Expression of ideation of violence (self/others): S.O. verbalized buotan man kaayu na siya, wala gyud na siyay problema sa iyang asawa, pamilya ug mga igsoon. Wala pud na siyay kaaway. Si-aw man gud kaayu na siya ug jokeron bah. Objective: Temperature: July 14, 2010 Temp - 36.3 0C July 15, 2010 Temp - 36.6 0C July 16, 2010 Temp - 37 0C July 17, 2010 Temp - 37 0C September 3, 2010 Temp - 37 0C September 3, 2010 None None None None None None None None

July 14, 2010 Diaphoresis: Scars: Rashes: Ulcerations: Blisters: Burns, degree/percent: Laceration: Ecchymosis: General Strength: Mild diaphoresis noted None None None None None None None

July 17, 2010 Mild diaphoresis noted None None None None None None None

32

July 14, 2010 Not able to move purposefully and actively; remained in bed the whole day

July 15, 2010 Not able to move purposefully and actively; remained in bed the whole day

July 16, 2010

July 17, 2010

September 3, 2010 Regained energy and strength to normal

Mild Weakness noted

Mild Weakness noted

July 14, 2010 Gait: Paresthesia/paralysis: XII. SEXUALITY Sexually active: July 14, 2010 Uo. As verbalized by S.O. Not assessed as patient was not able to stand and move out of bed None

July 17, 2010 Not assessed as patient was not able to stand and move out of bed None

September 3, 2010 Steady normal gait None

Breast cyst/lump/discharges: Testicular/Prostate problem: Practiced Selfexamination:

Wala man. As verbalized by S.O. Wala man siya nagreklamo. As verbalized by S.O. Wala man. Dili man pud tingali siya mag ingon kung gina himo niya. As verbalized by S.O. Wala pasad

July 17, 2010 Uo pero medyo laylo tong nagsugod ko og bati ug karon nga naa sa ospital. As verbalized by patient. Wala man sad karon. As verbalized by patient. Wala man. As verbalized by patient. Dili ko kabalo unsaon na. As verbalized by patient.

September 3, 2010 Uo. As verbalized by patient.

Wala. As verbalized by patient. Wala man pud. As verbalized by patient. Dili gihapon. As verbalized by patient.

Last

Wala man. As

Wala pako nakapa 33

proctoscopic/Prostate examination: Birth Control:

sukad. As verbalized by S.O. Naay I.U.D. iyang asawa. Nagpabutang to siya paghuman ug anak atong ikaduha nila nga anak. As verbalized by S.O.

verbalized by patient. Naay I.U.D. akong asawa. As verbalized by patient.

exam. As verbalized by patient. Naay I.U.D. akong asawa As verbalized by patient.

Others/Comments: Physical assessment of patients reproductive area was not done due to S.O. refusal and patients (4th day of assessment; where patient was already able to communicate clearly and spontaneously) refusal to conduct testicular examination. Patient verbalized (4th day of assessment), Okay raman among relasyon, mayo rasad (referring to sexual activities with wife) Patient verbalized (4th day of assessment), wala man puy gagawas nga lain sa akong kinatawo Patient verbalized (4th day of assessment), gituli ko atong grade 2 paman. XIII. SOCIAL INTERACTIONS Marital Status July 14, 2010 July 17, 2010 September 3,2010 S.O. Okay raman, Okay ra kayo, naa verbalized, Buotan makamingaw kay gyud siya gaatiman man kaayu na siya, wala siya diri. as nako. as wala gyud na siyay patient verbalized. verbalized by the problema sa iyang client. asawa. Iyang asawa ug Kami ra sa akung Uban naku karon duha ka anak. as asawa sa balay ug ang akung asawa verbalized by S.O. among anak dayon ug mga anak As silingan ra nako verbalized by akong igsoon. As client. verbalized by client. Kwarta raman na Usahay di pa kayo Okay na kayo, ilang ko katarong ug maayo na kayo gaproblemahon sturya ug katarong akong relasyon sa pero dili gyud ug halubilo sa akong pamilya ug 34

Living with

Concerns/stresse s

kaayu na sila ga- akong parente. As away kay kung verbalized by masuko natong client. asawa permi raman niya pakatwa.on SIaw man gud kaayu ni akong manghud, jokeron bah as verbalized by S.O. Extended Family Wala man, naa rami sa ilang tapad nga balay. as verbalized by S.O. Kami ra gyud sa akung asawa ug mga anak sa among balay pero karon kay akong mga igsoon ang ga-atiman nako. as verbalized by the client. Akong mga igsoon. as verbalized by the client. Kami duha gyud ga desisyon sa akong asawa, pero karon kay akong mga igsoon ang ga desisyon para kanamu. as verbalized by the patient Medyo dili pa gyud ako katarong ug halubilo sa mga tao sa akong palibot kay mawala-wala pa ko sa akong ginasturya usahay. as verbalized by the clientwala naman mayo na akong

silingan As verbalized by client.

Akung ugangan na babae ug bayaw. as verbalized by the client.

Other support person

Iyang asawa ug kami iyang mga igsoon. as verbalized by S.O. Siya gyud na kauban sa iyang asawa ang gadesisyon sa pamilya. Siya pud gapanginabuhi para nila. as verbalized by S.O. Usahay matingala nalang na iyang asawa kay dili siya makahinodom ug makalimot siya dali. Pero gi-ingnan niya iyang asawa daan nga sabton lang sa siya kay dili gyud daw niya gatuyu-on nga makalimot siya. as

Role within family structure

Akong asawa ugangan ug bayaw. as verbalized by the client. Kami sa akung asawa ang ga desisyon. as verbalized by the client.

Report problems related to illness/condition

Wala naman mayo na akong paminaw. as verbalized by the client

35

verbalized by S.O.

paminaw as verbalized by the client

XIV. TEACHING/LEARNING Subjective: Dominant language (specify):S.O. verbalized,Bisaya Literate: S.O. verbalized, Oo, makasulat na siya ug makabasa gamay. Educational level: S.O. verbalized, Elementary, grade 3 raman siya taman. Health beliefs/practices: S.O.verbalized, Gagamit mi ug mga herbal, banaba, mangga, sambong, bayabas, tawa2x.. ug haplas2x dayun-efficascent oil, shane Familial risk factors: ( / ) Diabetes Eldest Sister ( ) TB ( / ) Heart Disease Elder Brother ( ) Stroke ( ) Hypertension ( ) Epilepsy ( ) Renal Disease ( / ) Cancer Eldest Sister (Liver Cancer) and Mother (Breast Cancer) ( ) Mental Illness ( ) Substance Abuse Others; ( / ) Hepatitis B Elder Brother Comments: S.O. verbalized, Wala sad mi kabalo nganung nagkahepatitis to akong isa ka igsoon. Siya raman pud, wala may hepatitis iyang asawa ug mga anak. Ambut pud lagi aha na ni E.M. nakuha nga sakit. Patient verbalized upon home visit, wala man gyud mi nagka-uban sa akong kuya mga 1 year old pa lang ko kay nagbalhin na sila sa bukidnon. Wala pud ko katambong sa iyang lubong kay namatay man daw to siya tungod sa hepa." SO verbalized upon home visit Ni gawas mi sa hospital kay ingon man to ang doctor nga dili na siya ma uli-an so mypag mu uli nalang mi. Dili pud mi mu tuo nga naa siyay Hepa B kay wala man to sa iyang ultrasound pero okay raman siya karon, pasalamat sa Diyos. Patient verbalized, Lima ka adlaw rako naka-inom atong aminoleban pero wala na dayun kay perting mahala sa mga tambal. Use of alcohol (amount/frequency): S.O.verbalized, Gainum, kanang naay okasyon raman sad. Last July 14, 2010. Patient verbalized Wala man gyud ko niinom og dili na gyud kay mahadlok nako basin ma-unsa ko. Last September 3, 2010 . 36

Others/Comments: Patient is an occasional drinker; He drinks 5-6 bottles of Beer and 6-7 glasses of rhum (e.g. Tanduay, Fighter, San Miguel Beer and Beer na Beer) when theres occasion (2-3 times in a month); He started drinking at the age of 18.

Prescribed drugs/medications: Medications 1. Essential Forte (1 cap TID per NGT) 2. Lactulose (30 mL per NGT) 3. Metoclopramide (1 amp IVTT every 8 hours) 4. Ranitidine (50 g IVTT EVERY 8 hours) 5. Aminoleban (500 mL every 12 hours) 6. Metronidazole (500 mg IVTT EVERY 6 hours) 7. Citicoline (+6m q12) Indications fatty degeneration of the liver, hepatitis (including toxic hepatitis) portal-systemic encephalopathy in patients with hepatic disease, Constipation decreased nausea, vomiting antiulcer agent/ prophylaxis for ulcer used as general nutrients; enteral/nutritional treatment of anaerobic infections: intraabdominal infections signs and symptoms of cerebral insufficiency e.g. dizziness, memory loss, poor concentration, disorientation increased intracranial or intraocular pressure; toxic overdose prevention of bleeding; treatment and prevention of hypoprothrombinemia Reflux esophagitis Fever

8. Mannitol (20 mL IV bolus, STAT) 9. Vitamin K ( 1 amp, IVTT) 10. Omeprazole (40mg 1cap OD po) 11. Paracetamol (500 mg 1 tab now)

37

B. Body Maps. (Illustrate in the body map how your patient looks-like. E.g. tubes inserted bruises, surgical incisions, physical abnormalities, affected areas. DAY 1: July 14, 2010 (Tuesday; 11:00 AM and 3:00 PM)

Stuporous change in sensorium NGT on left nostril Oxygen inhalation @ 2 L/min via nasal cannula IVF of PNSS 1L @ 30 gts/min Condom Catheter attached to urobag

38

DAY 2: July 15, 2010 (Thursday; 3:30 PM)

Stuporous change in sensorium NGT on left nostril Oxygen inhalation @ 2 L/min via nasal cannula IVF of D5W 1L @ 30 gts/min

Condom Catheter attached to urobag

Patient still was not able to defecate during the day Patient still stuporous and does not respond verbally and does not obey simple command Patient complains of dizziness when ambulating and a feeling of general weakness Patient is being fed through the nasogastric tube Patient vomited twice during the day; vomitus was yellowish in color; approximately amounting to 550 cc all in all 39

. Day 3: July 16, 2010 (Friday, 12:30 PM)

Drowsyable respond verbally and actively NGT on left nostril Oxygen inhalation @ 2 L/min via nasal cannula IVF of D5NSS 1L @ 30 gts/min Condom Catheter attached to urobag

Patient was not able to defecate during the shift

Patient was already arousable by verbal stimuli Patient was able to respond verbally although speech is slurred and difficult to understand Patient still cannot retrieve remote memories and some recent memories Patient not oriented to time and place Patient able to follow/obey simple commands/instructions (e.g. flex the knee, make a fist) Patient was able to sit up but not yet able to endure standing Patient is being fed through the nasogastric tube

40

Patient vomited after being transported to the examination room (For ultrasound); vomitus was yellowish in color; approximately amounting to 200 cc all in all Patient was able to see clearly and read; but not able to write his own signature properly

Day 4: July 17, 2010 (Saturday, 11:00 AM)

Fully consciousable to respond NGT on left nostril Oxygen inhalation @ 2 L/min via nasal cannula IVF of D5NSS 1L @ 30 gts/min Condom Catheter attached to urobag Bipedal mild edema

Patient was not able to defecate. Patient is fully conscious and able to ambulate independently. Patient was oriented to time, place and person. Patient able to verbally and actively respond to command/instructions. Patients handwriting was better and was readable. Patient is being fed through the nasogastric tube. Patient is already allowed to take sips of water. Patient did not vomit for the whole day.

41

Day 5: (September 3, 2010) Friday 3:00pm

Fully consciousable to respond Complaints of near-sightedness Complaints of increase of abdominal size

Bipedal edema noted

Patient was able to defecate. Patient was fully conscious and able to ambulate independently Patient was oriented to time, place and person Patient able to verbally and actively respond to command/instructions Patients handwriting was better and was readable Patient was able to eat food as tolerated. Patient is already allowed to drink water. 42

Patient did not vomit for the whole day.

43