PATIENT’S DATA

General data
Name: J. S.
Age: 48 years old
Address: Batasan Hills, Q.C.
Occupation: Housewife
Marital Status: Married
Religion: Roman Catholic

Chief Complaint:
“Hindi gumagaling ung sugat ko sa paa.” As verbalized by the patient

History of Present Illness:

14 days PTA the patient asked her daughter to massage her feet with efficacent oil.
11 days PTA the client noticed painful blisters forming at her right foot then she washed it
with guava solution.
9 days PTA the wound opened and then the patient seek for consultations, the doctor
administered anti-tetanus vaccine and X-ray was done. She was prescribed to take cefalexin 2x a
day for three days. The patient went home and washed the wound with betadine and vinegar
solution.
5 days PTA the patient experienced high fever and took paracetamol 500mg. At around 7
p.m. the family noticed that the patient is chilling so they went to East Avenue Medical Center.
She was given 8 units of insulin and she was referred to go to other hospital.
1 day PTA patient went to PGH to seek further consultation they were advised to go to
other hospital and they went to QMMC and thus, the patient was admitted to QMMC.

Past Medical History:

Last 2009, the patient was accidentally burned by the exhaust pipe of a motorcycle. The
client went to the nearest clinic and was then undergone some examination, it was then she was
diagnosed with Diabetes and prescribed to take metformin as maintenance for one year.
Family History

Mother Father
(Deceased,DM) (Deceased,liver problems)

Brother Brother J.S Brother

(Deceased,Liver (DM) (Deceased,Liver
problem) problem)

As illustrated above, the client have a family history of diabetes in her mother side. Her
father and two brothers died in a liver problem due to excessive alcohol intake.

PERSONAL AND SOCIAL HISTORY

Mrs. J.S. is 48 years old, married to Leonardo Sumili (53 years old) who is a mechanist.
They have four children composed of two girls and two boys. Patient was a plain housewife. She
does not perform household chores because she avoids to get wounded and she easily feels tired.
Patient likes to eat foods high in cholesterol, fish, and sweets, and drinks alcohol occasionally.

ADMITTING DIAGNOSIS: DM right foot, non-healing wound

FINAL DIAGNOSIS: DM right foot, non-healing wound

PHYSICAL ASSESSMENT
GENERAL APPEARANCE  Mrs. J.S. is a medium frame, middle
age woman, who is weak looking.
 Her hair is fixed neatly and her clothes
are clean.
Vital signs:
BP: 110/70
HR: 71 bpm
RR: 24 bpm
Temp: 36.7 C

GENERAL STATUS  She is oriented to time, place and

person.
 She is conscious but responds to
questions slowly.

SKIN  The skin is dry, color is pallor, warm to

touch.
 She has poor skin turgor (wrinkle loss
of elasticity).

SKULL  The head is proportional to the size of

the body.
 There is no lumps, masses, scars, and
lesions,

HAIR  Evenly distributed and covers the

whole scalp.

EYES  Eye condition is normal with thick

eyebrows, symmetrically aligned and
equal movements.
 Eyelids are intact to the skin. Both
lower conjunctiva is pale and sclera is
white.
 The pupils are reactive to light and
accommodation.

 Parallel and symmetrically proportional

EARS to the size of the head.
 Able to hear and responds to normal
voice.

MOUTH  There is presence of black

discoloration of the enamel.
 Her lips color is pale and no lesions.
 Uvula is midline.
 Tonsils are not enlarged.

CHEST AND LUNGS  Breathing pattern is regular, when

auscultated breath sounds is vesicular.
 RR: 24 bpm
 PMI 2nd-5th ICS

ABDOMEN  The contour is round with presence of

straie.
 The bladder is not distended.
 Liver is not palpable.
 Bowel sound: 20/5mins

UPPER EXTREMITIES  IV line is present on her right

metacarpal vein.
 Muscle strength on both arms are
graded 3/5 (the joint can be moved
through its range against gravity).

NAILS  Nail bed color is pale.

 Capillary refill is 4 seconds.

LOWER EXTREMITIES  The texture of both legs are scaly.

 The right foot is numb, has a wound
with exudates on her second to third
toes and on her sole.
 Foul odor and swelling was noted.
 The left foot has rotten nails.
 Muscle strength on right foot is noted
2/5 (the joint can be moved through its
whole motion but only without gravity
resisting); left foot is noted 3/5 (the
 joint can be moved through its range
against gravity).

REVIEW OF SYSTEM

*GENERAL FINDINGS
Fever (-)
Unexplained wt.loss/gain (-)
Anorexia (-)

*SKIN
Rashes (-)
Soreness (+)
Dryness (+)
Itchiness (+)
Color change (+)

*PERIPHERAL VASCULAR SYSTEM

Intermittent claudification (-)
Numbness (+)
Swelling of legs (+)
Discoloration in hands or feet (+)

*MUSCULOSKELTAL SYSTEM (-)

Pain (-)
Stiffness (+)
Limitation of movement (+)
Muscle cramp,weakness (+)
Gait problem