I.

DEMOGRAPHIC DATA

A) Client's Name : Mr. P

B) Address : San Cristobal, Calamba City, Laguna

C) Age : 60 years old

D) Birthdate : 03/15/1960

E) Sex : Male

F) Marital Status : Married

G) Occupation : Wet Market Vendor

H) Religion : Catholic

I) Race/Nationality : Filipino

J) Chief Complaint : Breathing difficulty, chest pain and painful

cough that have lasted for more than three

weeks.

K) Admitting Diagnosis : Rule out pulmonary tuberculosis

L) Date of Admission : September 22, 2020

M) Hospital : Dr. Jose P. Rizal Memorial District Hospital

II. SOURCE AND RELIABILITY OF INFORMATION

All of the information gathered and listed came directly from the patient and the patient's

medical records during his confinement at Dr. Jose P. Rizal Memorial District Hospital. All of the

information used was with permission from the patient.

III. REASON FOR SEEKING CARE/CHEIF COMPLAINT

The patient sought care for breathing difficulty, chest pain and coughing that have lasted

for more than three weeks.

IV. HISTORY OF PRESENT ILLNESS

According to the patient, he would feel dizzy because of the weakness he feels and the

discomfort. The patient experienced pain on his throat and chest when coughing. On a 1-10

pain scale, patient rated the pain on his chest as 7. Coughing gets better when he drinks water

and worsens when he’s lying down.

V. PAST MEDICAL HISTORY

The patient’s first hospitalization happened in 1994 when he experienced a sudden

onset of fever for which he believed that he was bewitched. The client has no heart disease,

anemia, cancer, and seizure disorder but has a family history of diabetes mellitus and
hypertension. He did not undergo any physical examination. He developed allergies when he

eats sea foods like alimango, ulang, and tahong in excess. This causes his skin to be itchy. He

did not mention any allergies on medication.

VI. FAMILY HISTORY

Father
Mother

64 60 52
62 58 55
HTN PTB
DM HTN

Male Femal Decease Patient

d
Legend: e

VII. PERSONAL/SOCIAL HISTORY

The patient does not drink nor smoke. The patient lives with his wife, children and

grandchildren in an extended family.

VIII. FUNCTIONAL ASSESSMENT

A) Health Perception-Health Management Pattern

The reasons for admission were chest pain, ribcage pain, right-sided pain, and

abdominal pain. He thinks that the purpose of the treatment is to improve his condition and

hoping that he recovers. For the client, the treatment is working well since the pain he felt

lessened and is now tolerable. He expects to improve his condition and feel better again.

B) Self-Perception Pattern

He feels that he is getting old already because of his illnesses. He wants to feel better

again like he does not have any health concerns. He leaves all the things and happenings to

him to the Almighty God since he believed that that is his destiny. Nothing makes him anxious,

fearful or distressed, but thinks about his current health issues. He prays and talks to his family

to alleviate his feelings.

 C) Activity-Rest Pattern

Whenever he’s not working, he usually walks around their area and it became his usual

activity aside from watching television. He exercises regularly by walking around every morning,

every day. He has no problem experienced with usual activity and exercise.

D) Sleep-Rest Pattern

He usually wakes up around 3 am and go to sleep around 12 midnight. Sometimes he

takes naps, sometimes does not. But when he does, it lasts for 3-4 hours. He feels rested and

ready for daily activities after a sleep. He does not use any aids to help him sleep. According to

him, he does not usually experiences insomnia but when he got admitted to the hospital, he

can’t sleep well or is experiencing insomnia.

E) Nutritional-Metabolic Pattern

According to the client, his appetite is good and it did not change. In a typical day he

eats rice and vegetables with meat. No food restrictions or any special diet due to allergies. No

food tolerance. He likes to eat sweet foods, banana and meat though he is trying to lessen the

meat he consumes since he believed that too much meat is not good for his health. He doesn’t

usually go and eat to any fast food restaurants. He doesn’t experience any discomfort in eating

or swallowing. He drinks water adequately in a day and stopped drinking soft drinks.

F) Elimination Pattern

He usually eliminates two times a day. He does not experience any constipation or

diarrhea. Urinate 4-5 times a day with no any urinary abnormalities.

G) Interpersonal Pattern

The patient lives with his wife, children, and grandchildren in an extended family. He

asks for help to his family. Family members do not depend on the client since some of his

children have already their own family. His family takes care of him while he is ill. His health

status does not affect his relationship to others. Family and friends were saddened when they

learned that the client is ill and is being hospitalized but still the love, care and support

remained.

H) Coping-Stress Management Pattern

Comparing his current health status to before, he felt that he is becoming weaker due to

his illnesses. Financial deficiency situations cause stress in the past and present. It affects him

but he prays to God that problems will fade from time to time. He usually solves problems with

the help of his family members. He deals with stress and relieves tension by talking to his
family. He turns for help during crisis to his family. He handles problems successfully most of

the time.

I) Personal Habits

The patient stated that she does not have much interest in things other than using her

cell phone and taking care for her 4 year old child.

J) Environmental Hazard

The patient knows his neighbors well and has good access to transportation. According

to the patient, there are no hazards in the place particularly in their home since he feels safe

there.

K) Sexuality-Reproductive Pattern

The patient does not use contraceptives.

 IX. ANATOMY AND PHYSIOLOGY

There are two, large frontal sinuses in the

frontal bone, which forms the lower part of the
forehead and reaches over the eye sockets
Frontal Sinus
and eyebrows. The frontal sinuses are lined
with cells that make mucus to keep the nose
from drying out.
Situated back of the nose in the sphenoidal
bone, which forms a forward part of the base
of the skull and contains the depression, or
fossa, for the pituitary gland. The sinuses are
Sphenoidal Sinus
separated from each other by a bony wall, or
septum, that is rarely in the midline, and they
discharge their mucus through an opening in
the front wall of the sinus into the nose.
To increase the surface area of the nasal
cavity and to disrupt the flow of air as it enters
Nasal Conchae
the nose, causing air to bounce along the
epithelium, where it is cleaned and warmed.
Chambers of the internal nose. In front, the
nostrils, or nares, create openings to the
Nasal Cavity outside world. Air is inhaled through the
nostrils and warmed as it moves further into
the nasal cavities.
The prominent structure between the eyes that
serve as the entrance to the respiratory tract
and contain the olfactory organ. It provides air
Nose for respiration, serves the sense of smell,
conditions the air by filtering, warming, and
moistening it, and cleans itself of foreign
debris extracted from inhalations.
Connects the pharynx and trachea and helps
Larynx
to conduct air through the respiratory tract.
Part of the conducting zone for air into the
lungs. Therefore, one of its primary functions
Pharynx
is to warm and humidify air before it reaches
the lungs.
A conduit for air to pass through on its way to
or from the alveoli of the lungs. This transmits
Trachea
oxygen to the body and removes carbon
dioxide.
 A passage of airway in the respiratory tract
Bronchus
that conducts air into the lungs.
Carries oxygen rich air into the lungs and carry
carbon dioxide rich air out of the lungs,
thereby aiding in the processes of breathing
Bronchioles and respiration. The smooth muscle that
surrounds the bronchioles can constrict or
dilate the airway, which can aid in getting the
proper amount of oxygen into the blood.
Where the lungs and the blood exchange
oxygen and carbon dioxide during the process
of breathing in and breathing out. Oxygen
Alveoli
breathed in from the air passes through the
alveoli and into the blood and travels to the
tissues throughout the body.
The major muscle of respiration. It is a large,
dome-shaped muscle that contracts
rhythmically and continually, and most of the
Diaphragm
time, involuntarily. Upon inhalation, the
diaphragm contracts and flattens and the
chest cavity enlarges.