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Patient’s Profile:

Name : Camilo Ochinang Columbino

Address : Santa Maria Norte, Binalonan, Pangasinan

Date of birth : 01-11-1981

Age : 50 years old

Place of birth : Binalonan Pangasinan

Date Admitted : 02-17-2011

Time Admitted : 04:15am

Admitting diagnosis : Diffuse Subarachnoid Hemorrhage with localized hematoma at


right sylvian; Hydrocephalus Subarachnoid Hemorrhage, more in the right side with
minimal intraventricular hemorrhage; Aneurysm communicating segment of Right
internal carotid artery; HVCD

A. Health Maintenance and Perception Pattern

Client has normal pupil size and reaction on both right and left eyes. Client’s tongue
was pale and manifested abnormal tongue movement characterized by frequent
rolling of the tongue. Client has NGT insertion on her left nostril. Her skin was dry
and poor skin turgor was noted. Nail beds were also pale and cracked nails were
noted. According to brother the client’s health was good and does not smoke or use
street drugs. (However, he regularly consumes alcoholic beverages (one bottle of
beer per night) as verbalized by brother also has a history of TB. Client has recent
check-up with her physician due to headache and drowsiness. They have no
difficulty acquiring emergency services except for health facilities and pharmacies
since they live in a rural area.

B. Nutrition-Metabolic Pattern

Client was warm to touch upon assessment and pale. However, neither lesions nor
rash was noted. Client has dry mucous membranes in the mouth and around the
eyes, a lesion is present on his

lower lip, and lips were pale. Client has pale conjunctiva, tongue and gums.. Client
cannot easily turn by himself; constant restlessness and uncontrolled peripheral
muscle movements were noted thus restraints are provided to ensure client’s
safety. Before admission, according to client’s relative, client’s typical daily food
intake of rice, fish, vegetables and an occasional serving of meat and her daily fluid
intake is from 1-2L per day. He states that client has a good appetite especially if
the viand is vegetables (preferably, “laswa”) with rice or rice porridge. During
admission, client experiences nausea and vomiting.

C. Elimination Pattern

Patient has normal bowel sounds of 5 auscultated at right lower quadrant. Upon
palpation, patient’s abdomen is soft and not tender and no mass was noted. There
is no distention of bladder and any haemorrhoids. Patient has been normally voiding
to amber colored urine and normally defecates once a day and same time each day.
Stool was characterized as soft and yellow-colored. In addition, the client has no
history of constipation, diarrhea or incontinence. Client urinates 6-8 times per day.
No retention was noted upon assessment.

D. Activity – Exercise Pattern

Client’s carotid, jugular and radial pulses were easily palpable. Client’s extremities
were warm to touch and has a normal capillary refill of <2seconds. Cyanosis was
noted. Client has normal muscle strength on both upper and lower extremities.
Client requires help from another person in performing feeding, hygiene, dressing
and other forms of activities of daily living.

E. Sleep and Rest Pattern

Client’s brother verbalized that client is an early riser (he wakes up at 5-6am) and
sleeps before 9pm, even before admission. Client is the one who performs most of
the household chores and During admission, client has difficulty sleeping due to
frequent headache that he experiences as shown by facial grimace and nods when
asked if pain is felt at the head. Client also experiences cramping due to prolonged
positioning and requires help in helping him turn from side to side or from foot to
head of the bed. However, client becomes restless and irritable at times when he is
sleepy but cannot do so because of extreme pain due to the hematoma and
affected areas of the body. However, he sleeps after administration of medications
that decreases pain and provides comfort during his sleep.

Past health history

a. Childhood Illness

Client has no known serious childhood illness except for the usual bout of fever and
colds.

b. Past Hospitalization

Client has no history of past hospitalization.


c. Serious/Chronic Illness

Client was known to be hypertensive two days prior to admission after a


consultation with his physician. Client has also experience having Tuberculosis.

d. Previous Surgery

Client has not undergone any surgeries in the past.

1. Family/social history

Client has family history of hypertension. However, the client wasn’t diagnosed with
hypertension until two days prior admission.

VII. ASSESSMENT

(day 1)

GENERAL APPEARANCE
>Awake, restless and lying on bed, on semi-fowler’s position

LOC
> Responsive to painful stimuli;
>with GCS of 12 (E=4, V=2, M=6)

HEENT
> with symmetry of eyes noted (3mm)
>Pupils Equally Round, briskly Reactive to light and Accommodation with pupil
constriction of
2mm
>with pale conjunctiva and anicteric sclera noted
>mucous membranes pale, moist and intact
>no nasal and ear discharges noted

CARDIOVASCULAR
>on IVF bottle #4 PNSS 1 liter to run for 50 cc/hr infusing well at right cephalic
vein with remaining amount of 270 cc
> with good capillary refill < 2 seconds
>with blood pressure of 140/90 mmHg taken at left arm lying on bed
>with cardiac rate of 69 beats per minute taken at left arm lying on bed
>with weak, palpable peripheral pulse noted

RESPIRATORY
> with oxygen at 2 liters per minute via nasal cannula
> with respiratory rate of 24 cpm
> with clear breath sounds noted on both lung fields upon auscultation

GIT
>with normoactive bowel sounds of 12 cpm auscultated on right lower quadrant
>able to defecate upon initial assessment
>with semi-formed, dark yellow stools
> abdomen firm upon palpation

GUT
>voided freely to a clear-colored urine amounting to 420 cc upon initial
assessment

MUSKULOSKELETAL
>with normal muscle strength on upper and lower extremities
> responsive to localized pain

SKIN
>afebrile with body temperature of 36.8 °C
> with dry skin turgor and pale nailbeds

(day 2)
GENERAL APPEARANCE
>asleep, on bed, on semi-fowler’s position

LOC
>responsive to painful stimuli; with GCS of 8 (E=2, V=1, M=5)

HEENT
>with symmetry of eyes note (3mm)
> Pupils Equally Round, Reactive to light and Accommodation
> with pale conjunctiva and anicteric sclera
> mucous membranes pale, moist and intact
>no nasal and ear discharges noted

CARDIOVASCULAR
> on IVF bottle #7 PNSS 1 liter to run for 60 cc/hr infusing well at Left dorsal
metacarpal vein
> with good capillary refill < 2 seconds
> with blood pressure of 140/90 mm Hg taken at Right arm lying on bed
> with cardiac rate of 64 beats per minute
> with weak, palpable peripheral pulse noted

RESPIRATORY
> with oxygen at 2 liters per minute via nasal cannula
> with respiratory of 26 cycles per minute
>with ET tube attached to a mechanical ventilator with the following set up: TV:
400;
FI02=60%; BUR=16cpm
> with pulse oxymeter; with O2 saturation of 95%
>with dry skin turgor and pale nailbeds

VIII. LABORATORY AND RADIOLOGY

Complete Blood Count

Examination Resul Normal Values Justification


ts Interpretation

Hematocrit 0.39 F: 0.38-0.47 l/l Normal


This Hct is within normal
Hemoglobin 128 F: 110-150 G/L Normal
The Hgb of the patient is within the
normal value.
RBC 4.30 4-5.5 x 10^12/L Normal
The RBC of the patient does not show
anemia.
It is within normal.

WBC 35.03 5-10 x 10^9/L Increases


Increased level of WBC indicates
infection. Increase WBC can also be
present in stressful situations or in
cellular, or tissue injury. In this
patient he had a brain injury.

Differential Count
Myelocytes 0.00-0.00

Metamylocyte 0.00-0.01

Stabs 0.03-0.05

Segmenters 0.69 0.5-0.7 Normal


No signs of infection
Eosinophils 0.03 0.01-0.03 Normal
Usually, eosinophils increase in allergic
reaction or in parasitism. In this patient,
eosinophil count is within normal.
Basophils 0.00 0.00-0.01 Normal
Lymphocytes 0.08 0.25-0.35 Normal
No signs of infection, usually,
lymphocytes increase in viral
infection
Monocytes 0.06 0.03-0.07 Normal
In this patient, the monocyte count is
normal
Platelet Count 150-400
x 10 g/L

Computed Tomography Scan


–Non-contrast axial CT images of the head reveal hyper densities in the cistern sulci
and sylvian fissure, more in the right side
–The lateral ventricles are slightly dilated with minimal hypersensitivity in the
occipital horns.
–No shift of the midline structures
–Sulci are remarkable
– Post. Fossa, orbits, paranasal sinuses, petromastpoids, selia and bony clavarium
are unremarkable

**REMARKS:
–Diffuse subarachnoid Hemorrhage more in the Right side with minimal
intraventricular hemorrhage
–Consider underlying ruptured aneurysm
–MUD Hydrocephalus
–Cerebral Edema

Radiological Report
– Chest AP sitting shows no gross lung infiltrates.
– Heart is enlarged but cardiothoracic ratio is unreliable in this position
– Aorta is arteriosclerotic
– No other remarkable findings

**REMARKS:
–Cardiomegaly
–Artherosclerotic Aorta

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