MCN Form 003

Lyceum of the Philippines University

College of Nursing

Name Patient ET Age 49-years-old

Diagnosis Hospital No.
Ward/RM Emergency
Room

CLINICAL APPRAISAL

History of A 49-year-old male client was admitted last September 28, 2022, with a chief
Present Health problem of having low hemoglobin level and dizziness. The patient came to
Concern the hospital as he was supposed to have, first session chemotherapy,
unfortunately after his laboratory result came out his hemoglobin levels were
which became the reason of his admission.

Past Health Patient is known to have a rectal mass cancer which was diagnosed last April
History 2022. The patient’s sign and symptom before being diagnosed was he had
blood on his stools, and there has been changes in his bowel movements,
and there have been frequent episodes of abdominal pain. Patient has no
allergies.

Family History

Lifestyle and
Health The patient narrated that he was an avid smoker, he was able to finish at
Practices least 1-2 packs of cigarettes per day for the past 30 years.
 MCN Form 003

Lyceum of the Philippines University

College of Nursing

Name Patient ET Age 49-years-old

Diagnosis Hospital No.
Ward/RM Emergency
Room

CLINICAL APPRAISAL
Review of
Systems for General: The patient was awake, aware of time and environment.
Current Health Skin, Hair, Nails: The patient has a pale skin color, no bruises were present.
Problem HEENT: The patient is experiencing dizziness.
Respiratory System: The patient denies experiencing shortness of breath,
cough, cold, and dyspnea.
Cardiovascular System: The patient denies having palpitations and chest
pain.
Gastrointestinal System: The patient complains of abdominal pain.
Urinary System: The patient denies dysuria and urinary frequency.
Musculoskeletal System: The patient denies having myalgia, swelling and
joint pain.
Neurologic System: The patient is experiencing dizziness.
Psychiatric: The patient denies recent changes in mood. Patient also denies
anxiety and depression.

Developmental Middle Adulthood

Level - The patient was able to answer all the questions by himself, however
in this age his health is not at the best condition as there are a lot of
physical changes as well health changes that can occur in this stage
that could affect his daily activities.
MCN Form 003