I.

Introduction

II. PATIENT’S PROFILE

Name of Patient: R.M.J

Age: 53 years old

Sex: Female

Occupation: Teacher

Civil Status: Married

Religion: Roman Catholic

Address: Proper Brgy. Busay San Isidro Leyte

Nationality: Filipino

No. of Children: 2

Work of Husband: Brgy. Chairman

Date and Time of Admission: October 4, 2023 12:33AM

Chief Complain: Chest pain/Cough/Dyspnea

Admitting Physician: Dr. Moreno/Dr. Villaplasa

Admitting Diagnosis:

III. PRESENT HEALTH HISTORY

- 2 weeks PTA, noted of cough, productive -1 yellowish phlegm. This may associated -1

dyspnea, chest pain described to be -1 PS of 4-5/10.

- -1 progressive dyspnea patient was brought in for admission.

IV. PAST HEALTH HISTORY

- (+) Hypertension

- S/P = Left Breast

 V. FAMILY HEALTH HISTORY

- A history of breast CA within the maternal’s side of the patient.

VI. PHYSICAL ASSESSMENT

October 11, 2023

General Appearance: Awake, Tachypneic

V/S:

Skin: Good mobility and Turgor

Skull: Round, Symmetrical, normocephalic, absence of nodules and masses

Face: Symmetrical, absence of nodules and masses

Eyes: Round and symmetrical, equally distributed eyelashes and eyebrows, no

discoloration on eyelids, eyelids close symmetrically, blinks voluntary, pale conjunctiva

Ears: Symmetrical with no discharges, auricles aligned with the outer canthus of the eye

Nose: Symmetrical and straight, both nares are patent, no tenderness

Mouth: (+) Dry lips and tongue

Neck: With palpable modules on the left side of the neck, jugular veins are not distended,

neck muscles are equal in size

Chest/Lungs: (+) DBS with Wheezes, (+) course crackles on basal bilateral 12 > L

Abdomen: Mass

Extremities: Equal in size and length, absence of edema, both lower and upper extremities
move with coordination, with pinkish nailbeds

VII. DIAGNOSTIC AND LABORATORY PROCEDURES

Hematologic Results
 Date Exam Results Reference Significance
October 12, White Blood Cell 13.9 x 10^9/L 5.0-10.0
2023
15.3 x 10^9/L
October 06,
2023 12.1 x 10^9/L
Red Blood Cell 4.18 x 10^12/L 4.2-5.4 x 10^12/L
October 04,
2023 4.14 x 10^12/L

4.11 x 10^12/L

Hemoglobin 10.7 g/L 140-170g/L

10.4 g/L

10.9 g/L

Hematocrit 33.4 g/L 0.42-0.52 g/L

33.1 g/L

33.6 g/L
Platelet 234 x 10^9/L 150-450 x 10^9/L

291 x 10^9/L

367 x 10^9/L

Differential WBC Results

Date Exam Results Reference Significance
October 12, Neutrophils 91.3 0.43-0.65
2023
89.0
October 06,
2023 80.1

October 04, Lymphocyte 6.2 0.20-0.45

2023
6.9

13.9
Monocyte 1.9 0.05-0.12

2.5

4.0
 Eosinophil 0.4 1-6

0.8

1.4
Basophil 0.2 0.2

0.8

0.6

Blood Chemistry Results

Date Exam Results Reference Significance
October 12, Potassium 4.07 3.5-5.3
2023
3.3
October 06, Sodium 136 135-148
2023
150.00

Radiographic Results
Date Exam
October 05, 2023 Chest X-Ray
October 12, 2023 CT-Scan
October 04, 2023 Ultrasound- Right
Hemithorax
Results
Pulmonary Congestion and/or Pneumonia Resolving
Resolving Right Pleural Effusion
Atherosclerotic Aorta
Atherosclerotic Aorta
Non-specific Subcutaneous Nodule, Left Frontal
Region
There is a moderate amount right pleural effusion with
estimated volume of 992 ml. There are no septations
noted. Marker in place.

VIII. ANATOMY AND PHYSIOLOGY

3.6 LEVEL OF GROWTH AND DEVELOPMENT

3.6.1 Normal Development of an Middle adult

The primary psychosocial task of early adulthood—ages 20 to 40—is to develop intimate

relationship, or the desire to expand one's influence and commitment to family, society, and future
generations.

PHYSICAL DEVELOPMENT

At 40, most adults can function as effectively as they did in their 20s. However, during ages 40
to 64 many physical changes take place. Both men and women experience decreasing hormonal
production. The term menopause refers to the so-called change of life in women, when menstruation
ceases. It is said to have occurred when a woman has had not menstrual period for 12 months. This
usually occurs sometime between ages 40 and 55. At this time, ovarian activity decline until ovulation
ceases. Psychologically, the menopause can be an anxiety-producing time, specifically if the ability to
bear children is an integral part of the woman’s self-concept. For other women, menopause may
produce few symptoms, physically and psychologically.

PSYCHOSOCIAL DEVELOPMENT

The developmental tasks of middle-aged adults received little attention. Havighurst (1972)
outlined nine tasks for this group. Erikson viewed the development choice of the middle-aged adult as
generativity versus stagnation. Generativity is defined as the concern for establishing and guiding the
next generation. In other words, the concern about providing for the welfare of humankind is equal to
the concern of providing self. People in their 20s and 30s tend to be self and family-centered. In middle
age, the individual collaborates with others (Murray, Zentner, & Yakimo, 2009). Generative middle-
aged persons are able to feel a sense of comfort in their lifestyle and receive gratification from
charitable endeavors.

Erikson (1963) wrote that people who are unable to expand their interests at this time and who
do not assume the responsibilities of middle age suffer a sense of boredom and impoverishment, that
is, stagnation. These people have difficulty accepting their aging bodies and become withdrawn and
isolated. They are preoccupied with self and unable to give others. Some may regress to younger
patterns of behavior, for example, adolescent behavior.
 Middle adulthood is the time when most people become increasingly aware of the gradual
changes in their bodies that mark the aging process. People usually accept the fact that they are aging;
however, some try to defy the years by changing their dress and even their actions. Prior to this period,
the marriage partner or lovers and other individuals were crucial to definition of self. Now the middle-
aged person does not make comparison with others, often no longer fears aging or death, relaxes the
sense of competitiveness, and enjoys the independence and freedom of middle age. Other people’s
opinions become less important, and the earlier habit of trying to please everyone is overcome. The
person establishes ethical and moral standards that are independent of the standards of others. The
focus shifts from inner self and being to others and doing. Religious and philosophical concerns
become important.

COGNITIVE DEVELOPMENT

The middle-aged adult cognitive and intellectual abilities change very little. Cognitive processes
include reaction time, memory, perception, learning, problem solving, and creativity. Reaction time
during the middle years stays much the same or diminishes during the middle years much the same or
diminishes during the latter part of the middle years. Memory and problem solving are maintained
through middle adulthood. Learning continues and can be enhanced by increased motivation at this in
life.

MORAL DEVELOPMENT

According to Kolhberg, the adult can move beyond the conventional level to the
postconventional level. Kolhberg believed that extensive experience of personal moral choice and
responsibility is required before people can reach the postconventional level. Kolhberg found that few of
his subject achieve the highest level of moral reasoning.

SPIRITUAL DEVELOPMENT

At this stage, the individual can view “truth” from a number of viewpoints. Fowler’s fifth stage
corresponds to Kolhberg’s fifth stage of moral development. Fowler believe that only some individuals
after the age of 30 years reach this stage. People tend to be less dogmatic about religious beliefs, and
religion often offers more comfort to the middle-aged person that it did previously. People in this age
group often rely on spiritual beliefs to help them deal with illness, death and tragedy.

3.6.2 The ill person at a particular stage of patient

 Community-acquired pneumonia (CAP) is a disease in which individuals who have not recently
been hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and can
affect people of all ages and often causes problems like difficulty in breathing, fever, chest pains, and a
cough. CAP occurs because the areas of the lung which absorb oxygen (alveoli) from the atmosphere
become filled with fluid and cannot work effectively.
Causes of CAP include bacteria, viruses, fungi, and parasites. CAP can be diagnosed by
symptoms and physical examination alone, though x-rays, examination of the sputum, and other tests
are often used. Individuals with the kind of disease sometimes require treatment in a hospital and are
primarily treated with antibiotic medication.
The most commonly identified pathogens are Streptococcus pneumonia which has low
mortality rate. Signs and symptoms are fever, cough, pleuritic chest pain, dyspnea, tachypnea, and
tachycardia. Diagnosis is based on clinical presentation and chest x-ray. Treatment is with empirically
chosen antibiotics. Prognosis is excellent for relatively young or healthy patients, but much pneumonia,
especially when caused by S. pneumoniae or influenzavirus, are fatal in older, sicker patient.

COGNITIVE DEVELOPMENT

Young adults are able to use formal operations, characterized by the ability to think
abstractly and employ logic. For example, young adults are able to generate
hypotheses about what will happen, given a set of circumstances, and do not have to
engage in trial-and-error behavior. Most young adults identify strongly with the
values and norms of their social group and will act in ways that are consistent with
those norms (pfaffenberger, 2005).

MORAL DEVELOPMENT
Young adults who have mastered the previous stages of Kohlberg’s theory or moral
development enter the post conventional level. At this time, the person is able to
separate self from the expectations and rules of others and to define morality in
terms of personal principles. When individuals perceive a conflict with society’s rules
or laws, they judge according to their own principles.

SPIRITUAL DEVELOPMENT
According to fowler, the individual enters the individuating-reflective period sometime
after 18 years of age. During this period, the individual focuses on reality. A 27-year
old adult may ask philosophical questions regarding spirituality and may be self-
conscious about spiritual matters. The religious teaching that the young adult had as
a child may now be accepted refined. Cavendish, Luise, Bauer, et al. (2001)
demonstrated that the young adults may depend on spirituality and seek guidance
from a Higher Power, but do so privately