Professional Documents
Culture Documents
Marital status: Single Address: Mabini Homesite, Cabanatuan City Phone number: 09202835545 Educational level: not applicable Occupation: not applicable Race or ethnic background: not applicable Religion: Roman Catholic Nationality: Filipino Citizenship: Filipino Language spoken: tagalong Source of information: mother Reliability: not applicable
Initial Diagnosis
ALL Pre-B - June 6 2012 ALL Pre-B - June 15 2012 ALL Anemia leucopenia thrombocytopenia secondary to chemotherapy June 5 2012
Final Diagnosis
ALL Pre-B -June 6 2012-June 7 2012 ALL Pre B S/P Chemotherapy - June 15 2012-June 17 2012 ALL Pre b, SP PRBC transfusion, SP IV chemotherapy day 48 - July 05 2012- July 06 2012 ALL Pre B S/P PRBC and platelet transfusion - July 08 2012July 09 2012
Physical Examination
June
6 2012 General Appearance: ambulatory; irritable EENT: pink PC(pink conjunctiva), AS(anicteric sclerae) Chest and lungs: SCE(symmetrical chest expansion), CBS(clear breath sounds) Heart: Ap(adynamic precordium), NRRR(normoactive bowel sounds) Abdomen: Soft, NABS Extremities: pulses full and equal Clinical impression: ALL pre B
Physical Examination
June
15 2012 General Appearance: F/N, F/P EENT: (-) CLAD(cenical lymphadenopathy) Chest and Lungs: CBS, EUE Extremities: (-) swelling
Physical Examination
July
5 2012 General appearance: ambulatory Skin: (+) Pallor Chest and lungs: SCE, CBS Heart: AP.AB Abdomen: Soft NABS
Physical Examination
July
8 2012 General Appearance: Ambulatory, coherent EENT: pale PC AS (+) hematoma lower lip Chest and lungs: SCE and CBS Heart: Ap, ARRR Abdomen: non-distended, non-intended Extremities: pulses full and equal Clinical impression: ALL
June 1, 2012 Received a 2 year old boy brought by her mother. The patient was seen and examined by Dr. Mendoza with orders made and carried out. For intrathecal chemotherapy by Dr. Mendoza, consent was signed. Intrathecal chemotherapy done. To ward per wheelchair cuddled by the mother with on going IV fluid of D.5 0.3 NaCL 500ml. Present IV fluid was consumed and shifted to a heplock aseptically. The patient is pale in appearance and irritable when approached. Vital signs monitored and recorded.
June 6 2012 Admitted to E.R, the patient was cuddled by the mother conscious and coherent. Attended by ROD Dr. Uy with on going IV fluid of D5 0.3 NaCL 500ml connected to volumetric tube/chamber. The patient was weak in appearance. Added L-aspanagenase 3525 unit in 100ml of D5 was started. Encouraged mother to avoid environmental hazanious, rest and comfort promoted. L- aspanegenase 3525 unit in 100ml of D5 consumed and removed aseptically. Take home instructions, instructed to the mother and went home with relatives.
June 8 2012 Patient was admitted to the emergency room; ambulatory, conscious and coherent, with heplock and removed aseptically and replaced with IV fluid of D5 0.3 NaCL connected to microset. Seen by Dr. Mendoza. Chemo drugs started as ordered with precautions noted. All chemo drugs ended with no reactions noted. Health teachings done and instructed to mother/relatives. No complaints of any discomfort as claimed by the mother. Discharge instruction instructed to the patient relative well understood as claimed. Went home per wheelchair accompanied by the patients
June 15 2012 Received with dislodged IV fluid of D5 0.3 Nacl 500ml, currently saved set on sitting position; alert and afebrile, with no complaints of any discomfort as claimed. Health teachings done; Examined by Dr. Mendoza with orders made and carried. Above IV fluid shifted to L- asparagenase 3525 units 100ml 125 water and regulated at drip 100 gtts/min. Remove IV fluid aseptically; went home with relatives.
July 19 2012 Received with on-going IV fluid of Plain NSS 500ml on around 350ml level and regulated at 10mgtts/min; alert and awake; watch out hematoma on Left cheek noted with bleeding on mouth noted. Received SMS order from Dr. Puno-Mendoza and carried out. Examined by Dr. Puno-Mendoza and carried out.
GORDONS
GORDONS
NutritionalMetabolic The patient has a very consumption of food especially on vegetables and fluids. During the course of chemotherapy the patients appetite decreases and as verbalized by the mother the weight of the patient also decreased. Irregularity of the patients elimination occurs; sometimes the patients suffers diarrhea. One of the common side effects of chemo-drugs is loss of appetite and weight loss; also accompanied by nausea and vomiting; poornutrition. Diarrhea is one of the side effects of chemo-drugs, it is one to the response or induced response to the condition or treatment of the patient.
Elimination
GORDONS
ActivityExercise The patient is active on many activities. Upon hospitalization, the patient has decreased activity pattern and play. Fatigue and exhaustion; prior to medication, the patient is received chemotherapy, chemotherapy destroys the good cells and it decreases the patients energy and mobility range. Being a child he is not aware of its disease; lowcoping mechanism.
CognitivePerceptual
GORDONS
Sleep-Rest Prior to hospitalization, the patient has a normal sleep pattern. Upon hospitalization, the patient now has late sleep and wakes up early. It is due to the hormonal imbalance of the patient; uncomfortable of having side effects such as pain, fatigue, nausea and vomiting, etc. The mentality of a child cannot conceive his present condition of having a disease.
Before hospitalization, the patient has no clue or perception about the disease.
The child still doesnt know his disease and still has a childish perception.
Rolerelationship
Being the only son of his family and his present condition; he becomes the concern and priority of his family.
GORDONS
The patient has a strong belief that his disease will be cured. Daily prayers are done by the family members for their belief that the patients disease will be cured. Because of their strong belief that God can answer their prayers and makes miracle about it and boost their self esteem through faith.
Hygiene
There are no changes on the patients hygiene pattern/ the patient is now completely assisted in doing his routine hygiene.
Having some alternations on physical and hormonal state, the patient cannot do his normal routine; he is completely assisted.