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hazel ann
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markthesparkperez777@yahoo.com

Friday, December 30, 2011 4:42 PM

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a. Health perception and health assessment Patient mentioned that she has been having vaginal bleeding 4 days prior to admission which prompted her to consult in jrrmmc. Whenever she feels sick, she self-medicates with otc meds such as neozep for flu and colds and paracetamol for fever. Thus, patient does not undergo any routine or regular medical chekup. She believes in modern medicine and herbal medicine but not in supernatural healing. She has never tried supernatural healing even once. For her, its not scientifically proven and its not credible. She is aware of bad effects of smoking and adrinking alcohol. She is a smoker and has started smoking since she was 15 y/o. before, she smokes 2-3 sticks per day but now she said that she quits smoking. Patient bathes 1-2x/day, brushes her teeth after meal, washes her hands befor and after meal. The client did not have any body/breath odor during the interview. She was neat but

she looked distressed by her condition and her family does not visits her in the hospital b. Nutritional-metabolic pattern her typical intake 2 meals/day wherein meal consist of 2-3 cups of rice with a glass of water. In a day, she consumes 3 glasses of water. She stands 5 feet 2 inches tall and weighs 55kgs. She eats vegetable. During her stay in the hospital she consumes all of her food serving. C. elimination pattern She usually defecates 1-2x/day and describes his stool as yellowish to brownish and not having any strong odor and smell. She usually voids 5-6x/day describing his urine to be yellowish and sometimes reddish. No dysuria and diaphoresis noted. d. Activity exercise pattern Typically, she wakes up a 8am and sleeps around 9-10pm. She is not physically active. e. Sleep and rest pattern Her typical sleep is from 10pm-9-10am. She described her room as well ventilated, clen and quiet. f. Cognitive perceptual pattern Client does not wear reading glasses and does not have any hearing problem. During the interview, she had an understandable,

moderated pace of speech, logical sense or thoughts. She speaks in low-paced voice and hears normal voice sounds g. Self-perception and concept pattern Patient said that she is satisfied with her usual mood. Its just that she tends to smoke more whenever she got stressed. h. Role and relationship pattern The client is currently in a relationship. She said shes happy with her special someone but shes not really very serious with her boyfriend because she said shes still young. i. Sexuality- reproductive pattern She is contented with whom she is and expressing her being a woman by dressing, speaking and acting like one. She expresses his affection to his bf by treating him extraordinary and she believes that sex is an important thing in a relationship. She is sexually active but reluctant to discuss. She had 2 sexual partners in the past. j. Stress coping tolerance Her stressful event is her breakup with her 1st bf, lack of financial resources and health disturbances. She listens to rock music.

k. Value belief pattern Patient believes in the holistic definition of health. For her, a healthy person is someone whose life aspects are in equilibrium.

PA--- November 17, 2011 a. General appearance

Patient was conscious all throughout the interview. The client was relaxed and can move freely. Overall, hygiene and grooming was clean and neat with no body odor and no breath odor. Patient was cooperative and was answering actively. b. Vital signs T= 36.4 Pr=66bpm Rr22bpm Bp=120/80mmHg c. Skin- the client has good skin turgor w/o edema both in the upper and lower extremities d. Head and neck- the client is normocephalic and has no abnormal observation found e. Ears- the clients ears have no discharge and equal in size. Her pinna is inline with the corner of the eye. f. Nose- the clients nose has a clear discharge and is negative to tenderness g. mouth and throat- clients mouth is negative to bleeding of gums and dry mucosa h. Eyes- clients eyes are clear, pinkish bulbar conjunctiva i. Breast- there is no mass noted j. Chest and lungs- clear breath sounds k. Heart- clients heart has no murmurs, has a dynamic precordium and has regular rate and rhythm

l. Abdomen- the surfaces of the abdomen are smooth, flabby with non tender liver, spleen and kidney m. Extremities- there are no redness and edema noted on both upper and lower extremities n. Genitals- normal and has spotting discharge ROS SKIN (-) rashes (-) lumps (-) dryness Head (-) headache (-) head injury Eyes (-) blurred vision (-) pain (-) redness (-) glaucoma and cataract Ears (-) hearing loss (-) discharge (-) tinnitus Nose and sinuses (-) nosebleed (-) nasal stiffness Mouth and throat (-) sore throat (-) hoarseness Neck (- goiter Breast (-)lumps (-)pain (-) nipple discharge Respiratory (-)cough (-) hemoptysis (-)sputum Cardiac (-) heart problem (-) hypertension (-)pain Git (-)hematesis, vomiting, food intolerance (-)melena Urinary (-)nocturia , dysuria, hematuria Genital (+) spotting discharges Musculoskeletal (-) paralysis (-)limited movement Neurological (-) fainting, seizure and dizziness

Peripheral vascular (-) cramps, edema, thrombophlebitis Psychiatric (-) nervousness, disturbed mentation Hematologic (+) anemia (+) past transfusion (PRBC) 4 units Latest 107g/l First cbc nya 89, tpos 76.2 then 90, 99, 104

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