I.

Assessment
A. General Data
Patient: P.K.P.C.
Address: Las Piñas City
Age: 19
Sex: F
Date of Birth: 11/29/1989
Civil Status: Single
Occupation: Student
Informant: Patient

B. Chief Complaint
Follow-up Check-up for Hyperthyroidism, because I was not able to go back on the desired
date to have follow-up

C. History of present illness

1st semester school year 2007-2008, I observed that I am having palpitations and I
easily get tired, for example, Every morning I am walking then from my dormitory to
school about 200 meters in distance every morning, whenever I reach our classroom, I am
always having palpitations and I’m experiencing difficulty in breathing, I also experience
sudden weight loss in spite of my heavy appetite. My uncle also observed that my eyes
are protruding. September 2007, my mother observed that I have enlarged neck that is
when we decided to go to a doctor. T3, T4, TSH blood chemistry was done, and I was
diagnosed with Hyperthyroidism. He gave me Tapazole 5mg 4 times a day (6am-12pm-
6pm-12am), and Inderal 10mg, twice a day, these are for my maintenance.
August 2008, I was in RLE, and I experienced sudden heat intolerance despite of the
air-conditioned room, I was perspiring cold, and is experiencing palpitation. I went to the
clinic and the doctor told me that I just had “impending thyroid storm”. I was given then
my medicines, Tapazole and Inderal, and was given oxygen. I went to my doctor, and
laboratory tests were made. The doctor told me that I had heart failure and
thyroidtoxicosis. He told me that I should continue my medicines, with the same
frequency, and after a month if my hormones are still high, we should decide for
operation. But unfortunately, because of my busy schedule in school, until now I was not
able to go back to my doctor.

D. Past-History
1. Childhood Illness/es
Chicken Pox
2. Adult Illness/es
UTI, Dysmenorrhea
3. Immunization
Complete immunization (BCG, Hepa B, DPT, OPV, AMV)
4. Previous Immunization
I was only given a booster shot for Hepa B last July 18, 2007 since I have high
antibodies
5. Operations
None
6. Injuries
None
7. Medications taken prior to confinement (6 months)
Tapazole 5mg and Inderal 10mg
8. Allergies
Chicken, eggs due to Skin Asthma

E. System Reviews
Gordon’s Eleven Functional Areas
 1. Health perception – Health Management
So far my health was stabilized this past 4 months. My palpitation and shortness of
breath was quite stabilized. I had colds this past year and it only lasts for 2-3 days. I
had chicken pox last August 2008, that’s why I was absent for school for almost 3
weeks. As of the moment, since I am very busy with school, the only thing that I do to
keep myself healthy is by religiously taking my medicines for Hyperthyroidism. And I
think that this really helps and made a difference than my previous state of health. I
don’t smoke, I drink alcohol, about 1-2 times every 6 months, and I don’t take any
prohibited drugs. I don’t perform SBE and I was not engaged in any accidents. I have a
family history of Hyperthyroidism and both my parents had thyroid problems also. My
doctor told me that stress triggered mine. He prescribed me with Inderal and Tapazole
and until now I am still taking those medicines.

2. Nutritional Metabolic Pattern

1st day 2nd day 3rd day
Breakfast 1pc pandesal, 1 1 pc pandesal, 1 1 cup of coffee, 1
slice cheese, 1 pc sausage, 1 pc sandwhich, 1
cup coffee egg, 1 cup coffee slice cheese
Lunch 1 cup rice, fish ½ cup rice, 1 cup 1 cup rice, 2
fillet with oyster menudo, 2 slices matchbox size
sauce, spaghetti embutido beef (potchero)
Snack 1 slice cake None None
Dinner 1 cup rice, 1 cup rice, 2 cups 1 cup rice, 1
hamonado chayote with matchbox beef
slices of pork (potchero), ½ cup
baked mac, 1 cup
sopas
Approximately, I drink 1-2 liters of water a day. I also gained 8-10 pounds within 3
months. I am having hair fall, usually 60-100 strands everyday. I am not experiencing
any discomforts when eating.
3. Elimination Pattern
I usually defecate once or twice a day. My stool is brown in color and well-formed. I
am not using any laxatives. I urinate around 4-7 times a day, yellowish in color, without
any pain or discomfort. I am not experiencing any pain, discomfort or incontinence
when urinating and defecating.

4. Activity and Exercise

I don’t usually do formal exercises and is not enrolled in any gym membership. My
daily routine is just to go to school 2 to 4 times a week, go home and do school work
like working on assignments, reading textbooks. Every weekend, I usually have church
activities. During my spare time, I usually watch TV, read a book, cross-stitch, use the
computer or do errands for the house like paying bills. Thrice or 4 times every 2
months I usually go to mall and go out with friends.

5. Sleep-Rest Pattern
During school nights, I usually have 4-6 hours of sleep and I usually sleep in the bus
for 20-35 minutes. But every weekend, whenever I don’t have activities early in the
morning, I usually have 8-10 hours of sleep. I have dreams but seldom do I have
nightmares. Whenever I am very tired, I usually have dreamless sleep. I usually get
up to urinate in the dawn. I usually sleep around 11:00-11:30 pm. If I have slept
more than 5 hours I usually feel well rested and ready for daily activities.
6. Cognitive-Perception Pattern
I wear eyeglasses occasionally and whenever I am having headaches. My
grade is 50-75. I am having difficulty reading from afar. I had my first check-up to an
 optometrist last August 2008 I don’t have any hearing difficulties. I am not good in
memorizing texts word per word, but I am usually better in understanding the
concepts and ideas of what I read. If I’m trying to learn application or skills, I’m
better in learning it by practicing it often. I am more interested in reading novels
and articles rather reading my nursing textbooks.
As of the moment I don’t feel any pain or discomfort. Whenever I am
experiencing one, I try to tolerate it as much as I can. But seldom, whenever I can’t
tolerate it anymore, I usually drink pain-killer.

7. Self-Perception-Self-Concept Pattern
If I may say, Emotionally, Mentally, Intellectually, Socially and Spiritually, I am
contented with what I have now. Physically I’m not, usually, I complain about my
weight but I know that it is also because of my undisciplined eating habits. Although
my parents usually brag me from time to time that I should lose weight and stop
eating sweets etc, I myself cannot control it and I’m too lazy to do exercises
especially whenever there are classes, I always wanted to take a rest and study
rather than exercising. I’m usually hurt whenever my friends tell me that I’m
getting bigger from time to time and sometimes this makes me lose hope.
I usually get annoyed or irritated whenever I have disagreements with other
people. Fears that I have right now is losing my mother since she is the only person
that makes me feel complete everyday and not graduating in time.

8. Role-Relationship Pattern
I am living with my family. We have a nuclear family and patriarchal in nature
usually I listen more to my mother than to my father. My mother is already a retiree
my father is the only working for the whole family. Since I am the only child in the
family they do not demand on me that much but only to finish my studies in time.
Though the only child, they do not spoil me and let me have everything I want,
since I was a kid they always explain to me that I can’t have everything in life, but if
I really want something I have to save and work for it. I get along with my mother
better than with my father.
I am currently a member of a choir group at church, and I also have close
friends that I can run to whenever I have problems. But most of the time whenever I
have serious problems, I usually go first to my mother to seek advice.

9. Sexuality-Reproductive Pattern
My menstrual period is regular. I usually have 26-28 day cycle every month. I
had my first menstruation when I was 11 years old. I often experience
dysmenorrhea and I when the pain is intolerable I usually drink Ibuprofen 250 mg on
the first or second day of my menstrual period. On the first two days of my period I
usually consume 3-4 overnight napkins each fully soaked. On the 3rd and 4th day I
consume 3-4 maxi napkins, moderately soaked. And 5th day I usually consume 1-2
napkins with droplets of blood on it. My LMP was last December 21, 2008.
I haven’t used any contraceptives.
10.Coping-Stress Tolerance
October 2007, I transferred school, at first I have difficulty in establishing new
friends, but after a month, I was able to make new friends and adjust with the new
environment. As of now, our family is experiencing financial difficulties, but in spite
of this, my parents still don’t cut down my allowance and try to adjust other
expenses but not my allowance. But the stress that it brings to my parents also
affects me and the ambiance in our house. Whenever I have problems or I need
someone to talk to I usually go to my mother, she is always there for me no matter
what. Whenever there is RLE, exams or deadlines I already feel stressed. The only
thing that keeps me relaxed whenever I’m stressed or in tension is sleep.
I occasionally drink alcohol, about once or twice in six months.
 11.Values-Belief Pattern
I am a Catholic, I am a Lector in church and also a member of the choir. Every
weekend I usually do church activities. This helps to have stronger faith in myself,
and to overcome difficulties when arises.
I don’t usually get all the material things I want in my life, but what I have
now is enough and I’m contented with it.

F. Family Assessment

Name Relation Age Sex Occupation Educational

Attainment
DCC Father 42 M Contractor/Structura BS Civil
l Engineer Engineering &
Masteral in
Structural
Engineering
ZPC Mother 61 F Housewife BS Business
Administration
PKPC Patient 19 F Student College
Undergrad, 2nd
yr BS Nursing
G. Heredo-Familial Illness

Maternal: Diabetes, Hypertension, Leukemia, Colon Cancer, Nasopharyngeal Cancer

Paternal: Hypertension, Breast Cancer

H. Developmental History

Theorist Age Task Patient Description

Erickson 19 Intimacy versus
Isolation
Piaget 19 Formal Operations
Phase
Kohlberg 19 Level II, Stage 4
Fowler 19

I. Physical Examination

II. Personal/Social History

Habits: Reading, Surfing the Internet, Watching TV, Singing
Vices: None
Lifestyle: Sedentary
Social affiliations: Young Professional’s Chorale, Ministry of Lectors and Commentators
Rank in the family: Only child
Travel: Bicol, Pampanga
Educational Attainment: College Undergrad 2nd yr BS Nursing.

III. Environmental History

I live in a middle-class village, a depressed area is located at the next street. We have a two-
storey house and was recently repaired. We have a quiet environment and we don’t have
disagreements with other neighbors. Hospitals, Church, Schools, Police and Fire Station, and
Barangay Health Center are readily accessible.

IV. OB-GYNE HISTORY

Menarche: 11 years old
When: November 1999
Amount and Characteristics: few droplets of blood, brown in color.
Duration: 5 days
Associated Symptoms: Breast Swelling, Breast Tenderness
Operations: None