Republic of the Philippines

PALAWAN STATE UNIVERSITY

College of Nursing and Health Sciences
Tiniguiban Heights, Puerto Princesa City

I. PATIENTS PROFILE

Name: Mrs. L.A.

Age: 72 years old

Gender: Female

Status: Married

Birthdate: July 20, 1944

Birth place: Cuyo,Palawan

Address: Magara Araoan, Roxas, Palawan

Occupation: None

Nationality: Filipino

Religion: Roman Catholic

Educational Attainment: Elementary Graduate

Date and time of admission: February 06, 2017; 12:15 am

Ward: Gynecology Gyne/Bed 10

Condition Upon Arrival: Ambulatory

Admission Type: Service

Type of Patient: New; NBB; Indigent

Chief Complaint: Abdominal Enlargement

Treatment: CBC; BT

Admitting Physician: Dr. Karla Marfel T. Plagata

Attending Physician: Dr. Carol R. Dion

Admitting Diagnosis: T/C Ovarian New Growth

Discharge Diagnosis: G12P12 pelvoabdominal mass, ovarian new growth probably malignant

work-up done;

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 II. HEALTH HISTORY

A. Present Illness

3 months PTA, November 2016. Mrs. LA noted to have abdominal enlargement. She

consulted to the ONP-OPD last December 22, 2016 when she experienced abdominal pain. Upon

consultation, the ultrasound was done; there was a note of huge pelvoabdominal cystic mass

measuring 25 cm from the symphysis pubis. Thick walled multiloculated with thick septum,

with papillarities and contains mixed echoes. Sassone score is 12 with minimial free fluid in the

posterior cul de sac at the time of scan. After the consultation, the patient refuses to believe the

result and decided to go home without taking any medication. She chose to endure the pain

because she only believes on the albularyo.

4 hours PTA, she felt an intermittent pain with the pain scale of 7/10 then decided to go

to the emergency room of ONP on February 06, 2017 at 12:15am via tricycle with her daughter.

At the emergency room, she was diagnosed with T/C Ovarian New Growth. Initial vital signs

taken with RR: 17 cpm, PR: 104 bpm, Temp: 36.1 C and blood pressure of 180/80 mmHg.

B. Past Health History

Because of her condition, Mrs LA perceived herself as ill and unhealthy. During

her childhood days, she did not experience any illnesses except mumps and chicken pox. She had

cough and colds for several times. According to the patient, she was not able to complete all her

immunizations. She did not experience any surgical procedures and she had no known allergies.

The patient gave birth to her 12 children at home through NSVD and assisted by hilot and she

did not seek any medical assistance all throughout her pregnancy.

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C. Family History

Mrs. LA is 72 yrs old, she is the third child in the family and she is hypertensive, she has

three siblings, and two of them are dead. Her father died due to unknown cause of death, her

mother died at the age of 86 because of an old age. Her eldest brother died due to appendicitis at

the age of 75, her eldest sister is hypertensive and has UTI while her younger sister died to an

unknown cause. Her eldest son 55 y/o is hypertensive and a smoker, smoking three sticks per

day. Her second eldest son 52y/o and her eldest daughter 51y/o is alive and well, while her third

eldest son 49 y/o is dead and the cause of death is unknown, her second eldest daughter 46 y/o is

alive and well, her third eldest daughter 44y/o died due to heart attack, her fourth eldest son 43

y/o is an alcoholic and consumes 1 bottle of alcohol occasionally, her fifth son is 40 y/o was a

smoker and died due to a vehicular accident, her sixth son 39 and the youngest son 37 is alive

and well, her fourth elder daughter 36 y/o and the youngest daughter 30 is alive and well.

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D. Obstetrical History

MENARCHE: 13 years old

DURATION OF MENSES: 3-5 days

MENSTRUAL FLOW: Moderate to heavy

INTERVAL/CYCLE: 32 days

COLOR: Red

NUMBER OF PADS USED PER DAY: 3-5 pads

PREVIOUS USE OF CONTRACEPTIVE: None

OB SCORE: G12 P12 (T12 P0 A0 L9)

TYPE OF DELIVERY: Normal Spontaneous Vaginal Delivery (assisted by Hilot)

PRENATAL CHECK-UP: No history

MANAGEMENT DONE in OB Ward:

Monitored vital signs every 4 hours of duty

Strictly monitored the blood pressure

Measured abdominal size every day of duty

Monitored and regulated IVF

Provided comfort measures such as back rub and shoulder tap

Performed bed side care

Bed bath done

Performed oral, hair and perineal care

Health teaching about proper hygiene and hand washing

IV removal

Encouraged the patient to pray for her situation.