Professional Documents
Culture Documents
A case study on
Submitted to:
Mr. leonardo
Submitted by:
GROUP 50
A. General Data
Patient’s initials: A.R. m
Address:Binondo, Manila Informant: Client,herself
Age: 75 yo Date of Admission: 11/13/10
Sex: Female Order of Admission: via ambulatory
Date of Birth:02/08/1935 No. of Days in this hospital: 3 days
Place of Birth:Manila Date of History Taking: 12//16/10
Civil Status: Married Religion: Roman Catholic
Occupation: None
B. Chief Complaint(s)
Vehicular crash
3 days prior to confinement, client was hit by a tricycle after buying foods in Talipapa in the street of
Lavaranes, Bonondo. She then lose consciousness. She was brought by the nearest hospital which Saint Andres
Hospital. 1 day prior to confinement upon knowing by her relatives that she was not given Tetanus Toxoid, they
then decided to transfer her in Manila Doctors College. She was brought to the hospital at 7 pm.
She experience contusion at right clavicular bone, contusion on the left cheek below the eyes and lacerated
wound pleural left parietal part of her head.
D. Past History:
1.) Childhood Illness/es : none
2.) Adult Illness/es: none
3.) Immunization: complete unrecalled
4.) Previous Hospitalization: none
5.) Operation/s: thbso (1980’s)
6.) Injuries: none
7.) Medications taken prior to confinement: none
8.) Allergies: none
E. Systems Reviews:
Gordon’s Functional Health Areas
B. Nutritional-Metabolic pattern
Before admission, client typical food intake were vegetables, chicken, fish and meat. She consumed 6-8
glass of water a day. She starts her day by drinking a glass of coffee.She does have good appetite and has no
restriction in food. She doesn’t experience excessive sweating. Her wound heals well and sometimes she
experience skin dryness due to aging. She wears dentures.
During confinement, after her operation, she was prescribed NPO then general liquids. On the 3 rd day,
her doctor allows her to full diet. She is with IVF D5NSS 1000 l x KVO.
B. Elimination Pattern
Before admission client’s elimination pattern was twice a day. It is formed and yellowish. She doesn’t
have any discomfort and problem in control in defecating. He micturates 6-8 a day. Her urine is yellowish and
doesn’t contain blood. She doesn’t use any laxatives and doesn’t experience any discomfort. He wears dentures.
During confinement, client was not able to eliminate yet. At first, she just urinate sat the bedpan. But on
rd
the 3 day, she manages to urinate in the comfort room with assistance. She micturates 6-8 times a day.
C. Activity-Exercise Pattern
Before confinement, patient has sufficient energy for desired activity. But sometimes, she
experience exhaustion or he easily get tired. She is in full self car. She thinks that she gets enough exercise
through walking everyday when marketing in Talipapa. She allows herself to have chitchats with her friends and
watch television. She also mans the sari-sari store of her daughter-in-law.
During confinement, client does not have sufficient energy for desired activity. She feels weak. She can’t
move her arms the way she wants to because she has clavicular fracture. She needs assistance in getting up the
bed and sitting. She tries to ambulate a little for easy recovery. She just watches television in the room.
E. Sleep –Rest Pattern
Prior to confinement, client feels well rested and ready for daily activities after sleep. She sleeps for 6-8
hours a day. Sometimes, she wakes up during her sleep. He also experiences nightmares and early awakenings.
She allows herself for self-relaxation period.
During confinement, client
doesn’t have enough sleep. She complains that she can’t sleep at night because of the pain she feels when her
antibiotics was incorporated in her IV line.
F. Cognitive-Perception Pattern
Prior to confinement, client doesn’t have any hearing difficulties. She wears eyeglasses. She doesn’t
recall her last eye check-up. There are few changes in her memory since she growing older. If there’s any
important decision to make, she thinks about it several times, weighs, and think of what is best to resolve the
problem. She does this, because she knows her responsibilities and liabilities if she makes a bad decision. She
easily learns well and adapt to new things and changes. She is a visual and audio learner.
During confinement, she feels that her body is too weak to do things she wants. She thinks that
complying with doctor’s advice will help her get well soon. Her neuro vital signs are good. She can graps ideas
both concrete and abstract. She speaks in Filipino.
During hospitalization, client was being taken care by family and friends. She depends on them, at all
times. Her family worries about her. The suspect was put into jail easily because of her son’s job. She still
manages to have good relationship with them and she cannot wait to stay in the hospital for long to celebrate
Christmas day.
I. Sexuality – Reproductive Pattern
Prior to confinement, client has good relationship with family, relatives and friends. She is already a
widow. But she doesn’t feel lonely. Her menstruation period started when she was 13 years old and she had
menopause at age 48 years old.
Regional examination:
F. Family Assessment
Educational
Name Relation Age Sex Occupation
attainment
ASM Son 50 male Police College graduate
Daughter in Sari sari store
CSL 49 Female College graduate
law owner
KSM grandson 25 male Call center agent College graduate
I. Physical Examination:
Date of P.E: December 16, 2010 1000H
H. Developmental History
Jean Piaget –
Cognitive Theory
In making decisions, she weighs it first and thinks
Formal
40 carefully how to solve his problems because she
Operational Stage
knows his responsibility and liability.
Lawrence Kohlberg –
Moral Development She recognizes the higher authorities. She knows
40 Social contract what is right, what is wrong, how to make decisions
and his liability and responsibility.
James
Fowler – Spiritual He believes in God, the highest authority in the
Paradoxical-
Development 40 universe. She prays to him and believe that God will
Consolidative
not do any harm to people
III. ENVIRONMENTALHISTORY
Client is living with his family in Binondo, Manila. They are living in a 2 storey house. Their water is
NAWASA. They use MERALCO for electricity. They have a good drainage. They are near the Talipapa market.
She describes their place as a very crowdy place.
I. OB / GYNE HISTORY
Deliveries: G2 P2 operations: 1
OB Score: T2 P0 A0 L2
VII. LABORATORY RESULTS AND FINDINGS
MCH
27.50-33.2 This is use to measure amount per red
Mean corpuscular 31.5 Normal
pg blood cell
hemoglobin
MCHC
The amount of hemoglobin relative to
Mean corpuscular 33.40-35.50
31.3 the size of the cell (hemoglobin Normal
hemoglobin g/dL
concentration) per red blood cell
concentration
purpose:
X-rays - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal
tissues, bones, and organs onto film. Chest radiographs may depict segmental or lobar infiltrate but they more
commonly reveal a diffuse, fine, reticulogranular pattern, much like what is observed in RDS. Pleural effusions
may also be observed.
Result:
No fracture nor listhesis seen. There are osteophytes seen at the margins of the cervical vertebral bodies.
The pedicles, posteror elements, and intervertebral disc spaces are intact.
The usual cervical lordosis is maintained
The c7 vertebrae body is not visualized in the lateral view but appears intact in AP projection
Impression:
Cervical spondylosis
Radiology
Date: 12/13/2010
A small round calcified density is seen in the right lower hemithorax overlying the Right 8 th posterior rib. The
rest of the lungs are clear. The heart is enlarged
Aorta is atheromatous
The diaphragm and sulci are intact
Thoracic spondylosis is evident
Impression:
Right lower lobe cacific Granuloma
Atheromatous Aorta
Thoracic spondylosis
No demonstration of fracture is seen in this study. Soft tissue swelling over the left zygomatic arc is evident.
ABO : “B”
Rh Type : Positive
PATHOPHYSIOLOGY:book based: fractured clavicle communited
sternocleidomastoid muscle
elevates the proximal fragment
of the bone.
sternocleidomastoid muscle
elevates the proximal fragment
of the bone.
MEDICATION
- Nexium
- Arcoxia
- Dilantin
- Cloxacillin
EXERCISE
- ROM
- increase ambulation
-perform independent activities as tolerated
- Provide rest
- exercise should increase gradually
-
TREATMENT
-high back rest
HEALTH EDUCATION
- adequate rest
-increase oral fluid
OPD FOLLOW-UP
DIET
- Low Na and fat diet
SPIRITUAL
- Administer
analgesics as
prescribed such as