I.

DEMOGRAPHIC DATA:
Patients name: T.A
Sex: Male
Age: 63 years old
Address: Apparri, Cagayan
Date of Birth: December 08, 1950
Nationality: Filipino
Religion: Roman Catholic
Occupation: Carpenter
Living environment: Owned house with 2 participants
Source of Income: Sons income
Marital Status: Married
Admission Date/Time: April 22, 2014
Attending Physician: anastacio, antonio MD
A. IDENTIFYING DATA: The patient is a 63 year old male from Appari ,Cagayan
B. CHIEF COMPLAINT: Hyperplasia of the Prostate
C. Admitting Diagnosis: Hyperplasia of Prostate
II. PRESENT HEALTH HISTORY:
11 mos. PTA, the patient noticed an increase in urine frequency and feeling of
incomplete emptying of the bladder. This was accompanied by dysuria upon finishing urination.
He sought consult at a local hospital where he was prescribed with sambong herbal capsule
and unrecalled antibiotic. He took the said meds with good compliance no relief was noted. He
then noted increased urination in the in the evening, a weal stream upon urination and need to
strain achieve complete bladder emptying. This prompted the patients consult with Dr.
Anastacio for probable management.
2 mos. PTA, the patient had an ultrasound performed which revealed mild
pyelocaliectasis, cortical cyst and cystitis the right kidney. The left kidney was normal. He was
given finasteride 5 mg OD which provided relief his urinary symptoms.
3 weeks, PTA, he was admitted at our institution he had TRUS guided biopsy of the
prostate and the specimen was sent to the histopath lab for evaluation the patient was
discharged there on to avail results. His biopsy then revealed an evident benign prostatic
hyperplasia. The patient was therefore adured to undergo a TURP and address the calculus in
his urinary bladder , hence admission.
III. PAST HEALTH HISTORY:
FLU
Immunization unrecalled
(-) Hypertension, DM, Anemia
IV. FAMILY HEALTH HISTORY

V. DEVELOPMENTAL HISTORY
Generativity vs. Stagnation
According to Erik Eriksons Psychosocial Development Theory, the patient is in the stage of
Generativity vs. Stagnation (40-65 years old.)
The basic strengths in this stage are production and care. Middle-age is when people tend
to be occupied with creative and meaningful work and with issues surrounding their family.
Also, middle adulthood is when people can expect to "be in charge," the role we've longer
envied.
The significant task is to perpetuate culture and transmit values of the culture through the
family (taming the kids) and working to establish a stable environment. Strength comes through
care of others and production of something that contributes to the betterment of society,
which Erikson calls generativity, so when we're in this stage we often fear inactivity and
meaninglessness.
Based on the definition given above, the patient successfully achieved the stage of Generativity .
Based from our interview and role-relationship assessment, he feels so loved by his wife whom he was
married for almost 36 already. His wife is the one taking care of her in the hospital and he feels very
thankful of having him as her companion because he was being taken care so well. A close and happy
bond was observed within their relationship and he is close to his on even it is Taiwan or overseas .
Being a former carpenter , the patient told me that he had already accepted the fact that he has to rest
and stop working already. He believed that he has already reached his achievement in life and feels very
successful.
SURGICAL MANAGEMENT
I. Operative Diagnosis:
Cystourethoscopy TURP open cystolithotomy suprapubic cystostomy
Surgeon: Dr. Anastacio
Asst. Surgeon: Dr. Gasa


TEST

RESULT

UNIT

REFERENCE

ANALYSIS
HEMOGLOBIN Mass
C
132 g/L 140-160 Normal
HEMATOCRIT 39 % 40-54 Normal
RBC 4.4 X10^12/L 4.0 4.5 Normal
MCHC 33 % 32-37 Normal
MCH 30.0 pg 27.5 33.2 Normal
MCV 89 fL 80-94 Normal
RDW 13.6 % 11-15 Normal
WBC 17.6 X10^9/L 5-10
White blood cell
(WBC,
leukocyte)
count. White
blood cells protect
the body against
infection. If an
infection
develops, white
blood cells attack
and destroy the
bacteria, virus, or
other organism
causing it. White
blood cells are
bigger than red
blood cells but
fewer in number.
When a person
has a bacterial
infection, the
number of white
cells rises very
quickly..
NEUTROPHILS 95 % 40-75
Neutrophils
may increase in
response to a
number of
conditions or
disorders. In
many instances,
the increased
number of
neutrophils is a
necessary
reaction by the
body, as it tries
to heal or ward
off an invading
microorganism
or foreign
substance.
Infections by
bacteria,
viruses, fungi,
and parasites
may all increase
the number of
neutrophils in
the blood

VII. PHYSICAL ASSESSMENT
SYSTEM NORMAL FINDINGS ABNORMAL
FINDINGS
ANALYSIS
Head and Neck Scalp:
Clean and dry
black hair
Head:
No tenderness
No bleeding
Lymph nodes are non
movable and no
swelling present
Jugular venous pulse
not visible
No blowing/swishing
sound heard on carotid
arteries
Pulses are equally
strong (+2)







Eyes, Ears, Nose and
Sinus
Eyes:
Cornea reactive to
light
smooth and symmetric
eye movements
good papillary
constriction
Eyeballs not
protruding
Bulbar conjunctiva is
smooth, clear and
moist
Ears:
good hearing acuity
for L and R ear
Nose:
Patent nostrils
Sinus:
Non tender sinuses
No crepitus
Mouth:
Lips are smooth
No lesions
No swelling





LYMPHOCYTES 5 % 20-45
PLATELET Normal X10^9/L 150-440 Normal
MPV 8.0 fL 7.5-11 Normal
RBC Morphology Normochromic,
Normocytic
fL 7.5-11.5 Normal
Complete set of teeth
with yellowish color
Pink and moist tongue
Thorax Breast are symmetric
Nipples are nearly
equal bilateral in size,
same location on each
breast
S1 is loudest at the
apex, S2 loudest at the
base of the heart
HR: 90 beats/min
Bronchial sounds
heard on tracheal area
Bronchovesicular
sounds heard over
bronchi area

-







Abdomen Midline abdominal
area was covered with
a surgical dry dressing
with no exudates
Mild 8-10 normoactive
bowel sounds/min on
left abdominal area
No palpable nodes in
central area
Attached with an
ileostomy bag on the
left lower quadrant
Stoma is in reddish
color without any
presence of
inflammation and
swelling.
Guarding behaviour
towards the ileostomy
bag.



-post operative
procedure done

-Active GIT
(Flatus was observed)




Liver, gallbladder and
pancreas was not
palpated because on
clients contraptions.
Upper and Lower
Extremities
Arms are bilaterally
symmetric with
minimal variation in
size
Legs are free of lesions
Toes, feet and legs are
equally warm
No edema or venous
pattering in arms or
legs
Femoral pulses are
strong and equal
bilaterally
Dorsalispedis pulses
and posterior tebial
pulses are bilaterally
strong








No difficulty in
dorsiflexing her feet
Muscle strength of 4/5
Skin and Nails Skin:
warm
Smoot

Nails:
Clean
smooth
firm
capillary refill
(2 seconds)