DEMOGRAPHIC DATA Patient Name: Age: Birth date: Birth place: Address: Gender: Nationality: Religion: Civil Status:

Occupation: Date of Admission: Time of Admission: Chief Complain: Clinical Impression: Principal Diagnosis: Attending Physician: 68 June 24, 1943 Santiago City Buena Vista, Santiago City Male Filipino Roman Catholic Married Farmer

Difficulty of Breathing

PRESENT MEDICAL HISTORY 3 days prior to admission, patient experienced fever associated with cough. The following medication s were used for home management: Ambroxol, Neozep, Bioflu. Few hours prior to admission, patient experienced difficulty of breathing. Patient was at rest during the attack. ,Due to the persistence of the condition, he was brought in this institution for medical assistance. According to the patients wife, the patient is experiencing cough for more than three months now. He used to cough occasionally, productive, able to cough out phlegm characterized as whitish. The cough was considered as a mild illness and it was stated that the said condition did not have significant effect on the patients daily living. It was only exacerbated during the occurrence of fever. PAST MEDICAL HISTORY This is the 3rd hospitalization of the patient. First hospitalization was about 10 years ago due to Acute gastroenteritis. Condition was managed without complications. Hospitalization lasted for 2 days. Second hospitalization was 6 years ago due to heart condition. Hospitalization lasted for a day. His wife stated that he was admitted for general check up to diagnose his heart condition. During that time, he was experiencing bipedal edema. He was diagnosed with cardiomegaly, gallbladder atrophy, and as verbalized by his wife meron daw siyang spot sa kanyang baga. He was given medications, mostly supplements, which were unrecalled by him and his family members. Patient has unrecalled immunization status. He is allergic to chicken, egg and fish. Upon the ingestion of such food, he develops skin lesions on his head and his lower legs. He was not diagnosed with other illnesses such as hypertension, asthma and diabetes. Prior to admission he was not taking any maintenance medications or supplements. Patient is a cigarette smoker. He started smoking in his 20s. Usually, he consumes one pack of cigarette per day. He is also an alcoholic beverage drinker. He started drinking in his late 20s. He usually drinks every other day consuming 3 bottles of red horse per day.

The patient has family history of hypertension, cardiac disorder and cancer. All of his siblings are hypertensive. Two of his siblings, whom one is also diagnosed with cardiomegaly, died of cancer. He has no family history of diabetes and asthma. GORDONS FUNCTIONAL PATTERN A. Health Perception Health Management Pattern Patient verbalized that he needs further understanding on his present condition. He is concerned with his health condition. He used to have his blood pressure checked by his sister, a midwife, whenever hes not feeling well. During the occurrence of illness, he seeks for medical consultation. Patient uses over the counter dugs as management for illnesses such as cough, cold, and fever. His family also supports him in his health maintenance. They verbalized that they are prioritizing his health and they have enough finances for his health care. Patient is a cigarette smoker. He started smoking in his 20s. Usually, he consumes one pack of cigarette per day. He reported having cough for more than 3 months now, but he did not stop smoking. He still smoked even when he was experiencing fever prior to admission. His wife verbalized that he only stopped smoking now that he is in the hospital. He is also an alcoholic beverage drinker. He started drinking in his late 20s. He usually drinks every other day consuming 3 bottles of red horse per day. He and his family cannot remember about his immunization status. He is allergic to chicken, egg and fish. Upon the ingestion of such food, he develops skin lesions on his head and his lower legs. He avoids these foods but whenever having no choice, he also eats this kind of foods. Whenever lesion develops, the patient just let them subside. They usually disappear after 5 days to 1 week but appears again once he eats the kind of foods mentioned. At present, he is complying with the therapeutic regimen prescribed. He verbalizes how difficult it is to be hospitalized. Hes hoping that his condition will be better soon and that he can recover fast.

B. Nutritional Patient is 52 tall. He is weighing ______. There has been no evident weight loss. Loss of appetite occurred during the onset of fever. Prior to the onset of condition, patient has good appetite especially when it comes to rice and vegetables. He eats three meals a day and an AM snack. Usual breakfast consists of rice, fried canned or frozen food, coffee and bread. Lunch and dinner usually consists of rice and vegetables. Morning snack consists of coffee and bread. He also drinks coffee whenever he awakens at night. He does not drink softdrinks. He is allergic to fish, chicken and eggs but eats them whenever having no choice. He does not eat pork because he feels early satiety whenever he does, as verbalized madi ti riknak nu agsida ti baboy, alisto ak nga masuya. He is not fond of eating fatty and salty foods. His cough was not affecting his food intake. At present, he is on _____diet. He is on oxygen support at 5 LPM via face mask which affects usual diet. He still cannot tolerate oxygen delivery via nasal cannula. He is given with Ensure milk for the meantime. He can also tolerate regular diet but at small amounts. He has an intravenous fluid of D5NSS + regulated at _______. C. Elimination Pattern Before hospitalization, patient usually urinates 5- 7 times a day. He has no problems regarding urination. Urine characterized as clear to yellowish. He usually defecates once a day, regularly. At present, patient is weak thus he is being served with urinal whenever he eeds to urinate. He urinates 3-6 times per shift. He has an adequate urine output ranging from _______ per shift. Urine characterized as clear to yellowish in color. During this hospitalization has defecated once. Stool characterized as well formed, brown in color. May idadagdag pa. meds nia affecting elimination..wala aq list of meds..to follow D. Activity and exercise The patient is a farmer. Though, he stopped managing their farm for more than a year now. He visits their farm at times using his motorcycle. They also own a fish pond which he also visits at times. He usually stays at home. He owns a small piggery at their backyard. Daily chores

include cleaning their pig pens and feeding the pigs. He has no planned regular exercise. According to his wife, walking and doing his daily chores serve as his exercise. He is fond of having conversations with his neighbors. He visits some places and relatives using his motorcycle. At present, the patient is on oxygen support at 5 LPM via face mask. He is on moderate high back rest. He has muscle strength of 4/5 over all extremities. He needs assistance in most of his activities. He is being assisted during changing of position from lying to sitting, feeding, grooming, and elimination. He cant tolerate lengthy conversations due to shortness of breath whenever he does. E. Sleep/ Rest Patient usually sleeps at 6pm then awakens at 9pm. Then he drinks coffee, and usually just walks around the house or sits in their living room. Then he goes back to sleep before 1 am then arises at 6am. He usually sleeps at afternoon from 12 noon to 3 pm. Despite this sleeping pattern, patient verbalized feeling of being rested upon rising. This has been his sleeping pattern and he has not encountered problems regarding this. He uses one pillow in his sleep. He has not experienced disturbance of his sleep due to his cough. During his confinement, patient usually sleeps in the afternoon and at night. He has longer hours of sleep. He is on semi fowlers position even at rest. F. Cognitive perceptual pattern Patient is conscious and coherent. He is asleep most of the time, with GCS of 15/15. He is oriented to time, place and person. He is responsive and has intact memory. He is conversant, though he has problems on lengthy conversation due to shortness of breath. The patient does not use eyeglasses. He verbalized that his eyesight is still clear. Eyes are symmetrical. Eyebrows are equally distributed, no dryness and scaling noted. Ears have the same color with the face. He verbalized that he can hear well. Nose has symmetrical nares with no deformities, lesions, or occlusions. Able to distinguish odors. Mouth has symmetrical closure. Able to distinguish taste. There are no sensory deficits.

Patients educational attainment was until 1st year high school. H instructions. There are no complaints of pain. G. Self Perception / Self Concept

e is able to read and

write. E is able to speak Ifugao, Ilocano, Tagalog and English. He is able to understand

There is nothing unusual about the patients appearance. According to his wife, she was encouraging him to join Senior Citizen but he keeps on refusing and jokingly answering, pang lallakay lang dayta. During this assessment, patient appears calm. Patient is well-groomed. Regarding the present situation, his major concern is his recovery. He usually verbalizes to his children and to the nurses on duty, an-anusan dak a annakko. H. Role-Relationship Pattern Patient is married. His fist wife died 20 years ago but he got married again after 7 years. His wife watches over him in the hospital. He has five children, 3 of them belonging to his first wife and the 2 to his present wife. He is the head of the family. He lives with his wife, his eldest son, his two younger daughters, and his nephew. His two elder daughters already have their own families and are living abroad. They are always keeping touch in him and they send financial support whenever needed. He used to have four siblings but 3 of them died. His only sibling left, his sister, lives nearby and they are in good terms. He verbalized that there has been no problems encountered in the family. Hes first family has accepted his second wife and their children well. In the hospital, his wife serves as his primary care giver. His son and nephew also serves as watcher at times. I. Coping/ Stress Tolerance At present, patient does not have any problem in his family and financially. In the past, whenever he encounters problems at home he lives for a while then comes back after the situation

has cooled off. As verbalized by his nephew, nu adda problema atiddog nga tungtungan dayta ngem maayos met lang nukwa. The patients main stressor as verbalized is his condition. He is worrying if his condition will be getting well soon. His support systems helps him in handling the stress. J. Value / Belief The patients religion is Roman Catholic. He belongs to the ethnic group of Ifugao and Ilocano. According to the patient, he is often attending masses every Sunday. which may affect health. K. Sexuality reproduction Patient is married. He has five children. Hes eldest child is at his 30s, his youngest is 11 years old. No problems regarding sexuality and reproduction have been encountered. During his hospitalization, he keeps on saying, ti Diyos ti bahala kanyatayo. There are no other beliefs