I.

ADMISSION/FINAL DIAGNOSIS Upper Gastrointestinal Bleeding

II.

HEALTH HISTORY AND PHYSICAL EXAMINATION A. Demographic data 1. Clients initial: G. F. A. 2. Gender: male 3. Age: 54 4. Birthdate: January 11, 1956 5. Birthplace: Aklan 6. Marital status: Married 7. Nationality: Filipino 8. Religion: Roman Catholic 9. Address: Blk 90 Lot 16 Zone 10, Bautista Property, Dasmarias, Cavite. 10. Contact number: 09206544072 11. Educational background: High School graduate 12. Occupation: Tricycle Driver 13. Usual source of medical care: OTC, hospital 14. Date of admission: Sept 29, 2010 B. Source and reliability of information The patient was able to provide limited information due to the malaise he is feeling. He has slurred speech and prefers not to talk that much. Thus, much information was taken from the relatives present. They too, were able to provide limited information. C. Reasons for seeking care/chief complaints Severe vomiting, and sometimes with blood Stool was dark and foul-smelling Abdominal bleeding and severe headache D. History of present illness/present health Patient was in good condition until last Friday. He started vomiting and could not go to work because of this. His relatives also stated that his stool was of a formed yet dark color with a foul smell. None of them could think of the probable reason for the patients illness, because before the illness happened, the patient was doing his usual activities. The patient stated that his condition worsens during the morning when he is exposed to stimulants such as drinking a cup of coffee and

eating a slice of bread. He also complains of (+) abdominal bleeding, (+) headache, (+) fatigue, (+) malaise. The patient could only rest to alleviate the pain. They resorted to over-the-counter drugs but were unsuccessful. A few days later, when the patients condition worsened, her relatives took her to the hospital. E. Past Medical History/Past Health a. Peciatric/Childhood/adult illnesses Patient experienced occasional cough and colds. He also has hypertension. b. Injuries/accidents Patient experienced no pertinent injuries or accidents. c. Hospitalization and operation Patient experienced no confinement or hospitalization except the current condition he had. d. Reproductive health Information was not taken. e. Immunization Patient stated that he has complete vaccination. f. Allergies Patient has no known allergies. g. Medications Patient is taking Ranitidine, Iselpin and Diphenhydramine. F. Family History Legend: - male

- female

and

- deceased

- patient

DM

heart attack

The patients son stated that he had 11 uncles and aunts. 2 of which has already passed away. He could not remember the reason why they passed away, though. He

also stated that his grandfather died due to Diabetes Mellitus. He could not remember the information regarding his mother. His mother died because of heart attack a long time ago. His dad is currently married to his stepmother, to whom he, as well as his sister, could not provide much information as well. The patient also has hypertension. Based on the given information, their family is at risk for hypertension, because both parents are suffering from hypertension. G. Socio-Economic History Member G. A.(patient) J. A. (daughter) J. A. (son) M. A. (son) D. A. (son) Occupation tricycle driver Factory worker Machinery worker Income P300-400/day P300/day P200 and above/day -

H. Psychosocial assessment Patients age: 54 years old Development stage: middle adulthood Developmental task: Generativity vs. Stagnation At this stage, middle age individuals seek to establish and guide the next generation. They do this either through contributing to the society or through guiding ones family. If he/she does so, he/she can have a sense of generativity sense of productivity and accomplishment. Otherwise, he will have a feeling of stagnation due to lack of productivity. The patient has developed generativity in his own right. He has established and raised his children well despite the loss of his first wife. He is now in a relationship with his second wife, and both of them seem to be taking good care of each other as well as their family.

I. Functional assessment: 1. Health-Perception-Health Management pattern Though the patient could not answer much during the interview, the relatives were the ones who stated that the patient was usually healthy despite the illness he is in. They stated that the patient eats 3 meals a day and takes his medicine for hypertension regularly. He is an occasional drinker and a chronic

smoker. The familys history of illnesses, however, could not be answered much by the relatives for they are not knowledgeable enough, and the patient could not answer this due to the patients condition. 2. Nutritional-Metabolic Pattern Before the patient was confined, the relatives stated that the patient eats 3 meals a day and drinks around 7-8 glasses of water a day. But now he is limited with little sips of water (whenever medications are taken only) and no food intake due to his NPO (nothing per orem) status. The patient usually complains about having abdominal pain and headache during mealtime, and associates it with his hunger and thirst. The relatives stated that the patient has had episodes of nausea and vomiting during his stay at the hospital, and that he has not had any episode of bowel movement since. The relatives also stated that the patient had history of ulcer. 3. Elimination Pattern Patient voids at around 8x a day. He reports experiencing the urge to urinate but with little urine product during his confinement. Before the patient experienced his illness, he usually defecates once every 2 days. But now, he has not had any episode of bowel movement since his confinement. This poses a problem for the patient, for he worries that this is not his usual habit. Moreover, the last stool he had was of blackish color, formed consistency with foul smell. 4. Activity-Exercise Pattern Limited information was taken for this, since the patient was unable to relate his daily activities. The relatives, however, stated that the patient would usually wake up at around 5am or 6am in the morning. He gets ready for work and eats his usual meal a cup of coffee, bread, and morning meals. He then sets off for work. They stated that his rest periods were during noontime, where he dozes off to nap for about 1 hour. He also comes home in the evening when works done. 5. Sleep-Rest Pattern During the course of the interview, the patient looked quite anxious and perplexed, suggesting he lacks rest. The family verbalized that before confinement, he sleeps for about 8 hours a day. His usual sleeping time is from 9pm to 5am or 6am. In noon, he naps for about 1 hour. He had not experienced sleeping problems. However, since experiencing the illness, he had problems with sleep because of nausea. During confinement, he also had episodes of

nausea and vomiting during the evening which disrupts his sleep. Regular rounds by the nurses also disturb his sleep. 6. Cognitive-Perceptual Pattern Patient was oriented to time, place, and person, but was unable to answer the questions clearly and concisely. The relatives denied him having problems with his sensory faculties except for his vision, as verbalized. The patient uses eyeglasses whenever he reads, as verbalized by the family. He is a graduate of high school only and is currently self-employed as a tricycle driver. 7. Self-Perception-Self Concept Pattern Patient was unable to answer this pattern. He is quite withdrawn and taciturn during the interview. This, however, may be due to the illness he is feeling. 8. Role Relationship Pattern Patient is a husband and a father of four young adults. Since his wife passed, he raised his children on his own. Some of them are also earning a living now. He is currently married with his second wife now. 9. Sexuality-Productivity Pattern No pertinent information was taken for this pattern. 10. Coping-Stress Tolerance Pattern Financial burden is a common stress signal for the patient, as verbalized by the family. His source of strength is his family. The family denied him using medications to cope up with emotional distress, although they do confirmed him being an occasional drinker and a chronic smoker. 11. Value-Belief Pattern No pertinent information was taken for this pattern. J. REVIEW OF SYSTEMS SYSTEM R.O.S.

P.E.
Conscious Partial ROM T = 36.8C PR = 82 bpm RR = 16 cpm BP = 90/70 mmHg

1. General

pagod na pagod ako ngayon masakit ang ulo ko.

(+) fatigue (+) weakness (+) malaise

2. Integument

wala namang problema

Skin: dry skin on both upper and lower extremities warm to touch (-) hyperpigmentation Self-care through taking a bath. Hair: Normal hair distribution No parasites evident Nail: Clubbed at 180, yellowish, hard nails Capillary refill < 3 seconds Symmetrical, smooth, firm (-) lesions

3. Head

Sumasakit ang ulo ko.

4. Eyes

nagsusuot siya ng eyeglass pag nagbabasa Cotton buds gamit niya panlinis

Symmetrical blinking Round and equal iris (-) discharges on external ear (-) tenderness (-) nasal discharges (-) nasal stuffness (-) nosebleeds (-) nasal flaring Dry lips (+) hoarseness (+) slurred speech (-) lesions

5. Ears

6. Nose and Sinuses

minsan nakakainis itong nakadikit sa ilong ko

7. Mouth and throat

Wala naming masakit sa lalamunan ko

8. Neck

Hindi naman masakit

9. Breast and axilla

Movable without resistance (-) cervical lymph node enlargements No P.E.

Minsan nahihirapan siyang huminga

10. Respiratory

Slow-paced breathing (-) wheezing

11. Cardiac

Hindi na siya masyadong nakakadumi ngayon dahil di siya pwedeng kumain. masakit ang tiyan niya naiihi ako pero unti lng ang lumalabas.

Regular heart rate

12. Gastrointestinal

Round, flabby abdomen (-) rashes

13. Urinary

Urine output of <30ml/hr

14. Genitalia

No PE

15. Peripheral Vascular

Wala namang pagmamanas at malalaking ugat sa binti niya

(-) varicosities on both lower extremities (+) jaundice on nails. Capillary refill < 3 seconds Bilateral radial pulses strong and equal at 82 bpm With slight kyphosis (+) partial ROM

16. Musculoskeletal

medyo mahina na siyang gumalaw ngayon.

Wala naman siyang problema sa pag-iisip

17. Neurologic

Responds to questions and statements Oriented to time, place and person CN V: (+) sensation to light touch and pain CN XI: (+) able to shrug shoulders, able to move neck with partial ease. CN XII: (-) limitation of tongue movements (-) bleeding

18. Hematologic

hindi naman siya anemic. Nagsuka at nagdumi lang siya ng dugo. Mabilis siya pagpawisan

(-) bruising

19. Endocrine

(+) excessive sweating (+) heat and cold tolerance

20. Psychiatric

Minsan nagiging makakalimutin na siya. Sinasabi din nya na gusto na nya umuwi.

NO P.E.