Chapter 3 Client Presentation

Chapter 3
Client presentation
Demographic profile
Patients name: D.M.G.
Address: Sun Valley, Paranaque City
Age: 82years old
Gender: Male Nationality: Filipino
Religion: Roman Catholic
Civil Status: widow

Birth date: October 31, 1932
Birth place: Batangas
Occupation: Retired technician, body guard

Patient Information obtained from the caregiver (secondary source) last March 6, 2015.
Family History
(-) Hypertension
(-) Diabetes
(-) Cancer
(-) Asthma
(-) Stroke
Past medical history
Illness: Diabetes Mellitus for more than 5 years with no CBG monitoring, not on lantus
Surgery: none
Allergies: none
Medications: none
Immunizations: unable to recall
History of present illness
Chief Complaint: pneumonia, right sided body weakness
Admitting Diagnosis: aspiration pneumonia

Final Diagnosis: acute infarct, right parietal subcortical with chronic infarcts in both
centrum semiovale, left thalamus and right cerebellum; metabolic encephalopathy related
to hypernatremia secondary to nutritional intake; aspiration pneumonia; diabetes mellitus
Present illness:During first week of February, patient was admitted for severe cough and fever,
managed as a case of pneumonia with levofloxacin 500mg/ tab OD for seven days and coamoxiclav 625mg/tab three times daily for seven days. Patient was discharged well and stable.
Four days prior to admission, patient was noted to be drowsy with decreasing appetite and fever
with productive cough with yellowish sputum. Persistence prompted consult.
The patient is a known diabetic with no prior history of stroke. Premorbid, the patient is
ambulatory with assistance and needs assistance in all activities of daily living. Three months
prior to admission, his caregiver noted that the patient tends to drag his foot when walking. No
consult was done and no medications taken. Since then, it was noted that the patient deteriorated,
became bedridden with very minimal food intake. There were episodes that the patient would
choke on his food and medications. Three weeks prior to admission, the patient was admitted at a
hospital in Paranaque and was managed as a case of pneumonia and started on antibiotics. He
was discharged after 5 days. Since then, the patient remained bedridden with poor intake and
very minimal verbal output. Persistence of above symptoms with persistence of cough and fever
prompted admission at our institution.
Physical assessment
Functional Independence Measurement (FIM) Scoring
7= independent; no use of assistive devices
6= modified independence; use of assistive devices independently
5= supervision only; no actual physical contact/touching of patient
4= minimal assistance; 25% assistance from staff to complete activity; 75% actual performance
by patient
3= moderate assistance; 50% assistance from staff to complete activity; 50% actual performance
by the patient
2= maximal assistance; 75% assistance from staff to complete activity; 25% actual performance
by the patient
1= totally dependent; more than 75% assistance from staff to complete activity; less than 25%
actual performance by the patient.
Areas
Scores
1. Grooming
2. Dressing Upper
1
1
Extremity
3. Dressing Lower
Extremity
4. Toileting/ Elimination
5. Feeding/ Eating
6. Bathing
7. Vision
8. Cognition
9. Memory
10. Communication
1
1
1
6
1
1
1
Review of systems
Temp = 37.2
PR = 78
VITAL
oral SIGNS
rectal axilla tympanic
RR = 22
BP =120/70
PSYCHOSOCIA
L
Calm
Anxious
Cooperates with care
OTHER: none
NEUR
O except for:
Within normal level W NL
Level of Consciousness
GCS: 12
Orientation
Memory Deficit
Sensory Deficit
Aids hearing vision
Cranial nerve deficit
Language deficit
OTHER: drowsy
CARDIOVASCULA
Within normal level W NLRexcept for:
Irregular heart rate murmur
Edema (location)
Coolness (location)
Color (location)
Sensation (location)
Pulses (location)
Mucous membranes
IV lines
OTHER: none
Within normal level

Irregular heart beat
shortness of breath
cough
Breath sounds:
unequal
coarse/rhonchi
artificial airway
OTHER: none
MUSCOLOSKELETAL
Within normal level W NL except for:
limitation of movement (right side)
balance
gait
ROM assistive device
joint swelling
muscle weakness
muscle tone
flaccid
Activity level:
OOB
partial assistance
complete assistance
OTHER: none
INTEGUMENTAR
Within normal level W NLYexcept for:
ecchymosis
lesions
erythema
rashes
pressure ulcer/grade 1/sacral area
pressure relief device
incision (location)
drains
turgor
OTHER: rashes on face and gluteal
RESPIRATOR
W NLYexcept for:
dyspnea
nasal flaring
diminished
crackles
GENITOURINAR
Within normal level W NLYexcept for:
burning urgency dysuria hesitancy
urinary incontinence diaper
anuric
polyuria
nocturia
catheter
drainage tubes
Urine:
color amount
cloudy sediment
heme
Genitalia:
discharge
OTHER: diaper rash
rales
wheezes
GASTROINTESTINAL
Within normal level W NL except for:
NPO Diet
TPN
extraoral feeding: NGT
Nausea
Vomiting
dysphagia
gas eructation
regurgitation
Abdomen:
bruises
secretions
COMFOR
Within normal level W NLTexcept for:
pain location
pain characteristics
receiving:
narcotics
other analgesics
shower
bath
mouthcare
pericare
antiembolic hose
OTHER: none
HYGIEN
E
firm
tender
distended
Bowel sounds:
hyperactive
hypoactive
absent
Stool:
no flatus
fecal incontinence constipation diarrhea
Stoma
OTHER: none
falls
aspiration
neutropenia
suicide
airborne
seizure
radiation
OTHER
PRECAUTION
S
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Chapter 3

Gender: Male Nationality: Filipino

Religion: Roman Catholic

Civil Status: widow

Birth place: Batangas

Occupation: Retired technician, body guard

History of present illness

Chief Complaint: pneumonia, right sided body weakness

Admitting Diagnosis: aspiration pneumonia

Within normal level

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