This document provides demographic and clinical information for a 21-year-old male patient presenting with abdominal pain, nausea, vomiting and fever. It includes the patient's medical history, family history, social situation, and results of a physical examination. Specifically, it notes the patient's history of appendectomy and intestinal surgery, current symptoms of 10 weeks duration, vital signs, and findings from a review of systems examining the integumentary and hair/head systems. The patient has a history of malnutrition and appears weak with visible veins and pale nails. The physical examination found normal skin and hair aside from dry, scaly skin.
Surgery case presentation on anterior abdominal wall herniaAnandarup Das
This case presentation summarizes a 26-year-old male patient with a parumbilical hernia. The patient reported an abdominal swelling for 18 years that increased in size and caused pain over the past 4-5 months. On examination, a 3x4 cm oval, reducible swelling was found in the supraumbilical region. Investigations confirmed the diagnosis of a parumbilical hernia. The patient was diagnosed with a parumbilical hernia with an omentocele and divergence of the recti muscles. The management plan is primarily surgical to close the defect either primarily or with mesh placement.
Intracerebral Hemorrhage Case presentationUsama Ragab
1. This document presents the case of a 65-year-old male who presented comatose with right side weakness after suddenly feeling weakness on his right side while eating dinner.
2. His medical history includes hypertension, diabetes, chronic kidney disease, and smoking. On examination he was comatose with a Glasgow Coma Scale of 6.
3. Imaging showed a left basal ganglia hemorrhage. His management involved treatment of hypertension and coagulopathy. Guidelines recommend lowering blood pressure to 140 mmHg for hemorrhagic stroke patients to reduce hematoma expansion and improve outcomes.
This document summarizes a clinical meeting discussing a 60-year-old female patient presenting with recurrent upper abdominal pain over the past 2 years. Examination findings included tenderness and guarding in the epigastrium. Investigations revealed elevated serum lipase, anemia, and ultrasound findings suggestive of chronic pancreatitis. The provisional diagnosis was chronic pancreatitis, with differential diagnoses of chronic cholecystitis or peptic ulcer disease. CT scan and laboratory results confirmed the diagnosis of chronic pancreatitis due to pancreatic calculi, complicated by iron deficiency anemia.
CASE PRESENTATION OF JAUNDICE INCLUDES PATIENT DEMOGRAPHICS, PAST MEDICAL AND MEDICATION HISTORY, FAMILY HISTORY, SURGICAL HISTORY, PERSONAL HISTORY, ON EXAMINATION, LABORATORY INVESTIGATIONS, DIAGNOSIS, SOAP NOTES, TREATMENT, DISEASE INFORMATION, PATIENT COUNSELLING, LIFE STYLE MODIFICATIONS.
A 35-year-old male presented with a left inguinal hernia. Examination and imaging confirmed a left inguinal hernia with omental fat as the content. The patient underwent a left hernioplasty surgery under spinal anesthesia. Post-operatively, the patient was treated with antibiotics and analgesics. By post-operative day 3, the patient had no complaints and was discharged on medications including antibiotics and supplements.
The document describes a case study of a 26-year-old male patient admitted with acute gastroenteritis presenting with abdominal pain, nausea, vomiting and watery stools. It provides background on acute gastroenteritis including common causes, signs and symptoms, and diagnostic tests. It also outlines the patient's history, physical exam findings, laboratory results, treatment including loperamide and hyoscine butylbromide, and nursing care plans to address his pain, fluid deficits, and gastrointestinal symptoms.
Mrs. Omi Devi, a 67-year-old female, presented with abdominal pain for 12 days and was diagnosed with cholelithiasis after an ultrasound revealed gallstones. She has a history of diabetes and hernia surgery. On physical examination, she had pain in her abdomen on palpation at the site of her recent laparoscopic cholecystectomy. Her lab tests showed elevated bilirubin levels. She is being treated medically with antibiotics and pain medications and was advised dietary and lifestyle modifications to manage her condition.
Surgery case presentation on anterior abdominal wall herniaAnandarup Das
This case presentation summarizes a 26-year-old male patient with a parumbilical hernia. The patient reported an abdominal swelling for 18 years that increased in size and caused pain over the past 4-5 months. On examination, a 3x4 cm oval, reducible swelling was found in the supraumbilical region. Investigations confirmed the diagnosis of a parumbilical hernia. The patient was diagnosed with a parumbilical hernia with an omentocele and divergence of the recti muscles. The management plan is primarily surgical to close the defect either primarily or with mesh placement.
Intracerebral Hemorrhage Case presentationUsama Ragab
1. This document presents the case of a 65-year-old male who presented comatose with right side weakness after suddenly feeling weakness on his right side while eating dinner.
2. His medical history includes hypertension, diabetes, chronic kidney disease, and smoking. On examination he was comatose with a Glasgow Coma Scale of 6.
3. Imaging showed a left basal ganglia hemorrhage. His management involved treatment of hypertension and coagulopathy. Guidelines recommend lowering blood pressure to 140 mmHg for hemorrhagic stroke patients to reduce hematoma expansion and improve outcomes.
This document summarizes a clinical meeting discussing a 60-year-old female patient presenting with recurrent upper abdominal pain over the past 2 years. Examination findings included tenderness and guarding in the epigastrium. Investigations revealed elevated serum lipase, anemia, and ultrasound findings suggestive of chronic pancreatitis. The provisional diagnosis was chronic pancreatitis, with differential diagnoses of chronic cholecystitis or peptic ulcer disease. CT scan and laboratory results confirmed the diagnosis of chronic pancreatitis due to pancreatic calculi, complicated by iron deficiency anemia.
CASE PRESENTATION OF JAUNDICE INCLUDES PATIENT DEMOGRAPHICS, PAST MEDICAL AND MEDICATION HISTORY, FAMILY HISTORY, SURGICAL HISTORY, PERSONAL HISTORY, ON EXAMINATION, LABORATORY INVESTIGATIONS, DIAGNOSIS, SOAP NOTES, TREATMENT, DISEASE INFORMATION, PATIENT COUNSELLING, LIFE STYLE MODIFICATIONS.
A 35-year-old male presented with a left inguinal hernia. Examination and imaging confirmed a left inguinal hernia with omental fat as the content. The patient underwent a left hernioplasty surgery under spinal anesthesia. Post-operatively, the patient was treated with antibiotics and analgesics. By post-operative day 3, the patient had no complaints and was discharged on medications including antibiotics and supplements.
The document describes a case study of a 26-year-old male patient admitted with acute gastroenteritis presenting with abdominal pain, nausea, vomiting and watery stools. It provides background on acute gastroenteritis including common causes, signs and symptoms, and diagnostic tests. It also outlines the patient's history, physical exam findings, laboratory results, treatment including loperamide and hyoscine butylbromide, and nursing care plans to address his pain, fluid deficits, and gastrointestinal symptoms.
Mrs. Omi Devi, a 67-year-old female, presented with abdominal pain for 12 days and was diagnosed with cholelithiasis after an ultrasound revealed gallstones. She has a history of diabetes and hernia surgery. On physical examination, she had pain in her abdomen on palpation at the site of her recent laparoscopic cholecystectomy. Her lab tests showed elevated bilirubin levels. She is being treated medically with antibiotics and pain medications and was advised dietary and lifestyle modifications to manage her condition.
The document describes a case of a 48-year-old male patient from Bangladesh presenting with abdominal pain and vomiting. Initial testing showed eosinophilia. Further investigation with endoscopy resulted in a diagnosis of eosinophilic gastroenteritis, which is characterized by eosinophil infiltration of the gastrointestinal tract. The disease can affect the mucosa, muscle layer, or subserosa. Diagnosis is confirmed by biopsy showing elevated eosinophils. The pathogenesis is thought to involve an allergic response in some cases.
This document summarizes an obstetric case of a 30-year-old pregnant woman. She presents with amenorrhea and easy fatigability for the past 2 months. Her medical history and examination reveal she is anemic, with a hemoglobin level of 7.4g/dl. She has two previous normal deliveries. A diagnosis of anemia is made based on her symptoms and laboratory results.
a case study on burn injury / case presentation on burn injury martinshaji
Damage to the skin or deeper tissues caused by sun, hot liquids, fire, electricity or chemicals.
The degree of severity of most burns is based on the size and depth of the burn. Electrical burns, however, are more difficult to diagnose because they're capable of causing significant injury beneath the skin without showing any signs of damage on the surface.
Symptoms range from a feeling of minor discomfort to a life-threatening emergency, depending on the size and depth (degree) of the burn.
Sunburn and small scalds can often be treated at home. Deep or widespread burns and chemical or electrical burns need immediate medical care, often at specialised burn units.
A burn is a type of injury to skin, or other tissues, caused by heat, cold, electricity, chemicals, friction, or radiation (like sunburn). Most burns are due to heat from hot liquids (called scalding), solids, or fire. While rates are similar for males and females the underlying causes often differ.
this is a case study on burn injury , this details about the diagnosis, management, treatment, patient counselling & pharmacist interventions , regarding medication etc , and also describes in detail about all aspects of burn injury .
please comment
thank u
Sarah is a 45-year-old female who presents with abdominal pain localized to her epigastric and right upper quadrant that worsened after eating. She has a history of similar pain episodes and comorbidities of diabetes and hypercholesterolemia. On examination, she has tenderness in her epigastric and right upper quadrants with a positive Murphy's sign. Imaging reveals findings consistent with acute cholecystitis. She is started on antibiotics and supportive care and recommended for a laparoscopic cholecystectomy to treat her acute cholecystitis.
A 47-year old female patient presented with hoarseness of voice, constipation, generalized weakness, myalgia, coarse skin, decreased appetite, and facial puffiness for 1-3 months. Physical examination and laboratory test results found decreased levels of T3, T4, hemoglobin, MCV and MCH, and an elevated TSH. Based on these subjective and objective findings, the patient was diagnosed with hypothyroidism and anemia. She was prescribed levothyroxine, ferrous sulfate, and advised to follow a healthy diet and lifestyle to manage her conditions.
It is also called as Coronary heart disease,usually caused due to BP,diabetes , obesity e.t.c.It leads to the restriction of the blood flow to the heart.
Tetralogy of Fallot long case discussionNizam Uddin
Ms. Lamia, a 10-year old girl from Potuakhali, Barisal, presented with breathlessness for 2-3 weeks and bluish discoloration of her skin since childhood. Examination found central cyanosis, clubbing, and a grade 3/6 ejection systolic murmur, suggesting congenital cyanotic heart disease, most likely Tetralogy of Fallot. Medical management and potential surgical options were discussed.
The patient is a 67-year-old male former smoker presenting with shortness of breath on exertion. Physical examination finds reduced breath sounds and wheezing. Tests show reduced lung function and oxygen levels. The differential diagnosis includes cardiac and pulmonary causes like COPD. Dyspnea is the medical term for shortness of breath and can result from various lung and heart conditions. Treatment focuses on the underlying cause, like using bronchodilators for COPD.
Myocardial Infarction - Case Presentation and an OverviewAbubakkar Raheel
Case Presented by Final Year MBBS sudents of Frontier Medical College at the 1st Clinico-Pathological Conference for the year 2015.The Presentation is divided into two parts. First part is about a case of an Acute ST Segment elevated Myocardial Infarction with. Its management at the Hospital and the findings. Second part is about the pathophysiology, Cinical signs and symptoms and an effective gold standard treatment of MI.
The document discusses a case study of a 24-year-old female patient named Kalpana Pandit who was admitted to the hospital for cholelithiasis (gallstones). It provides details of her medical history, symptoms, physical examination findings, diagnosis, and treatment plan. The causes and risk factors for cholelithiasis are also briefly explained.
This document contains a medical case report for a 52-year-old male patient presenting with hip pain. It includes details of the patient's history, examination findings, diagnostic test results, and initial treatment plan. The patient has paraplegia and diabetes following a spinal cord injury years ago. Examination revealed a pressure ulcer on his right buttock. Blood tests showed elevated white blood cells and slightly high blood glucose. The provisional diagnosis is a decubitus ulcer, which is being treated with antibiotics, wound dressings, and positioning changes to offload pressure on the affected area.
This document summarizes a 28-year-old Indonesian male patient who presented with abdominal pain, fever, and vomiting. On examination, he was found to have jaundice and tenderness in his right hypochondrium and epigastrium. Laboratory tests showed elevated liver enzymes and bilirubin. Ultrasound revealed gallbladder sludge and dilation of the bile ducts due to a large stone. ERCP confirmed choledocholithiasis with multiple stones in the common bile duct. The provisional diagnoses were ascending cholangitis and cholecystitis.
Mr. Sher Singh, a 68-year-old male farmer, presented to the hospital with weakness, loss of appetite, and cough with sputum for 3-4 days. After investigations, he was diagnosed with chronic obstructive pulmonary disease (COPD). He has a history of smoking. Physical examination found wheezing on auscultation of the lungs and decreased oxygen saturation. Blood tests showed increased creatinine and C-reactive protein. Chest X-ray found consolidation. He was admitted and started on treatment for COPD.
A 54-year-old man presented with a 1-month history of pain and swelling on the outer left foot and blackening of the left little toe for 15 days. He has type 2 diabetes for 5 years and underwent amputation of the left little toe. On examination, he has an 8.5x7 cm ulcer on the left foot dorsum and plantar aspect with features of peripheral neuropathy and restricted ankle range of motion. He was diagnosed with a left diabetic foot ulcer post little toe amputation that has improved from Wagner grade 4 to grade 2, along with bilateral mixed peripheral neuropathy.
A 28-year-old lady presented with headaches and palpitations for 3 months. On examination, she had a blood pressure of 155/98, heart rate of 117, BMI of 37.6, and fine kinetic tremors with sweaty hands. No significant abnormalities were found on cardiovascular, chest, abdominal, or neurological examinations. She was admitted for further investigation of secondary hypertension. Tests were ordered to evaluate endocrine and renal causes of her high blood pressure. A CT of the brain found evidence of a prior craniotomy but no acute issues.
this is the comparative case study on Choledocholithiasis with the patient admitted in TUTH Mahargunj. this presentation provide comprehensive knowledge on choledocholithiasis including its causes, pathophyisiology, clinical presentations as well as treatment modalities and nursing management.
Mrcpi part II General Medicine clinical exam formatNitashaMaqsood
The exam format for MRCPI part II clinical exam has made vast changes in its format. The new format is in form since 2013; however there are many students who are not aware of it fully. That’s why I dedicated this blog especially to discuss the changes made in the format of MRCPI General Medicine Part II Clinical.
1. JS, a 74-year-old man with COPD, heart failure, and pneumonia, presents with shortness of breath and fever. His medical history and physical exam reveal severe COPD and risk factors for exacerbation.
2. Chest X-ray confirms right lower lobe pneumonia. ABG results show respiratory acidosis. The patient is treated with antibiotics and oral steroids in the hospital with improvement.
3. Proper management of COPD includes educating patients about self-care, monitoring for exacerbations, promoting smoking cessation, and referring to pulmonary rehabilitation.
Case presentation on Decompensated Chronic Liver Disease (Non Alcoholic)DR. METI.BHARATH KUMAR
A 60-year old male was admitted to the hospital with complaints of blood in vomit, fever for 4 days, and pain in the right lower quadrant. Diagnostic tests found gastric varices, cirrhosis of the liver, ascites, anemia, and thrombocytopenia. The patient was diagnosed with cirrhosis of the liver with anemia and thrombocytopenia and varices in the stomach. Treatment included medications to reduce infection, reduce edema, promote clotting factors, and treat symptoms. Lifestyle modifications such as a low-sodium diet and avoiding alcohol and infections were also recommended.
The document describes a case of a 48-year-old male patient from Bangladesh presenting with abdominal pain and vomiting. Initial testing showed eosinophilia. Further investigation with endoscopy resulted in a diagnosis of eosinophilic gastroenteritis, which is characterized by eosinophil infiltration of the gastrointestinal tract. The disease can affect the mucosa, muscle layer, or subserosa. Diagnosis is confirmed by biopsy showing elevated eosinophils. The pathogenesis is thought to involve an allergic response in some cases.
This document summarizes an obstetric case of a 30-year-old pregnant woman. She presents with amenorrhea and easy fatigability for the past 2 months. Her medical history and examination reveal she is anemic, with a hemoglobin level of 7.4g/dl. She has two previous normal deliveries. A diagnosis of anemia is made based on her symptoms and laboratory results.
a case study on burn injury / case presentation on burn injury martinshaji
Damage to the skin or deeper tissues caused by sun, hot liquids, fire, electricity or chemicals.
The degree of severity of most burns is based on the size and depth of the burn. Electrical burns, however, are more difficult to diagnose because they're capable of causing significant injury beneath the skin without showing any signs of damage on the surface.
Symptoms range from a feeling of minor discomfort to a life-threatening emergency, depending on the size and depth (degree) of the burn.
Sunburn and small scalds can often be treated at home. Deep or widespread burns and chemical or electrical burns need immediate medical care, often at specialised burn units.
A burn is a type of injury to skin, or other tissues, caused by heat, cold, electricity, chemicals, friction, or radiation (like sunburn). Most burns are due to heat from hot liquids (called scalding), solids, or fire. While rates are similar for males and females the underlying causes often differ.
this is a case study on burn injury , this details about the diagnosis, management, treatment, patient counselling & pharmacist interventions , regarding medication etc , and also describes in detail about all aspects of burn injury .
please comment
thank u
Sarah is a 45-year-old female who presents with abdominal pain localized to her epigastric and right upper quadrant that worsened after eating. She has a history of similar pain episodes and comorbidities of diabetes and hypercholesterolemia. On examination, she has tenderness in her epigastric and right upper quadrants with a positive Murphy's sign. Imaging reveals findings consistent with acute cholecystitis. She is started on antibiotics and supportive care and recommended for a laparoscopic cholecystectomy to treat her acute cholecystitis.
A 47-year old female patient presented with hoarseness of voice, constipation, generalized weakness, myalgia, coarse skin, decreased appetite, and facial puffiness for 1-3 months. Physical examination and laboratory test results found decreased levels of T3, T4, hemoglobin, MCV and MCH, and an elevated TSH. Based on these subjective and objective findings, the patient was diagnosed with hypothyroidism and anemia. She was prescribed levothyroxine, ferrous sulfate, and advised to follow a healthy diet and lifestyle to manage her conditions.
It is also called as Coronary heart disease,usually caused due to BP,diabetes , obesity e.t.c.It leads to the restriction of the blood flow to the heart.
Tetralogy of Fallot long case discussionNizam Uddin
Ms. Lamia, a 10-year old girl from Potuakhali, Barisal, presented with breathlessness for 2-3 weeks and bluish discoloration of her skin since childhood. Examination found central cyanosis, clubbing, and a grade 3/6 ejection systolic murmur, suggesting congenital cyanotic heart disease, most likely Tetralogy of Fallot. Medical management and potential surgical options were discussed.
The patient is a 67-year-old male former smoker presenting with shortness of breath on exertion. Physical examination finds reduced breath sounds and wheezing. Tests show reduced lung function and oxygen levels. The differential diagnosis includes cardiac and pulmonary causes like COPD. Dyspnea is the medical term for shortness of breath and can result from various lung and heart conditions. Treatment focuses on the underlying cause, like using bronchodilators for COPD.
Myocardial Infarction - Case Presentation and an OverviewAbubakkar Raheel
Case Presented by Final Year MBBS sudents of Frontier Medical College at the 1st Clinico-Pathological Conference for the year 2015.The Presentation is divided into two parts. First part is about a case of an Acute ST Segment elevated Myocardial Infarction with. Its management at the Hospital and the findings. Second part is about the pathophysiology, Cinical signs and symptoms and an effective gold standard treatment of MI.
The document discusses a case study of a 24-year-old female patient named Kalpana Pandit who was admitted to the hospital for cholelithiasis (gallstones). It provides details of her medical history, symptoms, physical examination findings, diagnosis, and treatment plan. The causes and risk factors for cholelithiasis are also briefly explained.
This document contains a medical case report for a 52-year-old male patient presenting with hip pain. It includes details of the patient's history, examination findings, diagnostic test results, and initial treatment plan. The patient has paraplegia and diabetes following a spinal cord injury years ago. Examination revealed a pressure ulcer on his right buttock. Blood tests showed elevated white blood cells and slightly high blood glucose. The provisional diagnosis is a decubitus ulcer, which is being treated with antibiotics, wound dressings, and positioning changes to offload pressure on the affected area.
This document summarizes a 28-year-old Indonesian male patient who presented with abdominal pain, fever, and vomiting. On examination, he was found to have jaundice and tenderness in his right hypochondrium and epigastrium. Laboratory tests showed elevated liver enzymes and bilirubin. Ultrasound revealed gallbladder sludge and dilation of the bile ducts due to a large stone. ERCP confirmed choledocholithiasis with multiple stones in the common bile duct. The provisional diagnoses were ascending cholangitis and cholecystitis.
Mr. Sher Singh, a 68-year-old male farmer, presented to the hospital with weakness, loss of appetite, and cough with sputum for 3-4 days. After investigations, he was diagnosed with chronic obstructive pulmonary disease (COPD). He has a history of smoking. Physical examination found wheezing on auscultation of the lungs and decreased oxygen saturation. Blood tests showed increased creatinine and C-reactive protein. Chest X-ray found consolidation. He was admitted and started on treatment for COPD.
A 54-year-old man presented with a 1-month history of pain and swelling on the outer left foot and blackening of the left little toe for 15 days. He has type 2 diabetes for 5 years and underwent amputation of the left little toe. On examination, he has an 8.5x7 cm ulcer on the left foot dorsum and plantar aspect with features of peripheral neuropathy and restricted ankle range of motion. He was diagnosed with a left diabetic foot ulcer post little toe amputation that has improved from Wagner grade 4 to grade 2, along with bilateral mixed peripheral neuropathy.
A 28-year-old lady presented with headaches and palpitations for 3 months. On examination, she had a blood pressure of 155/98, heart rate of 117, BMI of 37.6, and fine kinetic tremors with sweaty hands. No significant abnormalities were found on cardiovascular, chest, abdominal, or neurological examinations. She was admitted for further investigation of secondary hypertension. Tests were ordered to evaluate endocrine and renal causes of her high blood pressure. A CT of the brain found evidence of a prior craniotomy but no acute issues.
this is the comparative case study on Choledocholithiasis with the patient admitted in TUTH Mahargunj. this presentation provide comprehensive knowledge on choledocholithiasis including its causes, pathophyisiology, clinical presentations as well as treatment modalities and nursing management.
Mrcpi part II General Medicine clinical exam formatNitashaMaqsood
The exam format for MRCPI part II clinical exam has made vast changes in its format. The new format is in form since 2013; however there are many students who are not aware of it fully. That’s why I dedicated this blog especially to discuss the changes made in the format of MRCPI General Medicine Part II Clinical.
1. JS, a 74-year-old man with COPD, heart failure, and pneumonia, presents with shortness of breath and fever. His medical history and physical exam reveal severe COPD and risk factors for exacerbation.
2. Chest X-ray confirms right lower lobe pneumonia. ABG results show respiratory acidosis. The patient is treated with antibiotics and oral steroids in the hospital with improvement.
3. Proper management of COPD includes educating patients about self-care, monitoring for exacerbations, promoting smoking cessation, and referring to pulmonary rehabilitation.
Case presentation on Decompensated Chronic Liver Disease (Non Alcoholic)DR. METI.BHARATH KUMAR
A 60-year old male was admitted to the hospital with complaints of blood in vomit, fever for 4 days, and pain in the right lower quadrant. Diagnostic tests found gastric varices, cirrhosis of the liver, ascites, anemia, and thrombocytopenia. The patient was diagnosed with cirrhosis of the liver with anemia and thrombocytopenia and varices in the stomach. Treatment included medications to reduce infection, reduce edema, promote clotting factors, and treat symptoms. Lifestyle modifications such as a low-sodium diet and avoiding alcohol and infections were also recommended.
My little case study and a brief discussion about Pneumonia in general.
Constructive criticisms and reactions are welcomed. I'm still a nursing student, so I would like to thank you guys in advance for helping me to learn more.
:)
4 c roderos_familyhealthnursing&empowermentMitch Angela
This document discusses empowering relationships in family health nursing. It analyzes how empowerment occurs through moments of both agreement and conflict. Empowerment requires shifting power dynamics between healthcare professionals and clients, moving from a top-down model to one where the client is the primary decision maker. Nurses must use their expertise and skills to support clients' holistic needs rather than assert authority. True empowering relationships involve patiently listening to understand each client's unique situation and providing compassionate support to lead to good therapeutic outcomes.
The document summarizes a case study of a 25-year-old male patient who experienced an adverse drug reaction to anti-TB medication. He developed jaundice, fever, and hemoptysis after taking Isoniazid for 23 days. On admission, he was jaundiced with a temperature of 36.6°C. Laboratory tests and examinations were performed. The case provides details on the patient's history, symptoms, physical assessments, and initial lab results.
Courtesy to Kristiana Gomez et. al :P
Constructive criticisms and reactions are welcomed. so I would like to thank you guys in advance for helping us to learn more.
Tropical Sprue, Dr PHẠM CHÍ TÒAN, MEDIC CENTER, VIETNAMhungnguyenthien
A foreigner living in Vietnam for one year, presented diarrhea, weight loss, malabsorption. Successfully with treatment of tropical sprue, he remains well and getting 8 kilograms in the first month.
This document is a newsletter on nanomedicine from January-February 2011. It contains sections on news, patents, events, scientific articles, and regulations related to nanomedicine. The newsletter provides updates on recent research, clinical trials, market reports, and developments in applications of nanotechnology for medical purposes.
This document is a newsletter about nanomedicine published in February 2011. It contains several sections, including news briefs on recent research developments, patents, events and conferences, and scientific articles. Some of the news items describe using nanoparticles to deliver cancer-killing genes or stimulate long-lasting immunity, developing multifunctional implant coatings, and tracking stem cells. The patents section lists recently published nanomedicine patents. Events include conferences on topics like nanotoxicology and commercializing nanomedicine. Scientific articles investigate things like using nanoparticles for cancer drug delivery and detecting diseases.
Este documento contiene 15 entradas enumeradas que incluyen información sobre equipos formados por 2 o más integrantes, su género musical preferido e intérprete representativo. Adicionalmente, incluye una tabla con 3 canciones que incluyen el nombre de la canción, año de lanzamiento y si cuenta con bibliografía. Finalmente, hay una sección que pregunta si se conoce en persona al intérprete de cada canción.
Este documento contiene 15 entradas enumeradas que incluyen información sobre equipos formados por 2 o más integrantes, su género musical preferido e intérprete representativo. También incluye 3 tablas al final con canciones, año de lanzamiento y si cuentan con bibliografía o no.
This document provides a summary of recent news articles and publications related to nanomedicine from April 2011. It includes over 90 articles organized by category - News, Patents, Events/Courses/Seminars, Scientific Articles, Regulations, and Reports. The articles cover a wide range of topics including nanotechnology for drug delivery, cancer treatment, medical imaging, and regenerative medicine.
Malabsorption syndrome results in chronic diarrhea, abdominal distention, and failure to thrive due to impaired digestion and absorption of nutrients in the small intestine. It can be caused by disorders that affect digestion, nutrient breakdown, micelle formation, brush border enzyme activity, or nutrient transport. Evaluation involves laboratory tests of nutritional deficiencies, imaging of the gastrointestinal tract, and biopsy of the small intestine to identify the specific cause and guide treatment, which focuses on correcting nutritional deficiencies and treating the underlying disorder.
Junior Certificate History Second Year NotesNoel Hogan
This document provides an overview of the Age of Exploration from 1400 to 1750. It discusses key explorers like Prince Henry the Navigator, Bartholomew Diaz, Vasco da Gama, Christopher Columbus, Ferdinand Magellan, and their voyages which expanded geographical and cultural knowledge of the world. It also describes the technological advances in navigation that enabled these long voyages, such as the development of the caravel ship design, the astrolabe, quadrant, compass, and other instruments. The voyages resulted in increased wealth and power for European nations.
This document provides an overview of history from prehistory to the Renaissance in 5 sections. It summarizes the key developments in ancient Ireland and Rome. For medieval times, it outlines the feudal system and aspects of daily life such as castles, knights, manors, towns, churches, and the Black Death plague. The Renaissance section notes the rebirth of learning from ancient Greece and Rome and influential figures such as Gutenberg, da Vinci, Michelangelo, Durer, Galileo, and Shakespeare.
The document provides an overview of the Age of Exploration and Discovery from the 15th century onwards. It describes how new ship technologies like the caravel enabled longer voyages. Portuguese explorers like Henry the Navigator and Bartolomeu Diaz explored Africa's coasts in search of a trade route to India. Vasco da Gama eventually found the route around the Cape of Good Hope. Christopher Columbus sailed west hoping to reach India but discovered the Americas instead. Ferdinand Magellan led the first circumnavigation of the globe, though he was killed in the Philippines. The Spanish conquistador Cortez conquered the Aztec Empire in Mexico, and Pizarro did similarly to the Incas in South America. The effects
This document discusses traumatic brain injury (TBI). It defines TBI and describes the types of brain injuries including concussion, contusion, epidural hematoma, subdural hematoma, and diffuse axonal injury. It lists common causes of TBI such as motor vehicle accidents and falls. It then provides objectives for gaining knowledge on handling patients with brain injuries and skull fractures through a case presentation.
Running head SKIN CONDITIONS AND DIFFERENTIAL DIAGNOSIS 1SKIN.docxjeanettehully
Running head: SKIN CONDITIONS AND DIFFERENTIAL DIAGNOSIS 1
SKIN CONDITIONS AND DIFFERENTIAL DIAGNOSIS 7
Skin Conditions and Differential Diagnosis
Adesola Turner
Walden University
NURS-6512N-17
Advanced Health Assessment.
December 22, 2019.
Introduction
The number 2 graphic (figure below) is characterized as Cherry angiomas that appear in older adults. With time cherry angiomas turn dark, though after infection it is identified by round tiny bright ruby red papules. As age numerically increase Dunphy et al (2015) argues that the disease virtually occurs to everyone above the age of 30 years. One of the ways in which I would perform differential diagnosis is by observing the skin of a patient who is 70 years of age.
Graphic #2
Patient Initials: AB Age: 70 Gender: male
SUBJECTIVE DATA:
Chief Complaint (CC): AB comes in clinic complaining about development of hard red bumps on the chest
History of Present Illness (HPI): Patient AB who is 70 years old comes in the hospital with complaints of having red bumps on his chest that appeared 2 weeks ago. He states that he wants to be done aa physical examination to be performed. AB says that last year he developed at least 4 new bumps on his chest that formed gradually. He is filled with anxiety because upon doing a Google search about his condition, he found that it could some tumors that are developing on his chest. He deniesrefutes any bleeding, painful and itchy bumps, exudation, or any climate variations. The bumps are located around the chest and the abdomen. AB says he has not come into contact with an irritant, denies having a fever, or does he take medications. Also, he reports he is neither under stress nor lifestyle changes. He claims, no one in his family lineage has ever been diagnosed with skin cancer.
Medications: none
Allergies: NKDA
Past Medical History (PMH): identified with stage 4 blood pressure Hypertension and the age of 60 which was well managed.
Past Surgical History (PSH): At age 40, his left shoulder was repaired from a torn rotator cuff.
Sexual/Reproductive History: Married and not sexually active.
Personal/Social History: denies smoking, taking alcohol, substance abuse, or under any influence of ETOH
Immunization History: His immunizations are current. In 2017, he got immunized of Pneumococcal vaccines and influenza vaccine
Significant Family History: Living with no parents who perished from a car accident. Living with his healthy daughter whom he got at his 30s
Social History: Live with her daughter and his 3 grandchildren. Being a widow for 8 years, he has been working as an engineer before he retired. In his free time, he does light exercises. Every day he attends catholic mass and then joins his 6 friends for breakfast at the local diner.
Review of Systems (ROS):
General: Mr. AB is a well-organized and neat man. He is alert and corporate during the discussion. He responds t ...
1. Enteng is a 39-year-old single Filipino man from Ilocos Sur who was living independently as a farmer and fisherman until he developed an illness that left him unable to move or care for himself.
2. He is currently residing with his parents and is dependent on them for care. He has few close relationships and feels ashamed of his loss of independence.
3. Enteng has reduced sensation and mobility throughout his body below the knees due to his illness. He is alert and oriented but experiences pain, difficulty sleeping, and inability to change positions in the hospital.
1. The document presents a case study of a 9-year-old male child diagnosed with a urinary tract infection and a simple renal cortical cyst. The child presented with abdominal pain and fever. Diagnostic tests revealed the presence of E. coli in a urine culture and an ultrasound showed a right renal cortical cyst.
2. The case study aims to understand the nature and management of urinary tract infections with renal cysts. Specific objectives include applying knowledge of pathophysiology and nursing care using a holistic approach. The case study methodology involved history taking, physical examination, record review, and discussions.
3. Findings included abdominal pain, fever, frequent urination and burning sensation. Diagnostic tests confirmed
The document discusses gallstones, which are crystalline formations that occur in the gallbladder when bile components accumulate. Their presence can lead to inflammation of the gallbladder (cholecystitis) or obstruction of the bile ducts, both of which can become life-threatening if not treated. The case study focuses on a 54-year-old female patient admitted with abdominal pain and a possible diagnosis of obstructed bile duct stones or hepatoma. It provides details on her medical history, examinations, treatment, and nursing management for her condition.
This document provides a case study of a 64-year-old male patient who presented with stiffening of the extremities. The patient has a history of hypertension, diabetes, and thyroid cancer. Physical assessment revealed weakness on the right side of the body. Diagnostic tests showed signs of inflammation and slightly abnormal thyroid and kidney function. A CT scan found lesions in the brain consistent with ischemic stroke. The case study aims to educate nursing students on assessing and caring for patients with ischemic stroke through knowledge of pathophysiology, appropriate interventions, and developing rapport with patients.
This document provides a case study on a 10-year-old female patient diagnosed with dengue fever. It includes an introduction to dengue fever, the patient's profile, physical assessment findings, laboratory results, and nursing care plan. Key findings include the patient presenting with fever, abdominal pain, and vomiting. Laboratory tests showed low platelet count and a positive torniquet test, confirming dengue fever syndrome. The patient's activities of daily living were affected as she had limited range of motion and could no longer attend school or help with chores due to weakness from the disease.
An Irish surgeon recently rediscovered the 79th organ in the human digestive system, the mesentery, which had previously been discovered by Leonardo da Vinci but later ignored. A common anatomical variant seen in the gallbladder during imaging is called the Phrygian cap due to its resemblance to headwear associated with people from central Anatolia and the French Revolution. Dark urine in a patient taking an antibiotic for a UTI is likely caused by G6PD deficiency and hemolysis from the antibiotic. Infectious mononucleosis presents with swollen tonsils, lymphadenopathy, and atypical lymphocytes on blood smear.
Case history is the most important part when we enter clinics , it has a greater impact on the diagnosis and treatment planning . It also helps to maintain a good rapport with the patient . It is most important with concern to medicolegal point of view . Thus, a Dr should always have a detailed case history.
The document summarizes a situational diagnosis of the 18 February community in Lambayeque, Peru. It describes the key problems in the community as lack of access to water and sanitation services, leading to common diseases. Housing materials and lack of drainage also contribute to respiratory and other illnesses. The community suffers from poverty and social exclusion. The main diseases affecting residents are digestive issues, diarrhea, and respiratory diseases.
The document provides information about appendicitis and the case of a 21-year-old female patient admitted with partial gut obstruction. It includes sections on the anatomy and physiology of the digestive system and appendix, the patient's nursing history and assessment, diagnostic lab results showing signs of infection, and the patient's nursing care plan while in the hospital.
Assignment DetailsMN551-2 Apply knowledge of tissue and organ.docxstandfordabbot
Assignment Details
MN551-2:
Apply knowledge of tissue and organ structure and function to physiologic alterations in systems and analyze the cause and effect relationship in response to disease.
Select one of the case studies below.
In your discussion be sure to include evidence of your knowledge of tissue and organ structure and function to physiologic alterations in systems and analyze the cause and effect relationship in response to disease.
Requirements
Make sure all of the topics in the case study have been addressed.
Cite at least three sources—journal articles, textbooks, or evidenced-based websites—to support the content.
All sources must have been written within five years.
Do not use .com, Wikipedia, or up-to-date, etc., for your sources.
Case Study 1
Mechanisms of Infectious Disease
Thirty-two–year-old Jason is a general laborer, who fell ill shortly after working on a job digging up old water pipes for the town he lived in. The task involved working around shallow pools of stagnant water. Ten days after the contract ended, Jason developed a fever and aching muscles. He also had nausea, vomiting, and diarrhea. Jason’s friend took him to his physician who listened carefully to Jason’s history. She told him she suspected West Nile fever and ordered serological testing. Jason went home to recover and was feeling better by the end of the week.
Jason’s physician ordered serological tests. How would antibody titers assist the doctor in confirming his diagnosis?
When Jason was feeling at his worst, he had extreme malaise, vomiting, and diarrhea. What stage of the illness was he experiencing at that time? What are the physiological mechanisms that give rise to the signs and symptoms of infectious illness?
West Nile virus has a single-stranded RNA genome. How does this virus replicate? In general terms, what are the various effects viruses can have on host cells?
Case Study 2
Innate and Adaptive Immunity
Melissa is a 15-year-old high school student. Over the last week, she had been feeling tired and found it difficult to stay awake in class. By the time the weekend had arrived, she developed a sore throat that made it difficult to eat and even drink. Melissa was too tired to get out of bed, and she said her head ached. On Monday morning, her mother took her to her doctor. Upon completing the physical exam, he told Melissa the lymph nodes were enlarged in her neck and she had a fever. He ordered blood tests and told Melissa he thought she had mononucleosis, a viral infection requiring much bed rest.
Innate and adaptive immune defenses work collectively in destroying invasive microorganisms. What is the interaction between macrophages and T lymphocytes during the presentation of antigen?
Melissa’s illness is caused by a virus. Where are type I interferons produced, and why are they important in combating viral infections?
Humoral immunity involves the activation of B lymphocytes and production of antibodies. Wh.
This case summary describes an 8-year-old girl admitted to the hospital with multiple chronic issues including skin lesions, fever, cough, and poor growth. She has a history of recurrent skin infections, oral ulcers, ear infections, and gastrointestinal problems. Initial workup showed anemia, elevated inflammatory markers, and immunodeficiency. A working diagnosis of combined immunodeficiency and Hyper IgE syndrome was made. She is being treated with antibiotics, antifungals, IVIG, and workup is ongoing.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
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Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
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In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
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Malabsorptionsyndrome
1. A care for client with Malabsorption Syndrome
In partial fulfillment of Related Learning Experience (R.L.E)
Submitted By:
Roderos, Mitch Angela
BSN 4C GROUP II S.Y 2011-2012
Clinical Instructor
Sir. Oliver Virata
2. INTRODUCTION
The human gastrointestinal (GI) tract is the site of absorption of a wide variety of
ingested nutrients,including vitamins, proteins, carbohydrates and fats.Much of this absorption
occurs in the small intestine(SI), where the high surface area provided by thevillous and
microvillous architecture optimizes uptake of dietary substances. The specialized SI mucosa
contains numerous digestive enzymes on its surface,as well as an intricate network of lymphatics
and blood vessels providing access to the bloodstream. Adequate digestion and absorption
depend on a multitude of factors, including mechanical mixing, enzyme production and activity,
proper mucosal function, adequate blood supply, intestinal motility and even normal microbial
ecology.
Accordingly, malfunctions in any of these components can lead to failure to absorb
nutrients from the diet, often resulting in some combination of diarrhoea,steatorrhoea,
malnutrition, weight loss and anaemia. The resultant symptoms are known as the malabsorption
syndrome(s), which can be grouped bytheir aetiology into three broad categories.
Thus,malabsorption may result from maldigestion, such as occurs in inadequate mixing (e.g.
after gastrectomy) or in enzyme or bile salt deficiencies, from mucosal or mural problems, such
as various enteropathies or neuromuscular conditions, or from microbial causes,such as bacterial
overgrowth and various infections ⁄infestations. The vast number of causes of intestinal
malabsorption precludes an exhaustive review. Therefore, we will attempt an overview of the
most common and interesting aetiologies in the three categories, with a morecomplete discussion
of a handful of entities in each,along with a review of current concepts. Special emphasis will be
afforded to mucosal problems, as well as to several microbial conditions.
3. DEMOGRAPHIC DATA
1. Client’s name : Patient A.D
2. Gender: Male
3. Age, Birth date and Birth place: 21 years old, September 2,1990 at Zamboanga City
4. Marital Status: Single
5. Nationality: Filipino
6. Religion: Roman Catholic
7. Address: 15 Natividad St. Bangkal Quezon City
8. Educational Background: College Undergraduate
9. Occupation: Student
10. Usual Source of Medical Care:
A. SOURCE AND RELIABLITY OF INFORMATION
Patient’s Chart
Patient’s father
B. REASON FOR SEEKING CARE
“Ang sakit sakit ng tsyan ko” As verbalized by the patient
C. HISTORY OF PRESENT ILLNESS
2 years prior to admission (September 2009) – Patient had his appendectomy last 2009,
abdominal surgery done the same year. A tumor was marked visible in the colon and
likewise excised.
1 year and 8 months prior to admission (January 2009) – Patient was operated due to
dehiscense of his intestines
10 weeks prior to admission – Patient complaints of abdominal pain, with presence of
nausea and vomitting and associated with on and off fever.
D. PAST MEDICAL HISTORY
Pediatric/Childhood/ Adult Illness: Mumps (7 y/o); Chiken Pox (17 y/o)
Injuries or accidents: The client recieved multiple injuries due to stampede (10 y/0)
Serious/ Chronic Illnesses: The client has Hypertension X4, HBP of 200/100 UBP 150/80
4. Hospitalizations: The client’s father verbalized of frequent admission for the previous
months and up to present. The client’s father was not able to recall the recent of his
son’s admission
Operations: The client undergone appendectomy last 2009 and was operated due to
intestinal dehiscence after 4 months of previous surgery around January of 2009
Immunizations: The client verbalized of having complete immunization of DPT, OPV,
BCG and Measles vaccine.
Allergies: No known Allergies
Medications prior to confinement:
Last Examination Date: December 13, 2011
E. FAMILY HISTORY
Father Mother
(+) HPN (+) HPN
(+) DM (+) Asthma
(
25 y/o 21 y/o 18 y/o
LEGEND
Male Female Client
5. 1.) Heredo-Family Illness:
Maternal –
Patient B’s mother is known to have High blood pressre and Asthma. Currently,
his older sister next to him has asthma and so as his only daughter started when
she was 2 years old.
Father-
Patient’t B’s father has no known family illness running in their blood.
F. SOCIO-ECONOMIC
The client consists of a nuclear family and lives together with his parents and
three siblings. His father works as a sea man and presently at home due to expiration of
contract, however, they are able to generate income from their previous savings and from
managing a computer shop at Zamboanga, and the client’s father obtains an approximate
per month, adequate enough for a living. The client’s eldest brother works in a call center
which also helps in shouldering some of their expenses. The client states that he
contributes for the family financial expenses.
DEVELOPMENTAL HISTORY
Erik Erickson Age Task Patient’s Description
Psychosocial Theory
IntimacyVs. 19 – 30 Young adults need to form The client is presently
Isolation y/o intimate, loving relationships stopped from studying
with other people. Success college and known to have
leads to strong relationships, frequent admission at
while failure results in hospitals.
loneliness and isolation. The client is evidenced to
have activity intolerance due
to poor nutrition that he is
not able to interact from
other people and to perform
activitiees of daily living by
himself. The Client at risk
for isolation from social
peers that will affect his
Pyschosocial development if
the problem still persists.
6. G. REVIEW OF SYSTEMS
1. Regional Examinations
(December 1, 2011 9:30 am)
Vital Signs:
Temp : 37.1°c RR: 18 cpm PR: 105 cpm BP: 100/80mmHg
General Assessment:
Patient is seen conscious and coherent; garbed clothing appropriate for weather and
occasion.sitting on wheel chair with facial grimace, the client cannot fully perform
activities and requires assistance. Skin is clean and smooth with normal skin turgor.
Nails are long but not dirty and with normal capillary refill. Patient is with ongoing
IVF of D5 NSS 1 L X 8 hr Infusing well at his left matacarpal vein.
Date of Assessment System Normal Findings Actual Findings
December 14 ,2011 Integumentary Smooth and good I:
skin turgor, no
lesions or any Brown color, no lesion, no swelling
discoloration, no and edema.
clubbing, no breaks Weak Looking
&abnormal Visible veins on both arms
curvature. Has a temperature of 37.1°c.
With visible longitudinal scar
below the umbillicu
In nails:
Long and clean nails and round
nails. Pale Nail beds
P:
Cold,dry scaly skin,normal
capillary refill. Good skin turgor
December 14 ,2011 Hair and Head No lesion, no I:
tenderness, no pain
on palpation, no -His hair color is black, hair is evenly
masses, no lumps, distributed,
7. no nodules or -Has thick hair.
depression,
symmetrical -No presence of parasite and dandruff.
-In scalp: Symmetrical and round and
no lesion.
P:
-Hair texture is smooth and soft.
-In head the texture is smooth and
firm.
December 14,2011 Eyes Eyelid intact, no I:
redness, swelling,
discharge or lesions. -Lid margins moist and light pink,
Eyeballs are moist & lashes short, evenly spaced and curled
glossy, conjunctiva outward.
numerous small -Bulbar conjunctiva is clear with tiny
blood vessels. Sclera vessels visible, palpebral conjunctiva
white. Good eye is pale with no discharge, white sclera.
contact.
- In PERRLA:
*Cornea is transparent and the shape
of the iris and pupil is round and
equal.
*The left and right eye has a good
reaction to light (constrict and dilate)
-In extra ocular movements:
*Both eyes coordinated well in all
directions.
December 14,2011 Ears Ears are symmetrical I:
with 10 degrees
angle. Color is same -Equal size and similar appearance.
in facial with no -No lesions, brown in color same with
8. tenderness or any his complexion.
nodule and without
any presence of P:
discharge. -Warm, smooth, no nodules and no
tenderness in auricle and tragus.
December 14,2011 Mouth and 32 adult teeth are I & P:
Throat present with moist
and pink mucous -Lips and surrounding tissue relatively
membrane without symmetrical.No lesions, swelling and
any lesions or drooping.
swelling. -Lip is pale pink; moist, smooth and
with no lesions.
-Buccal mucosa is light pink, moist
and without lesions.-Gums are light
pink, and moist.
-In tongue:
*Moist, some papillae present,
symmetrical appearance, midline
fissures present and the color is pink
and color white at the center and no
lesions as well as the sides of the
tongue.
*Hard palate: slightly pink. *Soft
palate: pink, -Has 32 teeth and stained
with a hint of yellow color.
December 14,2011 Neck No tenderness on I: -Neck is symmetric with head
palpation, no pain, centered and without bulging masses.
symmetrically align,
no enlarged lymph P:-Smooth skin, firm, and none tender
nodes, no tracheal and none enlarged nodules.
lateral deviation.
December 14,2011 Breast and No palpable nodules I:
Axillae and lesions. Breast is -Nipples have no discharges and not
firm and round. cracked.
9. December 14,2011 Respiratory Intercostals spaces I:
are even and
relaxed; chest -The color of his chest is similar to his
symmetry is equal, complexion.
no pain or -Visible Rib Cage
tenderness, and no
abnormal breath -Chest symmetry is equal
sound.
-Respiratory rate of 18.
P: No pain or tenderness.
A: Lung is clear to auscultation on
inspiration and expiration.
December 14,2011 Cardiovascular No fatigue on simple PR : 105
activities, no
arrhythmias and BP: 100/80 mmHg
heart murmurs. I:-Neck veins are not distended.
PR=60-100bpm.
P:-No vibrations or palpitation in
aortic, pulmonic, or tricuspid area.
A:-No murmur sound heard.
December 14,2011 Abdominal No pain, No I:
palpable masses and
tenderness, Flat and -With
round. P:
-(+) Tenderness, with inflammation on
intestines as observed in Lab Result
December 14,2011 Musculoskeletal Have good range of -Requires assistance to stand and toes
motion and no point straight ahead.
limitation of
movements. With marked activity intolerance
-With marked muscle waisting
December 14,2011 Neurologic Have no tremors -No presence of tremors, oriented, no
paralysis. Oriented, history of seizures,without mental
no history of dysfunction or hallucinations.
seizures, mental -Slow and low soft voice
10. dysfunction or -Weak looking
hallucinations. Lethargic, slow response
December 14,2011 Lympathic Has no bleeding No swollen lymph nodes.
tendencies, normal
lymph nodes.
2. Laboratory Studies/Diagnostics
12/15/11 Clinical Chemistry Section
Test Name Range Unit Result Interpretation
Albumin 3.92 – g/dL 2.05 Below Normal
4.94
Indicates poor nutritional state, poor protein intake,
Renal/Kidney Dysfunction
H. FUNCTIONAL ASSESSMENT
HEALTH PERCEPTION-HEALTH MANAGEMENT
Prior to admission, patient’s father sasys the his son sees health being able to do everyday
things well according to the manner he wants it. The client stated he doesn’t easilly get sick and
when he does, he just let it subside not until if his condition worsens, that’s the time when he
would visit the hospital. The client does not use any vitamins and medications. Client has not
experienced colds in the past month.
SELF-ESTEEM, SELF CONCEPT/SELF PERCEPTION PATTERN
Prior to confinement, the client’s father states that his son has a good concept at
himself and describes himself like any typical normal college boy. He says that his child
perceives good self-concept as evidenced by being active in the activities held in his institution.
Presently, the client stopped schooling due to persistent abdominal pain. The client
permanently resides in Zamboanga and went to Cavite from a relative’s house to sought for
treatment.
ACTIVITY/EXERCISE PATTERN
11. Prior to confinement, the patient father remarks that his son used to have an active
lifestyle, the client is once a varsity player in Basketball. The patient engages in sports such as
Basket Ball, Volley Ball and Badminton. The patient studied college last semester but now
stopped due to present situation.
Presently, the patient is admitted in ward 3A, under bed rest. The client assistance from another
person or device in terms of the following indicated below:
Feeding III Grooming III
Bathing III Gen. Mobility III
Toiling III House III
maintenance
Bed mobility III Dressing III
Legends:
Level 0 – Self Care
Level I – Use of equipments
Level II– Assistance from another person
Level III –Requires assistance from another person or device
Level IV – Dependent and does not participate
SLEEP/REST PATTERN
Before the client was admitted, the client’s father stated that his son usually sleeps around 10:00
pm and wakes up around 6:00 am with an average sleep of 8 hours without any use of sleepint
aids
Presently, the client’s father describes that his son is experiencing difficulty in sleeping due to
persistence of pain that he experiencing because of that the client frequently naps in the morning
and still feels tiped upon waking up
NUTRITIONAL-METABOLIC PATTERN
The client presently eats in small frequent feeding at an average of 5 times a day. the
client has poor appetite and usually eats in soft-non-seasoned food or broths. The client cannot
tolerate to eat regular meals as observed from vomiting. The client’s father frequently observes
his child to vomit usually after eating. There is an observed muscle wasting as evidenced from a
weight loss of 48 kg to 32 kg. The client has no dental problems and without foul odors.
12. ELIMINATION PATTERN
The client states that he defecates every other day usually in the morning in scanty soft
brown stool. The client’s father believe that his son’s bowel pattern due to his poor fluid and
food intake. The client urinates 2X a day or varies in his fluid intake without no difficulty
SEXUALITY/REPRODUCTIVE
The patient is not sexually active and was circumcised at the age of 12
.
INTERPERSONALRELATIONSHIPS/RESOURCES
The client is the second son among his 3 siblings. The client previously attended college but
presently stops due to persistence of abdominal pain affecting his studies. The patient’s father
says that his son attends to school trying to tolerate his abdominal pain The client’s father
verbalized that their family has an open and harmonious relationship. The client’s father states
that he would allow his son to decide by himself to promote independence but would be there to
guide and support him. In terms of major decisions affecting the client’s health, the father states
the he will use his authority as a father to intervene.
COPING & STRESS MANAGEMENT/ TOLERANCE PATTERN
The client states the he feels discomfort from his abdominal pain. The client’s father
verbalized that travelling far from home, unable to do his daily activities and being isolated and
stopped from school has been the client’s stress factors. However, the client’s father remarked
that his son has high tolerance from the pain, they would use ointment to help the client relieve
from pain
VALUES/ BELIEFS
The Client is a Roman Catholic. The client stated that he barely attends the church
because of his studies and presently because of his abdominal pain.
PERSONAL/SOCIAL HISTORY
13. Habits: The client is known an athletic student. The client prefers to do anything just to keep
him from being bored. Despite of eating, the client ignores to rest but goes straight from doing
such activities, that may be the reason why the client acquired appendicitis dated on year 2009
Vices: The client stated does not consume alcoholic beverages and does not smoke.
Lifestyle: The client was known to live in an active lifestyle.
Client’s usual daily life: The client’s typical day is studying in school at the morning, and
would plau basketball for his varsity in the afternoons. The patient’s states that his son prefers to
beat home watching television or taking siesta during his free time.
Rank/Order in the family: the Client is ranked as the second son from his 3 siblings.
Travel: The client previous travel was from Zamboanga to Cavite
I. ENVIRONMENTAL HISTORY
The client lives together with his family composed of 5 house hold members. A
bungalow type of house with 209 square meters is owned by the patient residing near the
highway. The client narrated that it is a cemented house with 2 bedrooms and 1 bath
room. The house is fully ventilated and well lit of 12 windows. Their doors for about the
size of 180X1 meter. The client stated that their surroundings are well-sanitized. Their
electricity supply comes from Meralco and their water supply are from Deep well. They
order Mineral water for drinking. The client’s residence is advantageous, since it is near
the public market, transportation, at school and Hospital.
J. PEDIATRIC HISTORY
K. MATERNAL AND BIRTH HISTORY
Birth date: September 2, 1990 Hospital: Not assessed
Birth weight: Unrecalled
Type of delivery: Normal Spontaneous Delivery
14. Condition after birth: In fine stable condition
Mother:
Complications of delivery: None
Anesthesia drug guring labor: Unrecalled
Exposure to Teratogenic Agents during Pregnancy: None
15. PATHOPHYSIOLOGY
MALABSORPTION
(Book Based)
PREDISPOSING PRECIPITATING
FACTORS FACTORS
Age Family history of Intestinal Excessive Alcohol Use of Mineral
Malabsorption Surgery Intake Oil or laxatives
Maldigestion
Inadequate mixing Insufficient digestive Mucosal Problems Bacterial Infections
mediators
Of gastric juices
MALABSORPTION
SYNDROME
16. CONCEPT MAPPING
1. Acute Pain related to
gastrointestinal inflammation as
evidenced by pain scale of 7/10
Malabsorption Syndrome
2. Imbalanced Nutrition
3. Activity Intolerance related
Patient A.D 21 y.o/ Male related to impaired absorption
to failure to nourish muscle
adequately as evidenced by Temp : 37.1°c RR: 18 cpm PR: 105 cpm BP: 100/80mmHg Wt: 32 kg of nutrients from the GI tract
generalized weakness as evidenced by weight loss of
Facial Grimace
Painscale of 7/10 48 kg to 32 kg
Guarding behavior
Abdominal distention
Weight loss from 48 kg to 32 kg
Hypoalbuminemia (2.95 n=3.92-4.94 g/dl)
Muscle waisting
Generalized body weakness
Slow movement
Slow response
Inaility to perfrom activities by himself
Verbal reports of wearines
17. I. PROBLEM LIST
Actual
Problem Number Problem Remarks
Acute Pain related to The client presently complaints of
1 gastrointestinal inflammation as prsistent abdominal pain due to the
evidenced by pain scale of 7/10 inflammation from malabsoprtion.
Pain is prioritized for it is the 5th
vital sign, and knwn to be the
chief complaint likewise.
Imbalanced Nutrition related to The body is unable to absorb the
2 impaired absorption of nutrients nutrients well due to occurence of
from the GI tract as evidenced an imflammed GI tract. Thus, the
by weight loss of 48 kg to 32 kg client is unable to be provided of
proper nutirion approrpiate for his
development thus manifested by
weigh loss
Activity Intolerance related to Due to failure of the client to have
3 failure to nourish muscle adequate nutrition for the body to
adequately as evidenced by recieve it’s energy that is
generalized weakness manifested by generalized
weakness.
18. II. NURSING CARE PLAN
Cues/Needs Nursing Planning Implementation Rationale Evaluation
Diagnosis
Subjective: Acute pain By the end of Monitored Vital signs q 30 until the Baseline data is important to By the end
“Masakit ang related to 8 hours of patient stable especially respiratory rate help Determine patient’s current of 8 hours of
tsyan ako” as inflammation nursing and blood pressure health status and evaluate nursing
intervention, efficacy of nursing interventions intervention,
verbalized by the and swelling
the rendered the
patient of the liver as Patient will Patient will
evidenced by verbalize a Assess the patient’s pain by using the 10 The client’s report of pain is the verbalized a
Objective: pain in right decrease in point pain rating scale q4 hrs or PRN single most reliable indicator of decrease in
Pain Scale of upper pain scale during the 2-10pm shift. pain. pain scale
7/10 quadrant from 6/10 to from 76/10
Facial grimace 0/10 to 3/10
Gurading Performed comprehensive assessment to Pain is a subjective experience
behavior pain include location , characteristic, and must be described by the “Mejo
With abdominal onset, duration, frequency, client in order to plan effective natitiis ko na
distention quality, intensity or severity treatment yung kirot”
as verbalized
by the patient
Provided nonpharmacologic pain relief Relaxation techniques decrease
methods, such as breathing exercises, oxygen consumption, respiratory
music therapy, distraction and progressive rate, heart rate, and muscle
relaxation before, after, and if possible tension, which interrupt the
during painful activities. cycle of pain–anxiety–muscle
tension.
Kept side rails up and bed in low position. To reduce likelihood of falls and
to promote a safe environment.
Administered Pain medications as ordered To promote pharmacologic
such as Tramadol measures in relieving pain
19. Cues/Needs Nursing Planning Implementation Rationale Evaluation
Diagnosis
Subjective: Imbalanced After 8 hours of Assessed the present weight of the Provides baselinedata about the After 8 hours
“Ang lake na nga Nutrition Nursing client by the use of weighing scale client. of Nursing
ng pinangayat ng related to intervention, the intervention,
anak ko” as impaired client will Determined the client’s attitude towards Psychological factors towards the client
eating. eating may affect one person’s
verbalized by the absorption of demonstrate Participated
appetite and also to know the
patient’s father nutrients from behaviors to client’s eating habits. and
the GI tract as regain and enumerated
Objective: evidenced by maintain proper To promote and sustain Ways to
Weight loss weight loss of weight Encourged the client tomash the foods adequate nutrition needed by regain and
from 48 kg to 48 kg to 32 kg mechanically and to eat in small the body and minimizing the maintain
32 kg frequent feeding occurance of malabsorption proper
Hypoalbumine
weight
mia (2.95 Instructed the client to avoid To decrease the likelihood of
n=3.92-4.94 caffeineated beverages like coffee, tea, GI upset
g/dl) softdrinks, chocolates and foods rich in
Muscle waisting fats To keep the client hydrated and
Generalized to monitor the fluid intake of
body weakness Monitored and regulated IV fluid patient
To provide pharmacological
Administered medications as ordered means of reducing occurance
of abdominal pain thereby
promoting the patient to eat.
Cues/Needs Nursing Planning Implementation Rationale Evaluation
20. Diagnosis
Subjective: Activity After 8 hours Determine factors contributing to The client marks to have After 8 hours
“Hinang hina ang Intolerance of nursing fatigue pulmonary congestion and under of nursing
pakiramdam ko” as related to intervention, observation to have acute intervention,
verbalized by the failure to the client will coronary syndrome the client
patient nourish participate participated
muscle willingly in Evaluate client’s percieved limitations To provide comparative baseline willingly in
adequately as necessary and by asking past activities and present data and to provide information necessary
Objective: evidenced by desired activities about needed intervention and desired
generalized activities. activities.
Generalized body weakness Assess cardiopulmonary response to Manifestations results
weakness physical activity, including vital signs intolerance of activity The client
Slow movement verbalized of
before, during and after activity
Slow response
incorporating
Inaility to perfrom
activities by Assist client wit activities when To protect the client from injury such
himself walking to the wash room, getting up in exercises and
Verbal reports of bed and lying back to bed exposure to
wearines sunlight in
Provide intervals of rest between To minimize occurrences of his daily
activities fatigue living
Encourage and acknowledge the
difficulty of the situatio of the clientHelps to minimize frustration
and rechannel energy
Sunlight is rich in Vitamin D and
Encouraged patient to expose himself in
will help the client to increase
sun light around 7-8 am
vitality
Assist and provide passive and active
To maintain and enhance muscle
ROM
tone of client
21. MEDICAL-SURGICAL MANAGEMENT
i. Pharmacotherapeutics
DRUG NAME CLASSIFICATION INDICATION ACTION SIDE/ADVERSE NURSING PATIENT TEACHING
EFFECTS RESPONSIBILITIES
Hydrocortisone Therapeutic: Management of Supress CNS: depression, _Assess patient for _Instruct patient on correct
Antiasthmatics, adrenocortical inflammation euphoria,headache,increased swigns of adrenal technique of medication
Brand Name: corticosteroids insufficiency; and the normal intracranial pressure insufficiency. administration.
Cortef chronic use in immune (Children only),personality _Monitor intake and _Caution patient to avoid
Dosage: Pharmacologic other situations is response. changes, pyschoses, output ratios and daily vaccinations without first
5 mg I.V q8 Corticosteriods limited because Replacement restlessness weights. Observe consulting health care
(systemic) of theraphy in EENT: cataracts, increased patient for peripheral prifessionals.
mineralocorticoid adrenal intraocular pressure. CV: edema, steady weight _Review side effects with
activity. insufficiency. hypertension GI: Peptic gain, rales/crackles, or patient. Instruct patient to
Ulcer, anorexia, nausea, dyspnea. inform health care
vomitting. Derm: acne, _Children should professional promptly if
decreased wound healing, have periodic severe abdominal pain or tarry
ecchymoses, fragility, evaluation of growth. stools occur. Patient should
hirsutism, petichiae Endo: _Assess involvrd also report unusual swelling,
Adrenal suppresion, systems before and weight gain, and tiredness,
hyperglycemia. Hemat: periodically during bone pain, bruising, none
Thrombophlebitis, Metab: theraphy healing sores, visual
Weight gain MS: Muscle disturbances, or behavior
wasiting. Misc: Cushingoid changes.
apperance
22. DRUG NAME CLASSIFICATION INDICATION ACTION SIDE/ADVERSE NURSING PATIENT TEACHING
EFFECTS RESPONSIBILITIES
hyoscine butylbromide Therapeutic: Paroxysmal pain Acts by Agranulocytosis, _Patients who have Asthma, _Instruct patient to take
Gastro/ in diseases of interfering with pancytopenia. aspirin-induced allergy, and medication exactly as
Brand Name: Antispasmodics stomach & the transmission Bronchospasm, nasal polyps are at increased directed. Take missed dose
Buscopan Pharmacologic: intestine. Spastic of nerve Constipation, dry risk for developing as soon as remembered if
Dosage: Pyrroziline pain & functional impulses by mouth, trouble hypersensitivity reactions. not almost time for next
5 mg I.V q8 carboxylic acid disorders in acetylcholine in urinating, nausea, fast Assess for rhinitis, asthmas dose. Do not double dose
biliary & urinary the heart rate and urticaria _Instruct Patient to notify
tracts, female parasympathetic _Assess pain (note type, health
genital organs nervous system location, and intensity) prior Health care professional if
(specifically the to 1 -2 hr following allergic reactions occurred
vomiting center). administration (rash, pruritus, laryngeal
_Evaluate liver function edema, wheezing).
tests, especially AST and _Ask for your doctor's
ALT, periodically in patients advice if you are
receiving prolonged therapy. breastfeeding or likely to
May cause inccreased levels breastfeed during the
_May cause prolonged course of your medication
bleeding time that may persist _Special care is
for 24-48 hour following recommended during
discontinuation of therapy pregnancy, particularly in
_May cause increased BUN, the first three months.
serum, creatinine or Ask for your doctor's
potassium concentrations advice if you are pregnant,
or likely to become
pregnant during your
course of medication.
23. DRUG NAME CLASSIFICATION INDICATION ACTION SIDE/ADVERSE NURSING PATIENT TEACHING
EFFECTS RESPONSIBILITIES
Prednisone Therapeutic: Paroxysmal pain in Acts by Agranulocytosis, _Patients who have _Instruct patient to take
Gastro/ diseases of stomach interfering with pancytopenia. Asthma, aspirin-induced medication exactly as
Brand Name: Antispasmodics & intestine. Spastic the transmission Bronchospasm, allergy, and nasal polyps are directed. Take missed dose as
Buscopan Pharmacologic: pain & functional of nerve impulses Constipation, dry at increased risk for soon as remembered if not
V q8 Pyrroziline disorders in biliary & by acetylcholine mouth, trouble developing hypersensitivity almost time for next dose. Do
carboxylic acid urinary tracts, female in the urinating, nausea, reactions. Assess for not double dose
genital organs parasympathetic fast heart rate rhinitis, asthmas and _Instruct Patient to notify
nervous system urticaria health
(specifically the _Assess pain (note type, Health care professional if
vomiting center). location, and intensity) prior allergic reactions occurred
to 1 -2 hr following (rash, pruritus, laryngeal
administration edema, wheezing).
_Evaluate liver function _Ask for your doctor's
tests, especially AST and advice if you are
ALT, periodically in breastfeeding or likely to
patients receiving prolonged breastfeed during the course
therapy. May cause of your medication
inccreased levels _Special care is
_May cause prolonged recommended during
bleeding time that may pregnancy, particularly in the
persist for 24-48 hour first three months.
following discontinuation of Ask for your doctor's advice
therapy if you are pregnant, or likely
_May cause increased to become pregnant during
BUN, serum, creatinine or your course of medication.
potassium concentrations
24. DRUG NAME CLASSIFICATION INDICATION ACTION SIDE/ADVERSE NURSING PATIENT TEACHING
EFFECTS RESPONSIBILITIES
Pantoprazole Therapeutic: Paroxysmal pain in Acts by Agranulocytosis, _Patients who have _Instruct patient to take
Gastro/ diseases of stomach interfering with pancytopenia. Asthma, aspirin-induced medication exactly as
Brand Name: Antispasmodics & intestine. Spastic the transmission Bronchospasm, allergy, and nasal polyps directed. Take missed dose as
Buscopan Pharmacologic: pain & functional of nerve impulses Constipation, dry are at increased risk for soon as remembered if not
V q8 Pyrroziline disorders in biliary & by acetylcholine mouth, trouble developing hypersensitivity almost time for next dose. Do
carboxylic acid urinary tracts, female in the urinating, nausea, reactions. Assess for not double dose
genital organs parasympathetic fast heart rate rhinitis, asthmas and _Instruct Patient to notify
nervous system urticaria health
(specifically the _Assess pain (note type, Health care professional if
vomiting center). location, and intensity) allergic reactions occurred
prior to 1 -2 hr following (rash, pruritus, laryngeal
administration edema, wheezing).
_Evaluate liver function _Ask for your doctor's advice
tests, especially AST and if you are breastfeeding or
ALT, periodically in likely to breastfeed during the
patients receiving course of your medication
prolonged therapy. May _Special care is
cause inccreased levels recommended during
_May cause prolonged pregnancy, particularly in the
bleeding time that may first three months.
persist for 24-48 hour Ask for your doctor's advice if
following discontinuation you are pregnant, or likely to
of therapy become pregnant during your
_May cause increased course of medication.
BUN, serum, creatinine or
potassium concentrations
25. DRUG NAME CLASSIFICATION INDICATION ACTION SIDE/ADVERSE NURSING PATIENT TEACHING
EFFECTS RESPONSIBILITIES
Tramadol Therapeutic: Paroxysmal pain in Acts by Agranulocytosis, _Patients who have _Instruct patient to take
Gastro/ diseases of stomach interfering with pancytopenia. Asthma, aspirin-induced medication exactly as
Brand Name: Antispasmodics & intestine. Spastic the transmission Bronchospasm, allergy, and nasal polyps directed. Take missed dose as
Buscopan Pharmacologic: pain & functional of nerve impulses Constipation, dry are at increased risk for soon as remembered if not
V q8 Pyrroziline disorders in biliary by acetylcholine mouth, trouble developing hypersensitivity almost time for next dose. Do
carboxylic acid & urinary tracts, in the urinating, nausea, reactions. Assess for not double dose
female genital parasympathetic fast heart rate rhinitis, asthmas and _Instruct Patient to notify
organs nervous system urticaria health
(specifically the _Assess pain (note type, Health care professional if
vomiting center). location, and intensity) allergic reactions occurred
prior to 1 -2 hr following (rash, pruritus, laryngeal
administration edema, wheezing).
_Evaluate liver function _Ask for your doctor's advice
tests, especially AST and if you are breastfeeding or
ALT, periodically in likely to breastfeed during the
patients receiving course of your medication
prolonged therapy. May _Special care is
cause inccreased levels recommended during
_May cause prolonged pregnancy, particularly in the
bleeding time that may first three months.
persist for 24-48 hour Ask for your doctor's advice if
following discontinuation you are pregnant, or likely to
of therapy become pregnant during your
_May cause increased course of medication.
BUN, serum, creatinine or
potassium concentrations
26. DISCHARGE HEALTH TEACHING
Content Strategy
M-medication To adhere in prescribed Instruct patient to take the prescribed
therepautic regimen for medications as ordered by the physician.
health maintainance and Instruct patient to avoid taking OTC drugs
resistance. unless given with medical advice
Assist patient in performing passive ROM
E-exercise To promote a healthy exercises to maintain muscle tone and increase
lifestyle, maximizing the blood circulation.
level of health and increase Provide schedules of minimal activites tolerable
the body’s immunity. by the patient to incease self-reliance.
T-treatment Attending the follow up Educate client by adhering maintainance
check up. theraphy.
Teach patient of non-pharmacological treatment
Health teaching about the for occurences of abdominal pain such as deep
H-health disease, exercise and diet. breathing exercises, plinting with a pillow,
teaching applying warm compress, and utilizing
diversional activitities
Encourage patient to expose self from the sun
early morning for good source of Vitamin D
Instruct that they need to
O-OPD have a health check up. Emphasize the importance of adhering to
medications and attending follow-up check up.
Maintain and ensure Instruct patient to avoid consumption highly
D-diet adequate intake for seasoned foods, high in salt, fath, caffeneited
noursihment, beverages, and chocolates
Instructed patient to mash the foods well and eat
in small frequent feeding to reduce likelihood of
gastric upset
Encourage patient to drink energy drink as
adjuct supplement from client’s undernutrition
S-signs and If any signs of symptoms are Advise patient to refer to health care
symptoms present go to the nearest professional for persistence of abdominal pain,
hospital for check up. fever, vomitting, diarhea, and occurence of
black stools.
27. III. ONGOING APPRAISAL
Patient A.D a 21 year old male, has been admitted to St, Dminic Medical Center last December
14,2011 with a chief complaint of abdominal pain. Hence was admitted with initial diagnosis of
to consider colon cancer and and hooked of D5 NSS 1 L X 8 hr. Vital signs shows Temp :
37.1°c RR: 18 cpm PR: 105 cpm BP: 100/80mmHg Wt: 32 kg
Patient was orderd for Albumin Test and ordered medication of Hyrocortisone 100 mg TIV,
Buscopan 1 amp TIV q* RTC, Prednisone 250 mg/ Tab BID PO, Pantoprazole 40 mg 1 tab OD
PO and Tramadol 50 mg TIV q8.
Preesently, a final diagnosis of Malabsorption Syndrome was confirmed and the client is still
undergoing treatment, the client’s latest vital signs of Temp.: 37.5°c RR: 19cpm PR: 86 cpm
BP: 100/70mmHg. And for endoscopy