Access over 20 million homework & study documents

Case study CLINICAL INSPECTION

Content type
User Generated
Type
Study Guide
Rating
Showing Page:
1/13
I. Patient Profile
Name: Mark Bien Gamrot
Age: 21 years old
Gender: male
Occupation: construction worker
Educational Attainment: High School
Civil Status: single
Nationality: filipino
Address: 393 Cabugao Sto .Domingo ,Nueva Ecija
Religion: catholic
C/C: abdominal pain
Date Admitted: January 15, 2013 @ 2:25 pm
Admitting Diagnosis: Acute appendicitis
Final Diagnosis : Peri appendical Abscess
Attending Physician: Dr. Leonardo Flores
Source of Information: patient and mother
Reliability: 90%
II. Present Illness:
3 day prior to admission, the patient experienced mild pain on his right lower quadrant abdomen
associated with constipation and vomiting but no fever.
Few hours prior to admission still with abdominal pain now with fever consult at own laboratory of
pillar.
Has positive allergy to foods such as (pork).
“E” E/L, appendectomy, Cecorlaphy, and Peritoneal Washing
III. Past Health History:
. Pain in the right lower abdomen 1
st
felt 3 days prior to admittion in Our Lady of the Pillar Medical
Center in Cavite, but the result is now no pain and no history of hospitalization.
IV. Family History:
The mother claimed that her mother is asthma positive, and noted hypertension history on the
paternal side.
V. Psychosocial history:
The patient sorrounding is good. They used a mineral at faucet for drinking and taking a bath. He
smokes 5 sticks of cigar. Per day, and play basketball in freetime. He works in Cavite as Construction worker .

Sign up to view the full document!

lock_open Sign Up
Showing Page:
2/13
PATTERNS OF FUNCTIONING
CLINICAL INSPECTION
OTHER SOURCES
1. RESPIRATORY
- (+) Hx of Asthma
- Consumed 5 sticks of
cigar/day
- Started smoking since
17 y.o
2. CIRCULATORY
- (+)Hx of HPN
3. FOODS AND FLUIDS INTAKE
- Usual food taken: leafy
vegetables, fish, rice,
root crops
- (-)food allergies
- (-)food preferences &
dislikes
- Drink 4 glasses of water
each day
- Drink 10 glasses of tuba
occasionally
4. ELIMINATION
- Void more than 5x/day
- Defecate 1x/day or
sometimes 1 time every
2 days
- Fun of retaining stools if
at work
5. REGULATORY MECHANISM
- (+) mild fever during
childhood
6. HYGIENE
- Take a bath 1-2x/day
- Seldom use shampoo
- Change cloth everyday
- No allergies to soap &
shampoo
- Combs hair
7. EXERCISE & LOCOMOTION
- Take the daily activities
as exercise
- RR = 26cpm
- No accessory
muscle used
- No respiratory aids
used
- No cough and cold
- BP = 110/70 mmHg
- PR = 53 bpm
- No presence of
discoloured or
swollen parts
- Good capillary refill
- Good skin turgor
- Dry lips
- With an IVF of D5LR
@ 30gtts/min
- No NGT
- Not constipated
- Presence of
indwelling catheter
- (-) nausea
- T = 36.6
- Afebrile
- (-) chills
- Untidy to look at
- (-)skin lesions
- Hair is equally
distributed
- (+)Halitosis
- Poor dental care
- Presence of plaque
- Impaired mobility
due to pain
Hematology:
WBC: 18.30x10^9/L
Neutrophil: .90
Lymphocyte: .10
Hematocrit: .46
URINALYSIS
Color : Dark yellow
Transparency: Turbid
Specific gravity: 1.025
PH: 6.0
Glucose: negative
Albumin: trace
WBC: 2-3/hpf
Bacteria: moderate
Mucus threads: many
Costs: coarse granular: 0-1/lpf
Uric acid: moderate

Sign up to view the full document!

lock_open Sign Up
Showing Page:
3/13

Sign up to view the full document!

lock_open Sign Up
End of Preview - Want to read all 13 pages?
Access Now
Unformatted Attachment Preview
I. Patient Profile Name: Mark Bien Gamrot Age: 21 years old Gender: male Occupation: construction worker Educational Attainment: High School Civil Status: single Nationality: filipino Address: 393 Cabugao Sto .Domingo ,Nueva Ecija Religion: catholic C/C: abdominal pain Date Admitted: January 15, 2013 @ 2:25 pm Admitting Diagnosis: Acute appendicitis Final Diagnosis : Peri appendical Abscess Attending Physician: Dr. Leonardo Flores Source of Information: patient and mother Reliability: 90% II. Present Illness: 3 day prior to admission, the patient experienced mild pain on his right lower quadrant abdomen associated with constipation and vomiting but no fever. Few hours prior to admission – still with abdominal pain now with fever –consult at own laboratory of pillar. Has positive allergy to foods such as (pork). “E” E/L, appendectomy, Cecorlaphy, and Peritoneal Washing III. Past Health History: . Pain in the right lower abdomen 1st felt 3 days prior to admittion in Our Lady of the Pillar Medical Center in Cavite, but the result is now no pain and no history of hospitalization. IV. Family History: The mother claimed that her mother is asthma positive, and noted hypertension history on the paternal side. V. Psychosocial history: The patient sorrounding is good. They used a mineral at faucet for drinking and taking a bath. He smokes 5 sticks of cigar. Per day, and play basketball in freetime. He works ...
Purchase document to see full attachment
User generated content is uploaded by users for the purposes of learning and should be used following Studypool's honor code & terms of service.

Anonymous
Awesome! Made my life easier.

Studypool
4.7
Trustpilot
4.5
Sitejabber
4.4