II.

PATIENT’S PROFILE

PATIENT’S NAME: Lady L.

AGE: 48 years old
GENDER: Female
PERMANENT ADDRESS: Inosluban, Lipa City
BIRTHDATE: August 26, 1960
BIRTHPLACE: Lipa City, Batangas
CIVIL STATUS: Married
CITIZENSHIP: Filipino
RELIGION: Roman Catholic
ADMISSION DATE: August 22, 2008
ADMISSION DIAGNOSIS: Uterine Myoma
ATTENDING PHYSICIAN: Dra. Lovely Cacho
Dra. Alice Lojo

HISTORY OF PRESENT ILLNESSS

Present condition started about 6 years prior to admission. When patient noted
heavy vaginal bleeding and body weakness every menstrual period that last almost a
week. Due to that instance, she went to the hospital for check-up and she found out that
she has a myoma. Her attending physician said that she need to undergo surgery but they
didn’t have enough money that time, they would need to save for the hospitalization and
operation that will undergo. Until August 22, 2008, when her relative noted her to be
pale, having dizziness and body weakness brought her to the hospital. After a series of
examination, she was scheduled and prepared her to surgery.

PAST MEDICAL HISTORY

She has never been hospitalized except when she had two breech presentations
with her two sons. Other than that, she usually experiences cough, cold, fever and buys
over the counter drugs to treat the said illnesses. Prior to that, sometimes she consult the
said quack doctors or faith healers if she thinks that it’s just that a simple illness.

SOCIO – CULTURAL

She is a friendly person. She is close with her four sons and loves them so much. She
admitted that few years ago, she used to smoke when she is defecating and after eating.
She said that she loves to eat vegetables and she exercises regularly. She cooks in a
canteen in Lipa bus stop which sustains their basic needs.
III. PHYSICAL ASSESSMENT

ACTUAL VITAL SIGNS NORMAL VALUES INTERPRETATION

RR- 20 12-20 beats/min. Normal
PR- 80 60-100 beats/min. Normal
BP- 120/70 90/60- 130/90 mmHg Normal

Height = 5’1 ft.

Weight = 57 Kg.

Body Parts Technique Normal Actual Significance

used findings findings
Head Inspection Normocephalic Normocephalic Normal
Palpation No abnormal No abnormal Normal
mass mass
Hair and scalp Inspection Evenly Even Normal
distributed, distribution of
Thick hair, hair , no
no infection infection and
and infestation infestation
Eyes Inspection Symmetric to Sunken eyeball Not Normal.
the face, Due to
both eyes dehydration
coordinated
with parallel
alignment.
External eye
Structure

Eyebrows Inspection Hair evenly Evenly Normal

distributed, distributed with
Skin intact skin intact
Eyelashes Inspection Equally Equally Normal
distributed, distributed,
Curled slightly Curled slightly
outward outward
Eyelids Inspection Skin intact, Skin intact, no Normal
No discharge, discharge, no
No discoloration,
discoloration, lids are
Lids close symmetrical.
symmetrically
Lacrimal Inspection No edema or No edema and Normal
gland tearing. tearing
Upper
Extremities

Skin Inspection Pinkish in Pallor Not normal.

color It is a
manifestation
of in adequate
circulating
blood or
hemoglobin.
Palpation Slightly moist Poor skin turgor Not normal due
to dehydration
Palpation Normothermia Not warm, not cold Normal
to touch, T=36
Arms Inspection Normally firm, Normally firm, no Normal
no contracture, contracture, no
no swelling, swelling, equal size
equal size on on both sides of
both sides of body
body
Palpation Pulse Rate: 60- Pulse rate: 80 Normal
100
Nails Inspection Smooth, highly Pink, smooth Normal
vascular and texture, convex
intact curvature
epidermis
Palpation Capillary Refill Capillary refill: 2 Normal
of 1-2 seconds seconds
Chest and Inspection Symmetric Symmetric chest Normal
Lungs chest expansion, quiet,
expansion, rhythmic and
quiet, rhythmic effortless
and effortless respiration
respiration

Palpation No retraction, No retraction, no Normal

no tenderness, tenderness, no
no masses masses
Auscultation Quiet, Adventitious Not normal due
rhythmic breath sounds to presence of
secretion
Heart Auscultation Normal heart Cardiac rate of 80 Normal
rate 60-
100bpm