NUTRITIONAL MEATBOLIC PATTERN

My patient eats 3x a day with a regular afternoon snacks. She doesn’t have any allergies on

foods and drug. But then because of her condition, patient appetite decreases. She only eat 2x a day and

no more snacks. As I observed she almost eat about 1 ½ hours because of her gum bleeding. She also

verbalized that she decreases weight but cannot tell the exact kilo or pounds.

ELIMINATION PATTERN

My patient urinates about 4-5x a day without any difficulty prior and during hospitalization. She

defecates once a day with no regular time/pattern. During hospitalization her stool was harder in

consistency compared before.

ACTIVITY EXERCISE PATTERN

My patient does the household chores because she does not work. But due to her condition,

she experienced body weakness and thus at hospital before she go to comfort room she takes her

strength first and always asking assistance from others, and because she was afraid that she might fall.

SLEEP REST PATTERN

Before hospitalization, she sleeps around 11:00-12:00, because she always watches television.

She wakes up at 5-6:00 am to prepare their breakfast. She always takes a nap everyday for 2-3 hours.

During hospitalization, at night she sleeps 4 hours and does not taking a nap anymore because

of the environment. She cannot sleep because her bed was at hallway and she can get easily distracted

from noise and people who always walks beside her.

COGNITIVE PERCEPTUAL PATTERN

In terms of perceptual pattern she has no problems with her senses; she does not wear ant eye

glasses. In cognitive pattern, she has no p[problems too, she stated that she was the one teaching their

child. As I talked to her, she responds appropriately and can obey commands.

SELF PERCEPTION-SELF CONCEPT PATTERN

My patient thinks before that she was in good wife, relatives and of course as a mother. She

stated that she has no enemy and she cannot get angry easily.

ROLE-RELATIONSHIP PATTERN

According to her mother-in-law, she was a good person and fun to be with. She always helps her

and others when they need her. My patient said that she was so happy because she has a husband who

was so caring and supportive unlike before she was a teens her mother left them. She really appreciates

the effort of her husband relatives who always visit her.

SEXUALITY-REPRODUCTIVE PATTERN

My patient verbalizes that she was sexually active. As a couple they do not use any

contraceptive and were planning to have another child and at this time they were praying that it should

be girl

COPING-STREES TOLERANCE PATTERN

When she was a child she does not share her problem but now she already shares it to her

husband. Sometimes she watches comedy videos to relieve her anxiety.

VALUE-BELIEF PATTERN

Before marriage my patient had no religion, but of course she believes to God. Now they were

attending at Catholic Church every Sunday. My patient does not believe to quack doctors.
URINALYSIS

JANUARY 24, 2010

PHYSICAL EXAMINATION

Color: light yellow

Transparency: slightly turbid

CHEMICAL EXAMINATION

Glucose: negative

Protein: negative

pH: 7.0

specific gravity : 1.015

MICROSCOPIC EXAMINATION

Wbc: 2-4 hpf

Rbc: 1-3 hpf

Epithelial cells: moderate lpf

Mucus Thread: moderate lpf

Amorphous: phosphate: moderate lpf

CHEMICAL CHEMISTRY

JANUARY 19, 2010

RESULT REFERENCE

Hmg 116g/L 120-180g/L

Hmct 35.4% 38.5-54.0%

Platelet 2.4 10^9/L 150-450 10^9/L

SODIUM 140.2 mmol 135-148 mmol

POTASSUIM 3.78 mmol 3.50-5.3 mmol

JANUARY 19, 2010

RESULT REFERENCE

Hmg 123 g/l 120-180g/L

 Hmct 35.7% 38.5-54.0%

RBC 4.5 10^12/L 4.20-6.20 10^12/L

MCV 80.0 fL 80.0-96.0 fL

MCH 27.6 pg 27.0-31.0 pg

MCHC 345.0 g/L 320-36- g/L

Platelet 75.O 10^9/L 150-450 10^9/L

WBC 6.O 10^9/L 4.5-11.0 10^9/L

DIFFERENTIAL COUNT

NEUTROPHILS 29.1% 40.0-74%

LYMPHOCYTES 60.0% 19.0-48.0%

MONOCYTES 4.8% 3.4-9.0%

EOSINOPHILS 6.1% 00.0-7.0%

BASOPHILS O.O% 0.0-11.5%

PHERIPHERAL BLOOD SMEAR JANUARY 19, 2010

RBC’S shows non mocytic-slightly hypenethromic

Platelets are inadequate in number

WBC’S show notoxic granulation/no abdominal lymphocyte seen

JANUARY 20, 2010

UREA 3.7 mmol/L 2.5-6.1 mmol/L

CREA 44.0 umol/L 62-106 umol/L

JANUARY 21, 2010 10:24 AM

RESULT REFERENCE

Hmg 125 g/l 120-180g/L

Hmct 36.4 38.5-54.0

RBC 4.5 10^12/L 4.20-6.20 10^12/L

MCV 80.2 fL 80.0-96.0 fL

MCH 27.5 pg 27.0-31.0 pg

MCHC 343.0 g/L 320-36- g/L

 Platelet 3.4 10^9/L 150-450 10^9/L

WBC 4.7 10^9/L 4.5-11.0 10^9/L

DIFFERENTIAL COUNT

NEUTROPHILS 40.6% 40.0-74%

LYMPHOCYTES 47.3% 19.0-48.0%

MONOCYTES 6.6% 4.4-9.0%

EOSINOPHILS 5.5% 00.0-7.0%

BASOPHILS O.O% 0.0-11.5%

ABO TYPE: 0 RH: POSITIVE

JANUARY 24, 2010

RESULT REFERENCE

Hmg 103 g/l 120-180g/L

Hmct 30.4% 38.5-54.0%

RBC 3.7 10^12/L 4.20-6.20 10^12/L

MCV 81.5 fL 80.0-96.0 fL

MCH 27.6 pg 27.0-31.0 pg

MCHC 339.0 g/L 320-36- g/L

Platelet 3.0 10^9/L 150-450 10^9/L

WBC 6.7 10^9/L 4.5-11.0 10^9/L

DIFFERENTIAL COUNT

NEUTROPHILS 54.3% 40.0-74%

LYMPHOCYTES 36.0% 19.0-54.0%

MONOCYTES 3.6% 3.4-9.0%

EOSINOPHILS 6.1% 0.0-7.0%

BASOPHILS O.O% 0.0-11.5%

ABO TYPE: 0 RH: POSITIVE