III.

HEALTH HISTORY
A. BIOGRAPHIC DATA

Name: L.J.C.
Address: Caloocan City
Birthday: October 15, 1971
Age: 46 y/o
Gender: Male
Date of admission: September 8, 2018

B. REASON FOR SEEKING CARE

Diaphoresis, slurry of speech, and right sided body and facial weakness

C. PRESENT HEALTH HISTORY

20 minutes prior to admission, patient is apparently well until seen by coworkers having
diaphoresis with right facial asymmetry and slurry of speech with right sided body weakness,
hence, brought immediately to the emergency room. At 9:00 pm after a day of admission, the
patient was advised to have an emergency craniotomy. The surgery started at 10:15 pm and
ended at 12:15 am of September 9, 2018.

D. PAST HEALTH HISTORY

As the wife can recall, patient LJC was known to have asthma but was never hospitalised and
didn’t take any medication. Patient LJC has had PTB 10 years ago, but went through
complete treatment for 6 months. The patient has no known allergy to any food and
medication. The patient has no history of chicken pox, measles, and mumps. The patient also
has no history of blood transfusion and no previous surgery.

E. SOCIAL HISTORY

The patient lives in their own house in an urban area in Caloocan City. Patient LJC is
working as a delivery man. Their family’s top and main priority is food. Patient’s wife is
unemployed because she stays home to take care of their two children. Their family has one
dog and four cats.
F. FAMILY HISTORY

A + +
A D D
HPN

A A A A A
A HPN A A A D D A A
HPN D

A A

A = Alive and well

+ = Deceased

HPN = Hypertension

D = Diabetes

= Male

= Female

= Patient
A. GORDON’S LEVEL OF FUNCTIONING

PRIOR TO ADMISSION DURING ADMISSION

20 minutes prior to The patient experienced right

admission, patient is facial asymmetry and right side
apparently well until seen by body weakness, was ambulatory
coworkers having but had slurry of speech before
HEALTH diaphoresis with right facial the surgery. And can’t express
asymmetry and slurry of himself verbally after the
PERCEPTION speech with right sided body craniotomy.
weakness, hence, brought
AND immediately to the
MANAGEMENT emergency room.

PRIOR TO ADMISSION DURING ADMISSION

He eats three times a day. Patient is eating through NGT.

NUTRITIONAL- The patient doesn’t eat
METABOLIC vegetables and eats mostly
meat and fried food.
PATTERN

PRIOR TO ADMISSION DURING ADMISSION

The patient defecates The

ELIMINATION patient
regularly and he does not regularly.
defecates

experience any problems in

PATTERN defecation.

PRIOR TO ADMISSION DURING ADMISSION

ACTIVITY- He is able to perform The patient stays in bed and
EXERCISE activities of daily living can only slightly move the
independently with left side of his body. The
assistance from his family. patient needs assistance.
PATTERN
 PRIOR TO ADMISSION DURING ADMISSION

No difficulties encountered He is asleep most of the

SLEEP-REST in going to sleep as claimed time. But would get
and does not use any interrupted when there are
medication to promote sleep. procedures that need to be
PATTERN He sleeps 4-6 hours per day. done.

PRIOR TO ADMISSION DURING ADMISSION

No sensory deficits. The After the surgery, the patient

COGNITIVE- patient has no hearing
difficulty and is not using
is not oriented to people,
place and event. Cannot fully
PERCEPTUAL hearing aid. He responds to respond to stimuli verbally
stimuli verbally and and physically with body
physically. No problems in weakness noted.
PATTERN memory as reported.

PRIOR TO ADMISSION DURING ADMISSION

He believes that he is a The patient cannot express

SELF person with no sickness but himself verbally.
is aware of his hypertension.
PERCEPTION/
SELF-CONCEPT
PRIOR TO ADMISSION DURING ADMISSION

He is the third son of his His wife is always in the

ROLE parents. He is currently hospital looking after him.
RELATIONSHIP living with his wife and his
two children. He is loved by
her family as claimed. She
has a good relationship with
her family, neighborhood,
and friends.
 PRIOR TO ADMISSION and DURING ADMISSION
SEXUALITY/ The patient is married. He has no history of any sexually
REPRODUCTIVE transmitted disease.

PRIOR TO ADMISSION DURING ADMISSION

The patient coped up with The patient cannot express

COPING- stress by talking and himself verbally.
spending time with his
STRESS family and friends.
TOLERANCE
PRIOR TO ADMISSION DURING ADMISSION

His religious affiliation is The patient cannot express

VALUE-BELIEF Roman Catholic.
seldom go to church on
They himself verbally.

PATTERN Sunday's.

B. REVIEW OF SYSTEM

BODY PART METHOD FINDINGS

Skin Inspection Color: Pale
Moisture is present
Hair Inspection Thin hair
Short, brown in color
Dry
No infestation noted
Scalp Inspection Dry
Nail Inspection Pale
Concave in shape
Ear Inspection Pale
Mouth, throat, and lips Inspection Dry
Hard palate and soft palate Inspection Pale
Musculo Skeletal Inspection Body weakness noted