Vicente, Denice Bernadette L.

BSN 1-1
Health Assessment Laboratory December 18, 2018

Review of Systems
Patient X

1. Constitutional
 Fever
“ di naman ako nagkakalagnat.”as verbalized by the patient
 Chills
“isang beses lang nangyari sa akin ‘yun, siguro mga last year pa siguro dahil sa pagod
‘yun” as verbalized by the patient
 Fatigue
“kapag may mabigat na trabaho ganun o kaya pag mainit” as verbalized by the patient
 Large weight gain and loss
“tumaba ako kasi matakaw ako kumain, malakas ako sa kain tapos hindi pa ako stressed.
Tapos siguro dahilan din ng pagtaba ko ung pagtigil ko sa exercise ko” as verbalized by
the patient
 Somnolence
“kapag busog parang nakakaramdam agad ako ng antok” as verbalized by the patient

2. Eyes/Vision
 Vision Loss
“hindi ko pa naman yan nararanasan, Malabo lang ung mata ko kaya ako nakasalamin.”
as verbalized by the patient
 Redness
“kapag napupuwing lang ganun.” as verbalized by the patient
 Burning or itching
“ayun nga kapag napupuwing ako, nangangati saka parang naiiita kaya rin siguro
namumula” as verbalized by the patient
3. Ears , Nose , Mouth and Throat
 Hearing loss
“minsan di ko lang naiintindihan ung sinasabi ng kausap ko pero sa tingin ko naman
normal naman ‘yung pandinig ko” as verbalized by the patient

4. Cardiovascular
 Chest pain
“hindi naman sumasakit ‘yung dibdib ko kapag stressed lang.” as verbalized by the patient
 Palpitation
“minsan kapag pagod, oo, nararamdaman ko yan pero wala akong iniinom nagamot
nagpapahinga lang ako tapos okay naman na ung tibok ng puso ko ulit” as verbalized by
the patient
 Cramping in thighs/ claudications
“kapag matagal na nakatayo nagccramp ang mga hita ko” as verbalized by the patient
 High blood pressure
“oo meron akong high blood, normal na BP ko na ung 130/90” as verbalized by the patient
 Last ECG
“September 3, 2018. Normal naman ‘yung ECG ko napabasa ko na un sa doctor sa OM”
as verbalized by the patient

5. Respiratory
 Chest pain
“wala naman kapag stressed nga lang” as verbalized by the patient
 Dyspnea or shortness of breath
“hindi naman ako nahihirapan huminga” as verbalized by the patient
 Cough
“napapaubo lang ako kapag nabubulunan ako. Madalas ako mabunulan kapag kumakain
hindi ko alam kung bakit” as verbalized by the patient
 Asthma
 “asthma, may history ako, maliit pa lang ako… hanggang elementary siguro ‘yun. Pero
nung magcollege ako wala naman na, hind na ako hikain. Ewan ko rin pano nawala” as
verbalized by the patient

6. Gastrointestinal
 Vomiting and nausea
“kapag nakainom lang, nasusuka, dahil sa hang-over” as verbalized by the patient
 Change in bowel habits
“wala naman basta dalawang beses ako dumudumi. Isa sa umaga saka isa sa gabi” as
verbalized by the patient
 Diarrhea
“pag masama lang nakain ko pero madalang lang, tapos iniinuman ko na agad ng gamot
Diatabs ba un ay saka pala pag nalalamigan ako minsan nagkakadiarrhea ako””kapag
nagdidiarrhea ako syempre pururot, matubig tapos may mga maliliit na dumi” as
verbalized by the patient
 Dyspepsia
“bloated lang ako ganun matigas ung tyan ko kasi maraming nakain.” as verbalized by
the patient
 Stools
“madalas brown, halos karamihan brown kapag kumainlang ako ng dunuguan itim ang
dumi ko, minsan parang madilaw hindi ko nga lang matandaan ano kinain ko nung
nagging dilaw ang dumi ko…prutas ata” as verbalized by the patient

7. Genitourinary
 Frequency of urination:
“sa madaling araw 2 o 3… sa umaga marami bale mga nakakapito siguro akong ihi sa
isang araw. Malakas din kasi ako uminom ng tubig e” “ay marami akong naiihi mga 1litro
siguro sa isang araw” as verbalized by the patient
 Burning or pain when urinating
“noon lang kasi nagpipigil ako ng ihi kapag madaling araw pero ngayon wala naman na
okay na” as verbalized by the patient
8. Musculoskeletal
 Stiffness, arthritis or gout
“ay meron kapag kumain ako ng mga beans, nako kalaban ko jan baguio beans saka beef.
Minsan ung daliri, tuhod mga kasukasuan ko ung sumasakit. Pero nawawala rin minsan
iniinuman ko ng gamut Revicon forte pain reliever un e” as verbalized by the patient
 Neck or lower back pain
“madalang sumakit ung leeg ko kapag pagod lang o kaya pag mataas ung unan” “ay oo
sumasakit ung likod ko lalo na kapag nalamigan saka pag matagal akong nakaupo ung
parang squat ayan masakit ung likod ko dahan dahan ako kelangan tumayo. Tapos ung
sakit nya parang ngawit ganun” as verbalized by the patient

9. Integumentary
 Dryness or excessive sweating
“pawisin ako kapagmainit, pag maglalakad palang ako pawisin na ako lalo nakapag
nageexercise” as verbalized by the patient
 Hair loss
“2006 ata ako medyo nawalan ng buhok sa bumbunan pakiramdam ko hereditary naman
to kasi mga kamag-anak ko ganun din” as verbalized by the patient

10. Neurological
 Dizziness
“oo nung isang beses nung nagjogging kami ng anak ko, nagikot paningin ko nun kaya
ayun huminto kami sa pagjojogging pero hindi ako nagpacheck-up pagkatapos nun” as
verbalized by the patient
 Vision problem
“Malabo mata ko 225 ung grado nung isa ung isa naman 275. Nung 2000 pa ata ako
nagsimula magsalamin” as verbalized by the patient
 Memory loss
“konti, minsan nagiging makakalimutin na ako siguro dahil sa edad ko”
 11. Psychiatric
 Stress
“madalas, dahil sa mga anak ko” as verbalized by the patient
 Mood Changes
“madalas oo mainitin ulo ko nahihigh blood ako agad, di ko naiiwasan napapataas talaga
ung boses ko” as verbalized by the patient

12. Endocrine
 polyuria (increased urination)
“marami ako umihi dahil marami rin akong tubig na iniinom kasi ine-aim ko talaga na
maka-8 glasses kada araw” as verbalized by the patient
 polydipsia (increased thirst)
“hindi ko lang sigurado kasi kapag umihi kasi ako inom na agad ako ng tubig…kung
makaka 8 glasses edi maganda kasi un nga ang ine-aim ko” as verbalized by the patient
 polyphagia (excessive hunger)
“may times kahit na nakakain na ako, gusto ko pa kumain, di ko sigurado kung bakit” as
verbalized by the patient
 unexplained weight change
“wala naman basta ngayon alam ko tumaba ako malakas kasi ako kumain” as verbalized
by the patient
13. Hematologic/Lymphatic
 No known issues
14. Allergic/Immunologic
 No known issues
Gordon’s Functional Health Pattern
HEATH PERCEPTION AND HEALTH MANAGEMENT
Before Diagnosis Present Analysis
 Patient thinks that he is  Patient thinks that he is not Before, for Patient X, it is
healthy; doesn’t have any that healthy anymore just obligatory to have a
maintenance medicine because he has a medical check-up to be able
 He needs to have medical maintenance medicine to work but now, it is very
check-up every year (for  Tries to have an annual important for him to be able
his work requirement) medical check-up because to have an annual check-up
he thinks that he needs it because he thinks that he
more because of his age already needs it especially
now that he is aging.
NUTRITIONAL – METABOLIC PATTERN
Before Diagnosis Present Analysis
 Eat 3 times a day  Eat 3 times a day, There is no much change in
 Does not think twice sometimes with snacks in the nutritional-metabolic of
before eating oily foods between the patient. He just limits
 Eat any kinds of  Limits and avoids oily the oily food that he
vegetable foods consumes; he also tries to
 Weighs 70kg  Loves to eat rice avoid eating beef because it
 Does not eat Baguio beans causes joint pains for the
and beef because he patient.
experiences joint pains
after eating
 Weighs 76kg
ELIMINATION PATTERN
Before Diagnosis Present Analysis
 Eliminates during  Eliminates during morning There is also no much
morning and the evening and evening change in the patient’s
 Stool is brownish and  Urinate approximately 7 elimination pattern.
solid times a day; urine color:
 Perspires heavily when yellowish
the weather is hot  Stool color: brownish, solid
(normal)
 Perspires heavily when the
weather is hot, or by just
walking
ACTIVITY-EXERCISE PATTERN
Before Diagnosis Present Analysis
 Works as a chief cook in  Retired, cooks for family After the patient retired,
a ship  Does not exercise regularly some of the activities that he
 Exercise every morning  Usually at home does were limited. His
 Does not have time to  Facebook is his pastime exercise activities were
browse the net because reduced even though he is
now usually at home.
 signal is limited and
expensive in the ship
COGNITIVE – PERCEPTUAL PATTERN
Before Diagnosis Present
A. Sensory-Perceptual A. Sensory-Perceptual
 Does not have a blurred  Has a blurred vision
vision  Sometimes have a
B. Cognitive Pattern difficulty hearing
 Does not have a problem B. Cognitive Pattern
with his memory  Sometimes forget things
and thinks that it is because
of his age
SLEEP-REST PATTERN
Before Diagnosis Present
 Gets to sleep 6-8 hours  Gets 7-8 hours of sleep
when at work  Sometimes have trouble
 Sometimes have trouble falling asleep because he is has retired. If before, the
falling asleep because of thinking about some
some sea disturbances problems
 Does not use any  Takes a nap in the
medications to sleep afternoon
 Tried using sleeping pills
before but eventually
stopped
SELF PERCEPTION AND SELF-CONCEPT PATTERN
Before Diagnosis Present
 See himself as a strong  Still sees himself as a
and healthy man strong man even though he as strong even though he
 Serious type of person has maintenance medicines has maintenance medicines.
 Haven’t thought that  Gets irritated and angry
some of his hair would easily
not grow back again  Sometimes feel shy about
his semi-baldness
ROLE – RELATIONSHIP PATTERN
Before Diagnosis Present
 Does not usually stay at  Usually at home, and
home because of his job relationship with family
 Sees himself as the members improved
breadwinner of the family  Became more closer to
 Always asks for his God; serving the Lord
wife’s opinion  Autonomous in making
decisions since his wife
died
Analysis
There are times when
patient X forgets some
events or things and he
thinks that it is because of
his age.
Analysis
Patient X has more time to
sleep and rest now that he
ones keeping him awake is
the sea disturbances that
they may encounter, now,
he always thinks about
finances.
Analysis
Patient X still sees himself
Sometimes, he feels shy
about his hair.
Analysis
Now that Patient X is
retired, he now has more
time to spend with his
family. When his wife died,
he has now the
responsibility to decide for
the whole family.
 SEXUALITY-REPRODUCTIVE PATTERN
Before Diagnosis Present Analysis
 Married  Widowed  The patient did not have
 Father of 2 children a problem with his
 Does not have a history of genitals up until this
disease affecting his moment.
genitals
COPING/STRESS-TOLERANCE PATTERN
Before Diagnosis Present Analysis
 Stressed with work,  Stressed with his children;  Patient X copes better at
sometimes scared of the worried about finances the present than before.
sea disasters that they  Talks to his children about If before, he is stressed
may experience in the it with work, now, he is
ship  Tries to be optimistic about stressed with his
 Contacts his wife everything children. He tries to be
whenever available  Only drinks alcohol optimistic and does not
because signal in the ship occasionally drink alcohol whenever
is costly and sometimes he’s stressed.
unavailable According to Rutgens, loving
 Usually drinks alcohol “support systems” such as
family, friends, and
involvement in social groups
help when dealing with
stressful events.
VALUE-BELIEF PATTERN
Before Diagnosis Present Analysis
 Catholic  Catholic  His faith with God has
 Does not really have a  Has a strong faith in God become stronger and he
strong faith in God  Believes that he can now believes that he can
 Thinks that he can do surpass anything with God do everything with God
everything by his own by his side.
and does not need According to Chittaranjan
anybody’s help Andrade, Professor of
Psychopharmacology, people
pray for good health and for
relief from illness. Prayer may
result in health and healing
through one or more of several
mechanisms.