II.

Clinical Summary
Patient name is Mang Pandoy he is 75 years of age male and married he is living at Alanao lupi
Camarines Sur
Chief Complaint:
Tingling sensation of hands for 1 year
History of Present Illness:
3 days prior to consultation Mang Pandoy complaint of Joint pain for 1 week and Abdominal
pain for 1 week and prompt consultation.

Past Medical History:

One year ago Mang Pandoy is Diagnosed by Dr Oida of Community Acquired
Pneumonia/Chronic Obstructive Pulmonary Disease with a maintenance of Azithromycin 500mg
tab OD, fluimucil 600mg tab OD, Hydroxyzine 25mg tab OD HS, Multivitamins + Iron OD.
Then was advise for follow up after 1 week. But he didn’t came back. He seek medical
consultation to Dr Palima and was given salmeterol Fluticasone 500mg/250 mg 2x a
day,Cefixime 200 mg 3x a day,and Calcium Carbonate 1.25 mg Once day.

Familial history:
Mang pandoy recalled that he has a family history of asthma.

Socio Economic Status:

Mang Pandoy said that he has Coconut farm as a main source of income.He is enjoying Senior
Citizen discount which help him and his wife in daily expenses. He is receiving a monthly pay
out as member of Senior Citizen.He also receives money from his children.

Cognitive Status:
Upon Patient interview he was asked of three objects such as papel,mangga motorsiklo as we
asked him to recalled the 3 objects mention he just recalled magga out of the three object.he was
also asked to draw clock to show sampung minuto makalipas ang alas onse and he draw.

Psychosocial Status:
Mang Pandoy loves to chat to his family member when his at rest from farm,he likes to Clean the
house and cooked for sometimes and He goes to market for a while.

Physical Assessment:
Mang Pandoy BP: 100/70 HR:69 RR:19 Height:155 cm Weight:42 kg he said that he has pain
located at hands both,abdomen and back area for sometimes.his visual acuity is 20/200 at right
eye and 20/80 on left eye.

Review of System:
Mang Pandoy is Thin in appearance
EENT:he complaints of blurring of vision
PULMO:his chest xray result was minimal right upper lobe fibrosis atheromatous aorta
CVS:Sinus Tachycardia left atrial hypertrophy
GIT:soft, flabby non tender abdomen he has abdominal pain for sometimes
GUT:normal reading

Gordon’s 11 Functional Health Patterns

1. Health Perception/Health management

The patient rarely visits a doctor for check-up and medical assistance. He’s compliant with given
treatment plan. Has limited knowledge regarding his condition but trying to follow the plan of
treatment. The patient’s able to know his current condition by corresponding during treatment.

2. Nutritional and Metabolic

The patient weight is kg. His usual diet would include mainly vegetables, fish and meat. He
claims that their funds are adequate for food needs. No problem with chewing or digestion. The
patient abides with his diet list and is cooperative.
3. Elimination

He voids 5x a day with yellowish characteristic more or equal to 3L per day. He defecates daily.
Defecates as usual. There were no changes in the patient’s urine output.No changes with his
frequency of defecation. Urinary system is in good condition.

4. Activity-Exercise

He usually goes out with his children but doesn’t have the routine for exercise. He devotes his
time on watching TV and chatting with family members. His activity is altered due to his
physical structure and age, muscle weakness and joint pain. Physical structural changes caused
by arthritis hinders his activities of daily living.

5. Cognitive-Perceptual

The patient’s highest educational attainment was elementary graduate. No sensory deficits but
functions are diminished due to age. Patient is oriented to people, time and place. He is able to
understand and can speak Filipino and Bicol dialect. His last eye examination was unrecalled.
Eyes and vision as per Snellen Chart are 20/200 Right eye, 20/80 Left eye. “Garomay putiputi sa
paghiling ko” as verbalized by the patient. Advised to have Optha check-up but refused. Ears
and Hearing: Patient does not wear any hearing aid and doest not have difficulty in
hearing.Responds to stimuli verbally and physically. No changes were noted during hospital
check-up.

6. Sleep-Rest

He takes 6 hours of sleep a day. He makes 1-2 hours nap at home. He sometimes experiences
sleep interruption. “Napapaturog po ako bandang 8 ning banggi hanggang 2 ning aga” as
verbalized by the patient. No difficulties in going to sleep. With rest intervals.

7. Self-Concept/ Self-Perception

Practices being independent at home. He’s independent with regards to self-care. He’s able to
view his self as an important member of the family, as a husband and father. He’s able to accept
what he can and cannot do.
8. Role-Relationship

Married with 10 children. Close to his grandchildren. Well supported and loved by his family.
He’s participating in decision making at home. Not neglected as part of the family. His decision
matters at home.
9. Sexuality-Reproductive

He’s married and has 10 children. No history of sexually transmitted disease or any condition
affecting his genitals. He cannot manage to be active on coitus due to old age and his present
condition. He stillhave the desire to meet their physiologic need as a couple.

10. Coping- Stress Tolerance

He visits his friends and relatives often. His wife and children were his primary means of
support. He’s able to cope well and manage stress. Able to adjust on unfavorable situation.

11. Value- Belief

He’s a devoted Roman Catholic and active member of the church. Has a strong faith in God. His
present medical condition doesn’t interfere with his spiritual practices.