Casestudy

University of San Carlos College of Nursing Cebu City CASE STUDY FORMAT I. PATIENT DEMOGRAPHIC PROFILE Name:Ayda Bagayao

Age: 54

Religion: Catholic

Occupation: N-O-N-E

Nationality: Filipino

Status: Divorced

Gender: Female

Home Address: Sto. Rosario, Jagobiao, Mandaue City

II. HEALTH HISTORY PROFILE A. Past Medical History

(include dates, severity, complications if any)

1. Pediatric and Adult Illness Date Can’t recall

Illness Hypertension Pre-diabetes

Medication

Remarks

Meformine

2. Immunization Immunization BCG DPT OPV

Doses 1 3 3

Dates Can’t remember

Remarks

3. Hospitalization Date/Year Year 2000

Hospital Vicente Sotto MemoRial Medical Hospital

4. Injuries and Accidents

Diagnosis Menopausal

Duration 3 days

Nay Ayda has no past injuries and accidents. 5. Transfusions No past transfusions. 6. Allergies (specify) No allergies. B. Family History (support with a Genogram and limit to two (2) generation if patient can recall). Lola Anding (D,L)

Jonathan

Roger

Lolo Basik (D)

Ayda (HTN, DM)

Jennifer (M) Sheena (M)

Liza (L)

Jun2x (S)

Legend:

D– Deceased M- Married HTN - Hypertension DM - Diabetes Mellitus S– Single LLeprosy * Only the side of Ayda. She is divorced!

C. Social and Personal History Nay Ayda has no job. She stays at home. Cook for her grandchildren and nieces and also for her brother who stays in her and who supports them in their daily needs. Nay Ayda has (3) three children. Jennifer, as her eldest and is married. Sheena, her middle, also married and is pregnant. And her youngest who stays with her named jun2x, still studying and single. Nay Ayda has no experience in military or foreign travel. She has no habits at all. Her diet, before she likes sweets and loved to drink soft drinks. But she was advised by the doctor to minimize it because her glucose level is high. And so she did. Nay Ayda has an extended type of family. This composed of a brother, niece, grandchildren, and son. Her beliefs in cultural was, Leprosy is not a communicable disease but it is in the blood. Nay Ayda’s daily average day is, in the morning, she was clothes, cook, take care of her grandchildren, do household chores. She takes a nap during day time if she is done with her activities.

D. Review of System (for the past 6 months).

Physical Assessment

General

Weight Loss

Fatigue Anorexia Night Sweats Chills Fever Weakness - overwork because of activities in the house.

Skin

Itch

Eyes

Pain Discharges Itch Vision Loss Diplopia Excessive Tearing Glasses/Contact Lens Date of Last Exam: - when she stands up suddenly, she sometimes lose her vision.

Ears

Earaches

Nose

Obstruction

Throat and Mouth

Sore Throats

Neck and Head

Swelling

Chest

Cough Sputum: Amount and Character Hemoptysis Wheeze Pain on Respiration Dyspnea

Cardiovascular

Precordial Pain Palpitation Dyspnea on Exertion Paroxysmal Nocturnal Dyspena Orthopnea Edema Heart murmur Thrombophlebitis Claudication

Gastrointestinal

Heartburn Nausea Vomitting Diarrhea Food Intolerance Excessive gas or indication Constipation Change n Bowel Movement Jaundice Bloating Melena Hemorrhoids Hernia

Rash

Lesions

Discharges Discharges

Bruising

Tinnitus

Color Change

Hearing Loss

Epistaxis

Bleeding Gums

Dysphagia

Bleeding

Toothache

Dentures

Hoarseness

Genitourinary

Heartburn Nausea Vomiting Diarrhea Food Intolerance Excessive Gas or Indication Constipation Change in Bowel Movement Jaundice Bloating Melena Hemorrhoids Hernia

Extremities

Joint Pains Varicose Veins Claudication Edema Stiffness Deformities

Endocrine

Hot Flashes Polydipsia

Neurology

Numbness Tingling Tremor Fainting Headaches Muscle Weakness Ataxia Unconsciousness Paralysis/paresis Memory Loss Dizziness Seizure -bacause of overwork or over fatigue.

Psych

Anxiety Depression Nightmares

Others

Hair Loss Goiter

Back Pain

Temperature Intolerance

Sexual Problems

Insomia

Pathophysiology of Diabetes Mellitus

CASE STUDY Diabetes Mellitus

By:

DAN CAPAPAS JOHN KENNY CAMPOS HOPE BERNADAS Group 56 3L