Mam De La Cruz..6a

Date of assessment: November 23, 2009

Nursing Health History Name: Aireen Pama Sex::Female Age: 30 years old Address: 1440 Felix huesta st, Sta cruz, Manila Date of birth: October 08, 1979 Place of birth: Iloilo city Religion: Catholic Nationality: Filipino Marital status: Single Chief Complaint: Fever, headache and sudden neck mass AMD: Juanita Lu Lim Diagnosis: Lymphoma Next kin of data: Name: Lily Pama Age: 35 years old Relationship: sister Present Health History November 1, 2009, the patient experienced fever and severe headache for five days. She drinks Flanax as prescribed by her doctor to relieve the pain. After taking her medicine she experienced sweating and fever started to subside. Every morning her temperature started to increase and decreases after lunch where she takes her Flanax. She noticed that there was a mass growing on her neck. There were also rashes on her face and arms. Edema was also seen on her face. The patient also experienced drying of the mouth, sticky saliva, muscle weakness and joint pain. She is suffering for five days because she is waiting for her doctor on vacation. On the fifth day, Ms. Pama consulted on her physician for check up. She was confined at the Metropolitan Hospital Medical Center on November 19, 2009 for more observations and laboratories. In the hospital, she experienced insomnia for two days, vomiting, abdominal pain and frequent urination. The doctor’s primary finding was systemic viral lupus but still looking for a more objective diagnosis.

Past Health History

Ms. Pama experienced chicken pox, measles and mumps since she was 3 years old. There are no allergies noted in terms of food or things that surround her. Her childhood immunization is complete. The patient was hospitalized two times in Metropolitan Hospital Medical Center. During her first hospitalization, she undergo to splenectomy because of her immune system was weak. Her platelet started to decrease in number. After the procedure she did not go for her next check up. She taught that her disease was completely healed. Presently, it is her second hospitalization in metro with a diagnosis of lymphoma. Vitamins such as ascorbic acid and caltrate were taken regularly. Family Health History The Family has a history of hypertension and asthma. Ms. Pama does not inherited one of the disease from her parents. Her sister inherited her asthma to her mother. Social History The patient is living with her family and livin partner. She stops schooling when she was in her 1st year of college. She has difficulty in understanding the lessons because she stops too long. When in times of decision making, she can handle herself according to the situation. If she cannot handle the problem, she tries asking advice to her family and friends. When stress came, she likes to watch t.v alone. She likes to talk with their neighbors near them. The members of the family are open to share when there is a problem within the family or personal problems. They are very close to each other.

Lifestyle The patient is responsible for their household choirs. She frequently watch t.v when her households where done. On weekends, she chooses to walk going to the mall or with her friends which is near to their house. She avoids sweet foods because she is afraid to have diabetes. She eats lots of vegetables, less rice and much more on meat. Their family uncommonly eats fish. She stops her vices when she was 25 years old because it was advised by her doctor. Psychological data The patient participates well in the assessment. She is open in our conversation and gathering of all the data that I needed to her. She tries to ask me of what I am doing. She appreciates my work by saying thank you. If misunderstanding happens she tries to clarify what she doesn’t understand.

She told me that she feels sad after knowing that she cannot have her own children because of her condition. Patterns of Health Care The family seeks only for medical check up when the pain is unmanageable. She buys over the counter drugs if she experience common colds and pain. She knows who and where to run for emergency situations about the health of the family.

Review of the Systems Integumentary system: “wala naman akong allergies kahit saan” as verbalized by the client. “parang hindi nawawala ang rashes ko sa mukha at braso. Ano kaya pwede kong gawin? braso” as verbalized by the client. Respiratory system: “hindi naman ako nahihirapang huminga” as verbalized by the client. Cardiovascular system: “hindi naman naninikip ang dibdib ko ” as verbalized by the client. Musculoskeletal system: “masakit yung tiyan” as verbalized by the client. Urinary system: ”madalas akong umihi, yon lang ang napansin ko lang” as verbalized by the client. Nervous system: “makakalimutin nga ako minsan” as verbalized by the client. “ para saan ba yang gamot? Ang dami naman kasi. Kanina alas 7 nakainom na ako ulit. Mamaya ko na inumin yung gamut” as verbalized by the client. Digestive system: “parang masusuka ako pagkatapos ko uminom ng gamut. Sumakit din ang tiyan ko” as verbalized by the client. genitourinary system: “hindi na ako magkakaanak sabi sakin ng doctor bawal daw ako mag buntis dahil sa kalagayan ko” as verbalized by the client. Immune system “sabi sakin ng doctor mahina daw ang resistensya ng katawan ko” as verbalized by the client.