HISTORY OF PRESENT ILLNESS

3 months prior to admission, patient experienced sudden twitching pain in his stomach
with a pain scale of 7/10. He felt as if he was bloated and has difficulty of breathing. Symptoms
persist for 3 weeks interval until pain is un-tolerable. No medication taken, he only waited for the
pain to subside. No consultation was done.

2 months prior to admission, patient went to Aurora to go to an Albularyo, thinking it

may be cured but pain in his stomach and difficulty of breathing persist. He couldn’t walk, only
for a short distance and now using accessory muscles just to breathe. Patient stated that the
longer the symptoms persist, the little air he breaths. Therefore, went to consult at Amang
Rodriguez but doctor claimed it is only an Asthma, only gave him medications such as inhaler
and nebulizer prescribed for 7 days. He doesn’t remember the other medication given. No
laboratory tests was done. After taking the medications for only 3 days due to symptoms persist,
he stopped the medication.

1 month prior to admission, patient again experienced difficulty of breathing and stomach
pain with a pain scale of 9/10. He couldn’t do his activities of daily living such as cleaning the
house, difficulty eating, and walking. He was then brought to QMMC for consultation. Patient
then took tests such as X-ray, CT scan and Ultrasound and he was diagnosed for Pleural Effusion
secondary to Lung Adenocarcinoma. He was subjected to undergone surgery for Thoracentesis
and was transferred at Medicine Ward for 14 days. When discharged, he was then referred to
Lung Center for better treatment.

1 week prior to admission, patient went to Lung Center for referral and undergone several
tests such as CT scan, X-ray, and Sputum Culture, he couldn’t remember the other tests they did
to him and ended up with the same diagnosis, but he was not accepted due to CTT that needs to
be removed first and there was clogged in the tube.

1 day prior to admission, patient experienced pain in the insertion site with a pain scale of
9/10 and has difficulty breathing. Patient stated that there was no fluid draining in the J.P drain
and he easily gets tired and couldn’t even lie down to bed. He was then brought to QMMC and
was admitted at ER around 6:30pm. Patient stayed in the ER for 3 days for the inspection and
surgery of the CTT due to the clogged tube because of small particles, they decided to make the
insertion site bigger and changed the tube to a bigger one which caused the patient to be in so
much pain. He was then transferred and admitted to Medicine Ward.

PAST MEDICAL HISTORY

Patient stated that last 2011, he had Hypertension. 200/120 mmHg. When a Doctor check up on
him, he was given a maintenance of Atenolol 100mg.
FAMILY HISTORY
 Patient stated in his mother side they don’t have any history of Heart Disease,
Hypertension, or Diabetes. While in his father side they have a history of Hypertension.

SOCIAL HISTORY
 Patient stated that when he was 15 y/o he started smoking and drinking alcohol everyday
with his friends. He can finish one pack of cigarette in just one day.
 He drinks alcohol every night with his friends until morning but he couldn’t remember
how much bottle they can finish when they started drinking.
 He also stated that while drinking he also smoke because it feels good and makes you not
get drunk easily.
 He stopped smoking when he was 30 y/o because he started to have a family. But he
couldn’t stop drinking alcohol, it just became lesser than before. He now only drink
alcohol occasionally.

ENVIRONMENTAL HISTORY
 Patient stated that 20 y/o he tried to go to manila to look for a job. When he saw that a
small company was looking for an electrician and a helper, he tried to apply. Good
enough he was accepted and learned things about being an electrician, because he only
graduated in high school he was not accepted in large companies due to being failed in
written examinations.
 He also worked part-time as a construction worker. He learned how to be a welder,
painter and to be a laborer, because of his diligence he continued to work in a small
company until he was 58 years old. Due to being a construction worker he was exposed
to so much chemicals that’s being used in constructions.
 Patient stated that they don’t use protective equipment while working, because it is
irritable and hard for them to work properly. So they are used to different kinds of smell.
They only use protective equipment when the safety officer visits them.
 He even stated that he worked in renovating an old house and an old school, so he was
exposed to asbestos without wearing any mask or any other protective equipment which
lasted for two months.
 REVIEW OF SYSTEMS
I. GENERAL
 Patient stated that he feels weak and in pain due to the laceration in his CTT.
 Patient stated that he has difficulty sleeping due to the environment.
 Patient stated that he doesn’t like the food in the hospital because it has no
taste. Therefore, he had weight loss.
 Patient stated he doesn’t feel any itchiness on his body, no fever or chills and
no excessive sweating.
II. MUSCULOSKELETAL
 Patient stated he has difficulty when trying to stand up.
 Patient stated he has no swelling or any deformity. There is a slight restricted
motion, he couldn’t sleep on his both sides because of the pain he feels with
his CTT.
III. HEAD AND NECK
 Patient stated he don’t feel any dizziness or lightheadedness.
 Patient stated he has a slight burred vision due to his old age and needs
glasses.
 Patient stated he has no sensitivity to light, no pain or any discharges in his
eyes
 Patient stated he has no hearing loss, no pain felt in his ears and no discharges.
 Patient stated he has no changes in his sense of smell, no pain felt in his
sinuses and no post nasal discharges. There was a slight watery discharge but
no obstruction.
 Patient stated he has a slight hoarseness of voice due to slight cough he has
but no soreness of tongue, and buccal mucosa. He also stated that he has no
sore throat or any bleeding of gums.
IV. CHEST AND LUNGS
 Patient stated he has a slight dry cough and a white, sticky sputum. He has a
little difficulty of breathing due to the water in his lungs and has fast breaths.
V. HEART AND BLOOD VESSEL
 Patient stated he has no chest pain but has elevated blood pressure.
VI. GASTROINTESTINAL
 Patient stated that his appetite is poor but still tries to eat his food. He also has
abdominal pain due to CTT tube.
 Patient stated he doesn’t feel nausea or feels constipated.
VII. GENITOURINARY
 Patient stated he has no flank pain or pain when urinating. Has deep amber
color of urine.
VIII. ENDOCRINE

 Patient stated he has low heat intolerance because of the environment and has
no pain on his private part when urinating.
 PHYSICAL ASSESSMENT
Received patient conscious, lying on bed with a PNSS IV of 650ml remaining inserted on
the right anteroposterior of the hand. He appears alert, coherent and is well-oriented.

GENERAL:

LEVEL OF  Conscious and cooperative, oriented to time, place and

CONSCIOUSNESS & person
ORIENTATION:
SKIN COLOR:  Brownish in color

DRESS, GROOMING  Appropriately dressed, wearing t-shirt and short. No

AND PERSONAL hospital gown available. He is well-groomed.
HYGIENE:
FACIAL  Facial grimace
EXPRESSION:
ODOR  No body odor but has a mouth odor.
(BODY/BREATH):
BODY BUILT:  Medium frame body built

POSTURE:  Slight stooped in posture

GAIT:  Can walk but with assistance

OBVIOUS PHYSICAL  No obvious deformity and bone injuries

DEFORMITY:
VITAL SIGNS:  Blood Pressure: 140/90mmHg
 Temperature: 36.0 C
 Pulse Rate: 94bpm
 Respiratory Rate: 22cpm
 Pain scale: 7/10
LANGUAGE &  He uses simple and Tagalog word.
COMMUNICATION:

SKIN:

COLOR:  Brownish in color.

MOISTURE:  It is soft to touch.

 TEMPERATURE:  Cold to touch.

TEXTURE:  Has smooth texture.

TURGOR:  Skin easily returned with less than 3 seconds when

pinched.
LESIONS:  No presence of lesions.

HAIR  Hair is evenly distributed and is thick.

DISTRIBUTION:

NAILS:

COLOR:  Pinkish in color.

SHAPE:  Convex in shape.

CAPILLARY REFILL:  Capillary refill less than 3 seconds.

HEAD:

SKULL:  Proportionate to body size, no head injury or trauma.

SCALP:  No lesions or lumps palpated. No dandruff present.

FACE:  Symmetrical in shape, easy movement.

HAIR CONDITION:  It is evenly distributed. Black colored with some white hair
colored scattered all over the hair.

EYES:

POSITION &  Eyes are symmetrically in shape.

ALIGNMENT OF
EYES:
EYEBROWS:  Eyebrows are thin and evenly distributed.

EYELASHES:  Black and evenly distributed.

EYELIDS:  Normal and symmetrical.

 CONJUNCTIVA:  Slight pallor

SCLERA & IRIS:  Sclera appears white.

 Iris is dark brown in color and is equally round with no
abnormalities.
PUPILS:  Black and symmetrical in shape.

FIELD OF VISION:  Slight blurring of vision due to aging.

EARS:

AURICLE:  Normal racial tone

 Symmetrical in shape
 Elastic
PINNA:  Recoils when folded

EXTERNAL CANAL:  Some cerumen can be seen

 No abnormal discharge
HEARING ACUITY:  Patient can respond to normal voice.

NOSE:

NOSE:  Located at the mid portion of the face.

 Nostril is symmetrical.
INTERNAL NARES:  Both patent, nasal cavity is moist.
 Has some watery discharge.
PALPATE FRONTAL  No palpable mass.
SINUS:  No pain felt by the patient.
MAXILLARY  No palpable mass or nodules.
SINUSES:  No pain felt by the patient.

MOUTH:

LIPS:  Dry lips, pale in color.

ORAL MUCOSA:  Appears moist and pink.

 GUMS:  Pink and moist.
 No bleeding present.
TEETH:  Teeth are incomplete, with presence of decay on the front
teeth.
TONGUE:  Symmetrical, pink and moist.
 Able to move from side to side.
TONSILS:  Pink, symmetrical and normal-size tonsils of +1.

VOICE:  Clear voice.

NECK:

NECK:  Proportional to the size of the head and is symmetrical.

 No visible lumps or mass.
 No jugular venous distension
RANGE OF MOTION:  Able to flex and extend neck and move it laterally (left and
right)
THYROID GLAND:  No palpable thyroid gland.

NECK LYMPH  No palpable lymph nodes.

NODES:

HEART:

INSPECTION:  No visible pulsations, masses or lumps and no lesions

present
 Both sides are symmetrical.
PALPATE:  No palpable masses, heaves, lifts or thrills.

AUSCULTATE:  No presence of murmurs or bruit and no extra heart sound

heard.

ABDOMEN:

INSPECTION:  Slight distended

 No presence of scars, striae or veins.
 Umbilicus is located in midline. No hernia or
inflammation.
 It is symmetrical on both sides.
  No visible peristaltic waves or pulsations and no visible
enlarged organs.
AUSCULTATE:  No bruits, or friction rub heard.

PERCUSSION:  Dull sound heard on the right upper and lower quadrant of
the abdomen.
 Tympanic sound heard on the left upper and lower
quadrant of the abdomen.
PALPATE:  No palpable mass or tenderness and no enlarged organ.

UPPER EXTREMITIES:

LEFT UPPER AND  No lesions or any deformity.

LOWER ARM:
RIGHT UPPER AND  No lesions or any deformity.
LOWER ARM:
HANDS:  Both hands have a complete and normal number of fingers
 No lesions or any deformity.
 Nail beds are pinkish in color.
 Capillary refill less than 3 seconds
 IV on the right anteroposterior of the hand.
RANGE OF MOTION/  Muscle strength grading:
MUSCLE 4- full range of motion, some resistance
STRENGTH:

LOWER EXTREMITIES:

LEFT LOWER  No lesions or bruises and edema present.

EXTREMITY:
RIGHT LOWER  No lesions or bruises and edema present.
EXTREMITY:
RANGE OF MOTION/  Muscle strength grading:
MUSCLE 4- full range of motion, some resistance
STRENGTH: