PROBLEM LIST

Patients Name: L.A.Y Date of Admission: December 1, 2019

Age: 15 y.o Chief Complaint: Body weakness
Room: Pedia misc. 1 ward Attending Physician: Dr. YYY

Cues Date Prioritize Problem Physiologic Behavioral

Identified Rank Focus Problem Actual Potential Actual Potential
Subjective: Fluid volume Risk for Anxiety Ineffective
The following December 1 Swelling/Edema overload infection related to coping
were verbalized 2, 2019 related to related to change in related to
by the patient: decreased chronic perceived
physiologi
cardiac recurrence severe
“ Na ga banog output of disease cal health situational
akon duwa ka status crisis.
tiil ”

“ Hindi ko mayo
ka lakat “
“ mag tikang ko
kasakit ” 2 Body weakness Activity Risk for Anxiety Risk for self-
Intolerance muscle related to care deficit
“ Gina hapo ko related to stiffness changes in related to
mag ginahwa Ineffective related to health status pain
bago ko gin health prolonged
admit “ maintenance bed rest

“ Ga panaog
dayon ang sakit
sa tiil mabalik
naman dayon
sa dughan “

“ Hindi man ko
ka giho gd kaya
ng duwa ko ka
tiil ga habok “ 3 Knowledge Deficient Risk for Noncom- Risk for
Deficit knowledge ineffective pliance powerlessne
related to health related to ss related to
new manage- insufficient insufficient
Objective: condition, ment knowledge knowledge to
- Presence of procedure, related to about manage a
edema treatment cognitive/ph regimen situation
in both lower ysical
Extremities. limitations

Vital Signs:
December 2,
2019 / 12:00pm

Temp- 36.0 C
RR- 22 cpm
BP- 120/80
mmHg
PR-96 bpm

Laboratory
Findings:
November 30,
2019 / 9:30pm

Calcium:
4.12mg/dl
(normal:4.56-
5.4mg/dl)
Potassium:4.20
mEq/L(normal:
3.3 – 4.6mEq/L
Sodium:134.60
mEq/L
(normal:135-
145mEq/L)

November 30,
2019 / 11:07pm
Hgb: 138
(normal:140-
180g/L)
Hct:0.42
(normal:0.42-
0.52g/L)
RBC:5.05
(normal:4.3-5
.9x 10^12/L)
WBC: 12.9x
10^9/L
(normal:4.5-
11.0x 10^9/L)
Segmenters:
75%
(normal:50-
70%)
Lymphocytes:15
(normal: 20-
40%)
Monocytes:10
(normal:0-6%)
Platelet:329
(normal:150-
40010^9/L)

Other Persistent
Data:

2 weeks history
of migratory
joint pain in
soles – knees –
lumbar area
back to soles
and chest pain

ODC,
persistence of
symptoms now
with different
ambulating due
to pain

IVF: D5NM
x100
02 : PRN

Medication:
 Predniso
ne 20mg
1 tab TID
 Penicillin
G
Benzathi
ne 1.7M
units IV
drip x3-
min q6