1. West Visayas State University
COLLEGE OF NURSING
La Paz, Iloilo City
ISLET MY GUARD
DOWN
A Grand Case
Presentation By:
BSN I-A
Date Presented: May 20, 2013

2. VITAL INFORMATION
 Name: F. P. III
 Age: 21 years old
 Sex: Male
 Address: Turko St., San Jose, Antique
 Civil Status: Single
 Date and Time admitted: May 4, 2013 ;
10:00am
 Chief complaint: “Sakit akon sulok-sulok” as
verbalized

3.  Ward: Male Surgical Service Ward
 Bed No.: Bed No. 9
 Allergies: Alcohol (brandy)
 Religious Affiliation: Seventh Day Adventist
 Physician’s Initial: Dr. F
 Impression/Diagnosis: Pancreatic Pseudo
Cyst
 Date of Interview: May 15, 2013

4.  Informant: Patient himself
 Relationship to patient: N/A

5. A. Usual Health Status
According to F.P. III, he claimed that
he has many vices which include drinking
of alcoholic drinks and smoking. He
usually plays online games from 4:00 PM
-7:00 AM and skips much of his meals.

6. A. Usual Health Status
After playing games, he used to
drink with his friends with an empty
stomach. He drinks one to two cases of
“Red Horse” occasionally. He can
consume one pack of cigarette each day
and making it as his daily habit.

7. B. Chronologic Story
A month prior to confinement, he suffered
from abdominal pain. He made a consultation at
Delegate Angel Salazar Memorial Hospital in
Antique and the doctor gave him a Tramadol as
pain reliever. The symptoms were gradual.

8. B. Chronologic Story
Three weeks prior to confinement, the
pain was felt by the patient again. F.P. III noted
that he felt the pain 4 hours being the longest
and 10 minutes being the shortest. He also said
that every time he felt the pain, “Gastuck –up
ako.”
Day of confinement, May 4, 2013 around
10:00 AM, F.P. III felt again the pain on his
Epigastric Region with the scale of 9/10.

9. C. Relevant Family History
F.P III’s grandfather in both mother and
father side suffered from liver cirrhosis.
D. Disability Assessment
F.P III cannot lie down related to pain felt
in the Epigastric and right lumbar region.
Other problems interfered such as: limited
mobility, difficulty in facilitating sleep and
changes in Activities of Daily Living (ADL).

10. 2. Past Health Problems/Status
A. Childhood Illness
F.P III had dengue when he was 5 years
old and admitted for more than a week.
B. Immunization
Complete immunizations such as BCG as
evidenced by a mark on his right arm, Polio,
Measles and Hepa as claimed by F.P III but
cannot recall specific dates.
C. Allergies
F.P III is allergic to brandy with an
immediate chest pain reaction and rashes.

11. 2. Past Health Problems/Status
D. Accidents and Injuries
April 2013, he met a motorcycle accident and
injured his left and right elbows, and his left and
right legs.
E. Hospitalization for serious Illnesses
“Sang nagligad nga tuig (2012),
ginpasuyupan man ang Kidney ko kag last week
lang before ako gid maadmit ginpasuyupan man
ang baga ko” at Saint Paul’s, Iloilo which was a
serious illness that needs for hospitalization.
F. Medications
F.P III has been taking Omeprazole 20 mg od
for almost a month as his maintenance.

12. 3. Family History of Illness
Both paternal and maternal side’s
grandfather has alcoholism.

13. 4. Patient’s Expectations
“Maayo eh, kag bal.an ko buligan ako
sang mga nurse paagi sa ila pagtatap”, as
verbalized by the patient of what he expects
during hospitalization and with regards to
nursing care.

14. Patterns of Functioning
 Breathing Patterns
Respiratory problems: Chest pain associated with
drinking of Brandy
Usual remedy: Ignores pain until it
subsides
Manner of breathing: Normal breathing except
during chest pain

15. Patterns of Functioning
 Circulation
Usual Blood Pressure: 110/80-120/90 mmHg
Chest pain is felt after drinking alcohol
(Brandy), no history of palpitations,
coldness of extremities, etc.

16. Patterns of Functioning
 Sleep Patterns
Usual Bedtime: 9:00-9:30 A.M (F.P does not
sleep at night because he
plays LOL – League of Legends
(computer game)
Number of Pillows: 4 (1 pillow- head, 2
pillows- sides, 1 pillow-feet)
Bedtime Rituals: None
Problems regarding
sleep: None
Usual Remedy: N/A

17. Patterns of Functioning
 Drinking patterns
WATER: 700-1000ml
COFFEE: 500-900ml
BEER: 6000-7500ml
Total fluid intake
in 24 hours: 7200-9400 ml

18. Patterns of Functioning
Eating Patterns
Usual Food Taken Time
Breakfast 2 cups of rice & fish 7:00-8:00 A.M
Lunch 2 cups of rice & utan 4:00-5:00 P.M
Dinner 2 cups of rice &
“sinabawan na manok”
7:00-8:00 P.M
Snacks 3 pandesal 2:00-3:00 A.M
Food likes: “Biskan ano lang nga pwede makaon”
Food dislikes: “Pinaksiwan nga isda”

19. Patterns of Functioning
 Elimination Patterns
Bowel Movements
Frequency: 2-3 times a day
Problems or Difficulties: none
Usual Remedy: none

20. Patterns of Functioning
Urination
Frequency: 8 -10 times a day
Problems: none
Usual remedy: none

21. Patterns of Functioning
Exercise:
F.P doesn’t exercise regularly. He plays
volleyball occasionally which he considers as a
form of exercise.
Personal Hygiene
1. Bath
Type: Full body bath
Frequency: Once a day
Time of Day: 7:00 pm

22. Patterns of Functioning
2. Oral care
Frequency: Every after meal
Care of Dentures: Brushes the
dentures
3. Shaving
Frequency: Once a month
4. Cosmetics
Use of Cosmetics: Face Powder and
Facial Wash

23. Patterns of Functioning
Recreation:
F.P plays computer games everyday. He also
plays volley ball when he feels like it.
Health Supervision:
F.P has no medical & dental check up. He
only goes for check up if needed.

24. Clinical Inspection
Date and Time taken: May 15, 2013 ; 10:05
am
Temperature: 36.6º C/axilla
Pulse Rate: 71 beats/min
Respiratory rate: 20 breaths/min
Blood pressure: 110/80 mmHg
Height: 162cm
Weight: 42kg

25. Physical Assessme

26. General Appearance
 Appears older than stated age;
body built(ectomorph), height and
weight appears appropriate to his
age; demonstrate appropriate facial
expression, have coordinated body
movements, responds accordingly;
appears clean with no offensive body
and breath odor; no obvious signs of
illness.

27. Integumentary System
 Hair:
Black, thick, fine, oily, evenly distributed,
dandruff,scar at right frontal area about 0.1 cm.
 Nails:
Translucent, rounded no clubbing, smooth,
pink, black pigmentation in longitudinal streaks;
intact epidermis; Capillary refill is at 2 sec.

28. Integumentary System
 Skin:
Brown complexion, moist, warm and good
skin turgor; generally uniform except in sun
exposed areas; no presence of edema; Scar at left
and right elbow, at Right lateral area, and left and
right knee; localized acne at the back, keloid at
right inguinal area, scratch at left leg and Warts or
“kalonggo” at right knee; moisture in skin folds and
the axillae.

29. Neuro-Sensory System
 EYES:
Eyebrows: intact, evenly distributed,
aligned symmetrically; eyelashes: evenly
distributed and curled slightly outward; eyelids:
intact and close symmetrically; bulbar
conjunctiva: transparent, with no lesions; sclera:
white; palpebral conjunctiva: pink, shiny and
smooth; no edema or tearing in the lacrimal
apparatus; cornea: transparent, smooth and
shiny, PERRLA.

30.  EARS:
Auricles: symmetrical, aligned with the
outer canthus of the eye, has a color that is the
same as the facial skin color, firm, non-tender,
and recoils after it is folded; presence of wet
cerumen is noted in the external ear canal.

31. CRANIA
L NERVE
NAME NORMAL
FINDINGS
FINDINGS
I
Olfactory -must be able to
recognize common
odors
-able to identify the
aroma of coffee
bilaterally.
II
Optic -able to read the
student’s nameplate 2
feet away; able to see
objects in periphery
when looking straight
ahead
-able to read the words
on the nameplate at a
distance of about 2 feet;
able to see the objects in
periphery when looking
straight ahead.
CRANIAL NERVES:

32. III
Oculomotor -both eyes
coordinated, move
in unison, with
parallel alignment;
-direct and
consensual
reactions to light;
-light falls
symmetrically on
both pupils;
-uncovered eye
does not move;
- Pupils constrict
when looking at
near object; pupils
dilate when looking
at far
object
-both eyes moved in unison,
with coordinated
movements and parallel to
each other;
-illuminated pupils
constrict(direct), non-
illuminated pupils
constrict(consensual);
-light fell symmetrically on
both pupils;
-uncovered eye did not
move;
-pupils constrict when
looking at near objects and
dilate when looking at
distant objects.

33. V
Trigeminal -able to blink when the
cornea is touched by a
wisp of cotton;
-able to feel the wisp
of cotton touching the
face
-blinked when the
cornea was touched;
-able to identify when
the face is touched by a
wisp of cotton
VI
Abducens -able to move in the
six cardinal fields of
gaze
-eyes was able to move
in unison in six cardinal
fields of gaze
VII
Facial -symmetric facial
movements
-able to identify
common tastes
-able to raise the
eyebrows, lower the
eyebrows, close eyes,
open eyes, smile, show
teeth, frown and puff
cheeks;
-able to identify sweet
taste

34. VIII
Vestibulocochl
ear
-able to hear ticking
in both ears
-able to repeat the
words whispered in
both ears;
-slight swaying
(negative Romberg)
-sound is heard in
both ears(Weber
negative)
-Air conducted
hearing is greater
than bone conducted
hearing; AC>BC
-able to hear ticking
watch
-able to repeat the
words whispered in
each ear;
-negative Romberg-
client swayed slightly
but maintained upright
posture;
– sound was heard in
both ears
-Air conduction is
greater than bone
conduction

35. IX
Glossopharyn
geal
-gag reflex is
present
-rising of soft palate
while uvula hangs
freely
-must be able to
swallow
-positive gag reflex;
-soft palate rises, uvula
hangs freely;
- able to swallow
X
Vagus -gagging
- rising of soft palate
while uvula hangs
freely
-must be able to
swallow
-present gag reflex;
-rising of soft palate
noted, uvula hangs
freely;
-able to swallow
XI
Accessory -must be able to
shrug shoulders
despite the
downward
resistance, and
-able to shrug shoulders
with resistance, able to
move the head from side
to side with resistance

36. XII
Hypoglossal -must be able to move
the tongue freely; able
to resist the pressure
exerted by tongue
depressor or gloved
hand
-able to move the
tongue from side to side
with resistance

37.  Mental Status
Speech and language appropriate to
situation; patient oriented to time, place and
person; able to remember recent and remote
memories; able to calculate simple problems and
able to think abstractly (Aanhin pa ang damo kung
patay na ang kabayo?).
 Motor Function
Smooth, well-balanced gait with symmetric
arm swing; slight swaying on Romberg’s test was
observed; able to touch nose with alternating index
fingers; able to pronate and supinate forearms in a
rapid pace; able to slide heel down to opposite shin
in heel-to-shin test.

38.  Sensory Function included in CN
Able to identify light touch sensation when
different body parts are touch by wisp of cotton;
able to differentiate sharp from dull sensation; able
to differentiate warm from cold sensation; able to
detect vibrations using tuning fork; with close eyes
patient was able to identify a coin (stereognosis),
numbers written on his palm (graphesthesia), part
of the body being touch (topognosis).
 SENSES:
Able to identify taste of sugar and smell of coffee.

39. Reflexes:
• Biceps
- Present, graded as 1+
• Triceps
- Present, grades as 1+
• Brachioradialis
- Present, graded as 1+
• Patellar
- Present, graded as 2+
• Achilles
- Present, graded as 1+

40. Respiratory System
Nose: midline, symmetric, no discharge or
flaring, uniform in color, non-tender with no lesions;
Nasal Septum: midline, straight and intact, no
deformity or skin lesions, nares: patent; Nasal
Mucosa: intact, smooth, pink, no lesions, masses or
cyst seen; Trachea: midline; Sinuses: nontender, no
inflammation noted, intact, no discharge.

41. Respiratory System
 Posterior Thorax:
1:2 ratio of anteroposterior diameter
respectively, chest symmetric, spine vertically
aligned; spinal column is straight; Skin with
localized acne, intact, uniform temperature; no
tenderness or masses felt; breathing is effortless,
relaxed and unlabored, bilaterally symmetrical
chest expansion with symmetrical tactile fremitus;
resonant sound heard over lung area upon
percussion; vesicular and bronchovesicular sounds
with no adventitious sound heard over the area;

42. Respiratory System
 Anterior Thorax
Respiratory Rate: 20 breaths/minute,
Breathing: quiet, rhythmic and effortless
respirations; full symmetric excursion; bilaterally
symmetrical of vocal fremitus except heart and
breast tissue which is decreased; resonant sound
heard over lung area, dull on the areas of the heart
upon percussion. Bronchial, bronchovesicular and
vesicular sounds auscultated(specify location).

43. Cardiovascular System
 No pulsations felt on aortic, pulmonic, and
tricuspid areas, pulsation is felt on the apical
area, no presence of lifts or heaves; S1 and S2
heard in all areas; Aortic and pulmonic heart
sounds (S2 > S1); Tricuspid and Apical Areas (S1
> S2); no bruits auscultated. Heart rate is 52
beats/minute in regular rhythm.

44. Gastro-intestinal System
Lips: (check the color), dry, rough in texture and
symmetric in terms of contour; Buccal mucosa: pink,
soft, moist and smooth; intact dentures in the upper
central incisors; Dental Caries present in the right and
left lower and upper molars and in the right lower
second premolar; Gums: pink, no sign of retraction or
pulling away of the teeth; Tongue: midline, pink, smooth,
moist, with papillae at ventral surface, moves freely, no
palpable nodules, non-tender and no lesions noted;
Salivary ducts: pink, no swelling and redness noted.
Soft palate: pink and smooth; hard palate: pale pink and
irregular in texture; Uvula: midline, rises symmetrically
as the client says “ah”; Oropharynx: pink, smooth, no
inflammation, edema or lesions noted; Tonsils: graded
one, pink and smooth in texture without any discharges
or swelling noted; Able to swallow and positive to gag
reflex.

45. Gastro-intestinal System
Abdomen: unblemished skin, uniform in color,
flat; umbilicus located in the center, symmetric
movement cause by respiration, bowel sound are
absent, dull sound is heard upon percussion, the
liver and spleen in the LUQ and RUQ are normal in
size, No tenderness upon palpations.

46. Genito-urinary System
 Urethral meatus: pink and located at center tip;
circumcised; Urethra: soft and non-tender, no
discharges noted; Urinary bladder, Pubic hair is
black, fine, curly, and triangular in shape; Urine
color amber.

47. Reproductive System
 Penile skin is intact, light brown in color, no
lesions, nodules, swellings, or inflammation;
Scrotal skin is dark brown, left is descended than
right Testicles are smooth, free of nodules or
masses; Epididymis tender, resilient; Spermatic
cord firm. Urine color amber yellow.

48. Endocrine System
 Able to identify between hot and cold, no
excessive sweating, height and body size
appropriate for age, thyroid is not visible, non-
palpable and no tenderness, hair evenly
distributed.

49. Musculoskeletal System
 Able to stand erect, has smooth, coordinated
movements upon performing active ROM; able to
maintain balance while standing in right foot only
with eyes closed and vice versa for 5 seconds;
Muscle strength: 5/5; steady gait upon walking
with opposing arm swing, able to maintain upright
posture and foot stance; able to maintain heel-to-
toe walking along straight line; no tenderness or
swelling noted upon palpation of bones and
joints.

50. Lymphatic System
 Lymph nodes non-palpable, no nodules, masses
or depressions, no pain felt upon palpation.
Hematopoietic System
• no bruises, no lesions, blood able to return in
normal circulation. (Lab Results, CBC,
Components of Blood)