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  II. Assessment  A. Biographical Profile Name: AbBa  Address: Swa-on, Kapalong Davao Del Norte  Age: 53 years old Date of Birth: January 01, 1960 Date of Place: Kapalong, Davao Del Norte Gender: Male Status: Single Nationality: Filipino Religion: Roman Catholic Date of Admission: June 24, 2013 Time of Admission: 6:30 pm Initial Diagnosis: Acute Appendicitis Final Diagnosis: Acute Appendicitis  Attending Physician: Dr. Kharidz B. Macasayan, MD. B. CHIEF COMPLAINT Right Lower Quadrant Pain C. HISTORY OF PRESENT ILLNESS Several days prior to admission the patient experienced an abdominal pain at the right lower quadrant. These prompted her to seek medical advice, thus confined in Davao Regional Hospital last June 24, 2013 with the admitting diagnosis of Acute   Appendicitis under the service of Dr. Kharidz B. Macasayon, MD. Her medications were Cefoxitin, Metronidazol. Paracetamol, Tramadol and Ranitidine. D. PAST MEDICAL AND NURSING HISTORY The patient was born on January 01, 1960. He was delivered full term through Normal Vagina Spontaneous Delivery. The patient was completely immunized. He was never admitted to a hospital but he experienced common illness such as cough and colds. She occasionally drinks liquors and used cigarettes. Her usual diet includes food that are He prefers meat products in her meal than leafy vegetables. E. PERSONAL, FAMILY AND SOCIO-ECONOMIC HISTORY Personal History: Smoker (√  )  Alcohol drinker ( √  ) Family History Smoker (√ ) Father„s side   Alcohol Drinker (√ ) Mother‟s and Father‟s side   Asthma (×) Hypertension ( √)  Mother side DM ( √  )Father side Malignancy (×) Tuberculosis ( √  )Grand-grandmother side× Heart problem (×) Social History High School Level   Smoker, alcoholic drinker for 20 years Socialized with other people Urban Residence F. PATIENT NEED ASSESSMENT (Based on Maslow, Henderson, Abdellah, Gordon, and Growth Development Theories) II. Assessment    PHYSICAL ASSESSMENT General Survey Received lying on bed conscious, responsive and coherent. Fairly groomed. With clean and intact top dressing at right lower quadrant. With IVF #4 PNSS 1L infusing well at the right dorsal metacarpal vein regulated at 30 gtts/min. On NPO. Capillary refill of 2 sec. Genearal Appearance at First Sight Received sitting on bed awake, responsive and coherent. With an IVF # 3 D5LR 1L infusing well at the right dorsal metacarpal vein regulated at 80 cc/ . Patient has a mesomorphic type of body built and weighs 54.5 kilograms and stands 5‟4” tall. The patient was certainly oriented to time, place and persons. She was able to deal with her emotions appropriately as the interview went on. Wearing a cotton T-shirt and jogging pants, patient looked neat and tidy..  Vital Signs Date Shift Time CR PR RR BP Temp. 06-26-13 7-3 8:00am 89 88 18 129/83 37.4 12:00pm 90 92 19 130/80 37.0 Skin   Brown skin generally uniform in color in areas except in areas exposed in the sun   No jaundice   Normal capillary refill time 2sec. Head   No head and scalp lessions   Symmetric facial features and movements   Symmetric nasolabial folds   Evenly distributed black hair   No infestations Eyes   Eyebrows symmetrical with equal movement   Eyelashes equally distributed and curled slightly outward   Skin of eyelids intact with no discoloration   Eyelids close symmetrically   Bilateral blinking exhibited   No discharges   Slightly in pale palpebral conjunctiva
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