1.
HISTORY OF PAST ILLNESS
Patient X has no known allergy to any foods, medications, animals and any other
environmental agents. He stated that he does not have previous surgery and no known history of
cholera. He stated that he usually bought meals in the Carinderia near his house after his work
because no one could prepare his meals. He also stated that their water supply is from water
pump being used by the whole Barangay.
2. HISTORY OF PRESENT ILLNESS
Two days prior to admission the patient X experienced symptoms with abdominal cramps
and an intense urge to pass stool after every meal. His symptoms started to appear after eating his
dinner bought in the Carinderia and rapidly worsened with passage of stool becoming more
frequent. Within two days he was passing persistently watery diarrhea.
One day prior to admission he stated that symptoms persisted, and he experienced diarrhea
and vomiting after eating or drinking, which lasted for 48 hours.
On June 21, 2021 the patient X decided for consultation hence admitted at the hospital for
rehydration and further investigations. No conclusive diagnosis was made. Currently, patient is
passing 8-10 liquid stools per day. Diarrhea is watery. Occurs day and night.
He also complains of malaise, lethargy and anorexia. He has lost 5 kg in the past 2-3 days. Upon
examination he is thin ill looking male patient, conscious and alert, in obvious discomfort. His
weight was recorded for 48 kgs only at that time. He became bluish and weak due to loss of
water causing dehydration.
The Physician advised him for few tests (CBC+ESR, Rapid stool test to identify cholera
bacteria). Thus, confirms cholera by identifying bacteria in a stool sample. He was then admitted
for treatment and management.
Vital Signs:
Blood Pressure: 90/50mmHg
Cardiac Rate: 122bpm
Respiratory Rate: 28cpm
Temperature: 36.1 *C
3. 13 AREAS OF ASSESSMENT
I. Social Status
Patient X is a 27-year-old male, born on March 07, 1994 and currently residing in Tarlac
City he is away from his family since pandemic started because he is working as a construction
worker. According to the patient, he misses his family especially his wife because he cannot be
able to see them in almost a year, he stated that they usually talk using video call every night to
see her and their 3-year-old child he also said that he was excited be back on their hometown to
see them next month.
Upon interview, patient X is having discomfort because of his condition however he classified
himself as jolly person since we can able to joke around despite of his feelings because according
to him, he is the clown on their team or work as he usually tell funny stories, through this their
work seems to be easy, and he also stated that they treat each other as family or brothers by
sharing what they have and help each other at time of crisis.
Norms:
The ability to interact successfully with the people and within the environment of which
each person is a part, to develop and maintain intimacy with significant others, and to develop
respect and tolerance for those with different opinions and beliefs. (Fundamentals of Nursing:
Concepts, Process, and Practice, 7th Edition)
Analysis:
Patient X social status is normal despite of his condition. As he interacts successfully
with the people around him. within health care team and his environment. He also has a good
relationship with people as they maintain intimacy.
II. Mental Status
Upon assessment, Tagalog was used upon asking questions and Patient X stated that it is his
mother tongue. During the first day of hospitalization, patient is neat wearing appropriate
clothing according to the weather and was laying on his bed, appeared lethargic and anorexic.
Thin ill looking male patient, conscious and alert, in obvious discomfort.
However, he was oriented to current time and place when we asked questions like
“Nasaan po kayo ngayon?” and “Anong petsa na po?’ he answered it right and responded “Nasa
hospital ako” on place and “June 21,2021 na” on the date. We asked him to read a sentence on
the newspaper and he read it correctly.
Norms:
The patient should appear relaxed with the appropriate amount of concern with the
assessment. The patient should exhibit erect posture, smooth gait and symmetrical body
movement. The patient should be clean and well-groomed and should wear appropriate for age,
weather, and socioeconomic status. Facial should be appropriate to the content of the
conversation and should be symmetrical. The patient should produce spontaneous and coherent
speech. Content of the message should match the patient’s educational level. The patient should
be correctly responding to questions and to identify all the objects as requested. The patient
should demonstrate a realistic awareness and understanding of self. The patient should be able to
evaluate and act appropriately in situations requiring judgment. Thought process should be
logical, coherent, and goal oriented. Thought content should be based on reality. (Health
Assessment and Physical Examination, 3rd Edition)
Analysis:
During the first day of hospitalization, the patient is conscious and alert however he
appeared weak, and observable discomfort since he has diarrhea. He was responsive can
maintain spontaneous flow of the interview with good eye contact, produced spontaneous and
coherent speech as he responded correctly and directly to answer questions. He also acts and
thinks according to his age matches his educational level as high school graduate.
