A. Biographical Data

A.
Biographical Data
Name: DRA Age: 21 Gender: Female
Ward/Unit: Room #:
Home Address: 67-3Jacinto Street, Davao City.
Birthdate: 10/29/1999 Birthplace: Davao City Nationality: Filipino
Marital Status: Single Educational Level: 3rd year college (present)
Occupation: Student Religion: Roman Catholic
B. Admission History
Chief Complaint: Fever
Admitting Diagnosis: -
Date & Time of Admission:
Manner of Admission:
Ward/Room #:
Attending Physician: Dr. Lui
C. History of Present Illness
Patient is a diagnosed case of embryonal rhabdomyosarcoma currently

undergoing chemotherapy since February 2018. 2 days prior to admission
while on the 10th session of chemotherapy. Patient developed abdominal
pain and abdominal distention. Persistence of symptoms prompted the
patient to seek consultation hence admission.
Medication
D. Past Health History

Patient was admitted due to dengue fever way back 11 years ago.
Childhood immunizations completed. Patient does not use tobacco,
alcohol or any illicit drugs.
Social History
Patient is the eldest and has one sibling, and lives together with her family.
Living with their own house. Parents reported in good health condition. But
currently shes living with her sister because her parents are working
abroad.
E. Family Health History
Patient maternal side which her grandmother has diabetes mellitus and
her grandfather has prostate cancer. The paternal side/family is with
hypertension. Patient paternal, grandmother died due to tuberculosis and
grandfather died of hypertension.
F. Gordon’s Functional Health Patterns
I. HEALTH PERCEPTION
The patient
II. NUTRITIONAL-METABOLIC PATTERN
III. ELIMINATION PATTERN
IV. ACTIVITY-EXERCISE PATTERN

V. SLEEP-REST PATTERN
The patient’s chief complaint was abdominal pain with the scale of 5/10
therefore, it affects his sleep-rest pattern. However, in August 24, 2019
the abdominal pain stopped therefore he can sleep and rest well and
there was no problem at all.
VI. COGNITIVE-PERCEPTUAL PATTERN
Has no hearing and visual difficulty. The patient has no memory changes
lately. Decision making became dependent upon the doctors’ orders but
becomes irritable at everything when in pain. Father verbalized, “kung
nay gusto, dapat masunod”.
VII. SELF-PERCEPTION – SELF-CONCEPT PATTERN
The patient’s perception of recovery is when the pain is no longer felt

according to his father, though patient’s point of view is not known.
Excessive weight loss limited the patient’s movements and activities.
Patient is aware of his health progress. Since the illness, irritability
became frequent and patient became more silent and very dependent on
his father. Repetition of things that have already been said annoys the
patient. Loses hope at times, especially when in pain. Patient verbalizes
“unsa man ning nahitabo sa akua uy. Murag wala na man ko’y pag-asa”
according to the father.
VIII. ROLES-RELATIONSHIP PATTERN
There are three (3) people living together with the patient: father, mother,
and grandmother (father’s mother).
Patient’s current illness is the most difficult challenge the whole family is
handling, including finance. Extended family members are notably
supportive of the patient. The patient is close to his junior high school
friends, but was not able to see and catch up with them since December
of last year. Plays video games as pastime.
IX. SEXUALITY-REPRODUCTIVE PATTERN
Not done.
X. COPING-STRESS TOLERANCE PATTERN
The patient’s father verbalized “daghan kaayog changes” in their lives

since the onset of the patient’s illness. The family worries for the patient’s
condition as it is “life-threatening”. Highly relies on parents, but more on
his father for he is the one usually assisting the patient such as moving
from bed to chair. Without pain, the patient looks chill and relaxed but
frequently complains and irritable when experiencing pain. Intakes
medications prescribed by the doctors.
XI. VALUES-BELIEFS PATTERN
The patient’s parents gives everything the patient wants.
Rather than religion, it is the faith that is important. The family constantly
prays, though the illness interferes with the worship by not being able to
go to church.
The family is hoping for the patient to be able to go back to normal and be
able to eat well. “It’s all in God’s plan” according to the patient’s father.
G. Physical Assessment
General Survey
Body built is ectomorph, level of consciousness is alert, verbal response is

oriented. The client is well groomed and oriented, mood is appropriate.
Skin
Skin’s color is uniform, texture is smooth, skin turgor is good, temperature

is cool and the skin is dry. Nails are well trimmed.
Head
Configuration is normocephalic, the fontanelles are closed and the skull is
symmetrical. The scalp is clean and the hair distribution normally
distributed. Face has a symmetrical movements.
Eyes
The eyebrows are aligned and have symmetrical movements. The lids are
also symmetrical. Lashes are curled outward. Lacrimal ducts are normal.
The cornea and lens are smooth and clear. The conjunctiva is pinkish.
Sclera is anicteric. Pupils are isochoric and reacts to light briskly. Reacts
to accommodation uniformly. EOMs are normal. Convergence is normal.
Visual acuity is normal.
Ears
The pinna are symmetrical. External canal has no discharge. Hearing

acuity is normal.
Nose
The nasolabial fold are symmetrical. Septum is on the midline. Mucosa is

pinkish. No discharges present. Both sides are patent and sinuses are
non-tender.
Mouth
The lips are symmetrical, pale, and dry. The tongue is on the midline.
Teeth are complete. Gums are pinkish. Mucosa is pinkish. Palate is
pinkish.
Thorax
The shape is symmetrical, spinal alignment is normal. Breathing pattern is

effortless with a good chest skin turgor.
Heart
The aortic, pulmonic, tricuspid and apical pulse has a distinct sound.
Carotid pulse is strong, apical pulse is regular, brachial pulse is weak
and radial pulse is strong.
H. Conclusion
The patient

A. Biographical Data

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A. Biographical Data

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A.

Name: DRA Age: 21 Gender: Female

Home Address: 67-3Jacinto Street, Davao City.

Birthdate: 10/29/1999 Birthplace: Davao City Nationality: Filipino

Marital Status: Single Educational Level: 3rd year college (present)

Occupation: Student Religion: Roman Catholic

Chief Complaint: Fever

Date & Time of Admission:

Attending Physician: Dr. Lui

C. History of Present Illness

Patient is a diagnosed case of embryonal rhabdomyosarcoma currently

D. Past Health History

E. Family Health History

F. Gordon’s Functional Health Patterns

II. NUTRITIONAL-METABOLIC PATTERN

III. ELIMINATION PATTERN

IV. ACTIVITY-EXERCISE PATTERN

VI. COGNITIVE-PERCEPTUAL PATTERN

VII. SELF-PERCEPTION – SELF-CONCEPT PATTERN

The patient’s perception of recovery is when the pain is no longer felt

VIII. ROLES-RELATIONSHIP PATTERN

IX. SEXUALITY-REPRODUCTIVE PATTERN

The patient’s father verbalized “daghan kaayog changes” in their lives

XI. VALUES-BELIEFS PATTERN

The patient’s parents gives everything the patient wants.

Body built is ectomorph, level of consciousness is alert, verbal response is

Skin’s color is uniform, texture is smooth, skin turgor is good, temperature

The pinna are symmetrical. External canal has no discharge. Hearing

The nasolabial fold are symmetrical. Septum is on the midline. Mucosa is

The shape is symmetrical, spinal alignment is normal. Breathing pattern is

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