I. DEMOGRAPHIC DATA:

Patient’s name: T.A Sex: Male Age: 63 years old Address: Apparri, Cagayan Date of Birth: December 08, 1950 Nationality: Filipino Religion: Roman Catholic Occupation: Carpenter Living environment: Owned house with 2 participants Source of Income: Son’s income Marital Status: Married Admission Date/Time: April 22, 2014 Attending Physician: anastacio, antonio MD

A. IDENTIFYING DATA: The patient is a 63 year old male from Appari ,Cagayan

B. CHIEF COMPLAINT : Hyperplasia of the Prostate

C. Admitting Diagnosis: Hyperplasia of Prostate

II. PRESENT HEALTH HISTORY:

11 mos. PTA, the patient noticed an increase in urine frequency and feeling of incomplete emptying of the bladder. This was accompanied by dysuria upon finishing urination. He sought consult at a local hospital where he was prescribed with sambong herbal capsule and unrecalled antibiotic. He took the said meds with good compliance no relief was noted. He then noted increased urination in the in the evening, a weal stream upon urination and need to strain achieve complete bladder emptying. This prompted the patient’s consult with Dr. Anastacio for probable management.

2 mos. PTA, the patient had an ultrasound performed which revealed mild pyelocaliectasis, cortical cyst and cystitis the right kidney. The left kidney was normal. He was given finasteride 5 mg OD which provided relief his urinary symptoms.

3 weeks, PTA, he was admitted at our institution he had TRUS guided biopsy of the prostate and the specimen was sent to the histopath lab for evaluation the patient was discharged there on to avail results. His biopsy then revealed an evident benign prostatic hyperplasia. The patient was therefore adured to undergo a TURP and address the calculus in his urinary bladder , hence admission.

III. PAST HEALTH HISTORY:

FLU Immunization unrecalled (-) Hypertension, DM, Anemia

IV. FAMILY HEALTH HISTORY

V. DEVELOPMENTAL HISTORY

Generativity vs. Stagnation

According to Erik Erikson’s Psychosocial Development Theory, the patient is in the stage of “Generativity vs. Stagnation ” (40-65 years old.)

The basic strengths in this stage are production and care. M iddle-age is when people tend to be occupied with creative and meaningful work and with issues surrounding their family. Also, middle adulthood is when people can expect to "be in charge," the role we've longer envied.

The significant task is to perpetuate culture and transmit values of the culture through the family (taming the kids) and working to establish a stable environment. Strength comes through care of others and production of something that contributes to the betterment of society, which Erikson calls generativity, so when we're in this stage we often fear inactivity and meaninglessness.

Based on the definition given above, the patient successfully achieved the stage of Generativity . Based from our interview and role-relationship assessment, he feels so loved by his wife whom he was married for almost 36 already. His wife is the one taking care of her in the hospital and he feels very thankful of having him as her companion because he was being taken care so well. A close and happy bond was observed within their relationship and he is close to his on even it is Taiwan or overseas . Being a former carpenter , the patient told me that he had already accepted the fact that he has to rest and stop working already. He believed that he has already reached his achievement in life and feels very successful.

SURGICAL MANAGEMENT

I. Operative Diagnosis:

Cystourethoscopy TURP open cystolithotomy suprapubic cystostomy Surgeon: Dr. Anastacio Asst. Surgeon: Dr. Gasa

TEST RESULT UNIT REFERENCE ANALYSISHEMOGLOBIN Mass

C132 g/L 140-160 Normal

HEMATOCRIT 39 % 40-54 NormalRBC 4.4 X10^12/L 4.0 – 4.5 Normal

MCHC 33 % 32-37 NormalMCH 30.0 pg 27.5 – 33.2 NormalMCV 89 fL 80-94 NormalRDW 13.6 % 11-15 NormalWBC 17.6 X10^9/L 5-10 White blood cell

(WBC, leukocyte) count. White blood cells protect the body against infection. If an infection develops, white blood cells attack and destroy the bacteria, virus, or other organism causing it. White blood cells are bigger than red blood cells but fewer in number. When a person has a bacterial infection, the number of white cells rises very quickly..

NEUTROPHILS 95 % 40-75  Neutrophils may increase in response to a number of conditions or disorders. In many instances, the increased number of neutrophils is a necessary reaction by the body, as it tries to heal or ward off an invading microorganism or foreign substance. Infections by bacteria, viruses, fungi, and parasites may all increase the number of neutrophils in the blood

LYMPHOCYTES 5 % 20-45PLATELET Normal X10^9/L 150-440 NormalMPV 8.0 fL 7.5-11 Normal

RBC Morphology Normochromic, Normocytic

fL 7.5-11.5 Normal

VII. PHYSICAL ASSESSMENT

SYSTEM NORMAL FINDINGS ABNORMAL FINDINGS

ANALYSIS

Head and Neck Scalp:Clean and dryblack hairHead:No tendernessNo bleedingLymph nodes are non movable and no swelling presentJugular venous pulse not visibleNo blowing/swishing sound heard on carotid arteriesPulses are equally strong (+2)

Eyes, Ears, Nose and Sinus

Eyes:Cornea reactive to light smooth and symmetric eye movementsgood papillary constrictionEyeballs not protrudingBulbar conjunctiva is smooth, clear and moist

Ears:good hearing acuity for L and R ear

Nose:Patent nostrilsSinus:Non tender sinusesNo crepitusMouth:Lips are smoothNo lesionsNo swelling

Complete set of teeth with yellowish colorPink and moist tongue

Thorax Breast are symmetricNipples are nearly equal bilateral in size, same location on each breastS1 is loudest at the apex, S2 loudest at the base of the heartHR: 90 beats/minBronchial sounds heard on tracheal areaBronchovesicular sounds heard over bronchi area

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Abdomen Midline abdominal area was covered with a surgical dry dressing with no exudatesMild 8-10 normoactive bowel sounds/min on left abdominal areaNo palpable nodes in central areaAttached with an ileostomy bag on the left lower quadrantStoma is in reddish color without any presence of inflammation and swelling.

Guarding behaviour towards the ileostomy bag.

-post operative procedure done

-Active GIT(Flatus was observed)

Liver, gallbladder and pancreas was not palpated because on client’s contraptions.

Upper and Lower Extremities

Arms are bilaterally symmetric with minimal variation in sizeLegs are free of lesionsToes, feet and legs are equally warmNo edema or venous pattering in arms or legsFemoral pulses are strong and equal bilaterallyDorsalispedis pulses and posterior tebial pulses are bilaterally strong

No difficulty in dorsiflexing her feetMuscle strength of 4/5

Skin and Nails Skin:warmSmoot

Nails:Cleansmoothfirmcapillary refill (2 seconds)