UNIVERSITY OF SANTO TOMAS
COLLEGE OF NURSING
Espana Boulevard, Sampaloc, Manila, Philippines 1015
Tel. No 406-1611 loc.8241 | Telefax: 731-5738 | Website: www.ust.edu.ph
NURSING CASE ANALYSIS
I. HEALTH HISTORY
A. Biographical Data:
Name: M.A.T
Address: Candelaria, Quezon Province
Age: 39 years old Sex: Female Citizenship: Filipino Religion: Roman Catholic
Birthdate: August 6, 1979 Civil Status: Married Educ. Attainment: College Graduate
Birthplace: Quezon Province
Occupation: Public School teacher
Health Insurance: Philhealth? _/_ Yes __No
Health Maintenance Organization (HMO)? __Yes _/_No
If yes, please indicate:
Information obtained from: Mother
Date information was obtained: April 24, 2019
B. History of Present Illness
Chief complaint: Blurring of Vision; headache
Diagnosis: Intracranial Mass Left Frontotemporal lobe in location to consider Astrocytoma
Last October 2018 patient experienced headache in the holocranial area rated 4-5/10, non-
radiating, characterized to be “band-like”.
Interval history presented recurrence of headache 2-3 times a week. No consultation was
done.
March 15, 2019; sudden blurring of vision accompanied by vomiting, non-rotatory
dizziness and headache in the holocranial area (non-radiating rated 8/10). Co-workers noticed that
she has memory lapses characterized as difficulty remembering names of relatives; difficulty
writing and noted to have blank stares and inappropriate responses. Still, no consultation was done.
March 19, 2019; consulted neurologist, advised to undergo Cranial CT scan with contrast
which revealed: non-enhancing, well-marginated heterogeneous mass 6.5x5.24x6.36 cm with
midline shift to the right. Patient was advised to secure neurosurgical consent
C. Past health History
(-) DM
(-) Hpertension
(-) Thyroid Disease
(-) Asthma
(+) Adenomyosis s/p Dilation and curettage (D&C) (2018)
Allergies: none
D. Family Health History
(-) HTN
(-) DM
(-) Asthma
(-) Cancer
E. Assessment
Vital signs
BP: 120/80
Temp: 36.4
RR: 19
PR: 73
Positioning
Patient is on supine position with HOB elevated at 30-45 degrees
Psychosocial
Patient is calm when approached and cooperates with care.
Respiratory
Patient has normal breath sounds. Symmetrical lung expansion. No complaints of difficulty
of breathing during assessment.
Cardiovascular
Pulse is easy to palpate, not easily obliterated. (-) tachycardia. No murmurs or skip beats
noted. Heart sounds are regular at S1-S2 base.
Gastrointestinal
The abdomen is generally symmetrical in configuration and has normal bowel sounds. No
masses and tenderness noted upon palpation.
GU & GYN
Unremarkable. Excretion and elimination of waste is normal. Patient is currently on
diapers. Urine is light yellow in color and Stool, golden brown in color.
Musculoskeletal
Patient is in bed rest, ambulatory but with assistance.
Integumentary
Skin texture is cool and moist. Has ecchymosis behind the left ear.
Neurology
Patient is alert, oriented to time, place and person, opens eyes spontaneously and obeys
command. Pupils equally round, reactive to light and accommodation. White sclera. No hearing
difficulty and ear drainage.
Cranial Nerves:
CN I: unremarkable. Was able to identify aromas
CN II: pupils 2-3 mm ERTL; VA= 20/20 OD 20/20 OS
CN III, IV, VI: Intact Extraocular muscles; (+) diplopia (pre-op)
CN V: sensation intact; able to clench teeth
CN VII: no facial asymmetry; can raise eyebrows; can close eyes tightly; can smile
CN VIII: intact gross hearing.
CN IX: uvula is on the midline
CN X: intact reflexes
CN XI: able to turn head, shrug shoulders against resistance
CN XII: tongue midline when protruded
Motor: 5/5 all extremities
Reflexes: DTR= 2+
SUMMARY OF DIAGNOSTIC PROCEDURES
DATE PROCEDURE SIGNIFICANT FINDINGS INFERENCE
3/19/19 CT Scan Non-enhancing, well- Midline shift is often
marginated heterogeneous associated with high
mass 6.5x5.24x6.36 cm with intracranial pressure
midline shift to the right. (ICP), which can be
fatal. In fact, midline
shift is a measure of ICP;
presence of the former is
an indication of the
latter. Presence of
midline shift is an
indication for
neurosurgeons to take
measures to monitor and
control ICP. Immediate
surgery may be indicated
when there is a midline
shift of over 5 mm.
4/13/19 MRI Large heterogenousity
enhancing intraaxial mass at
the left Frontoparieto-temporal
region with necrotic
components, intralesional
blood products and mixed
signals in DWI
SUMMARY OF LABORATORY PROCEDURES
DATE PROCEDURE SIGNIFICANT FINDINGS INFERENCE
Nurse’s Notes
DATE/TIME REMARKS
02/27/2019 F: continuity of care
D: known case of bronchial asthma with acute exacerbation; verbalized no
difficulty in breathing;
occasional bibasal crackles; RR: 19; T: 36.5; O2: 96%
A: Monitored vital signs; Instructed to do deep breathing exercises; Kept in
comfortable position; Instructed to do proper handwashing
R: patient noted to have normal breath sounds
