Case Study
CASE STUDY
I. PERSONAL DATA
Name: Juana Talion
Age: 45 years old Birth Date: May 6, 1976 Address: Caramoran, Cataduanes
Civil Status: Married
Gender: Female Religion: Roman Catholic
Date and time of admission: September 20, 2010 10:30am
Chief complaint: hypogastric mass
Tentative Diagnosis: myoma uteri
Attending physician: Dr. Espinola
II. HEALTH HISTORY
a. History of Present Illness
Juana Talion, was admitted at the EBMC due to a hypogastric mass. She underwent ultrasound examination and found out that she is having a myoma of the uterus. On September 10, she was admitted and scheduled for an operation, but then after the result of her complete blood count was released her physician also found out she is having anemia. The operation was postponed and rescheduled after her anemia has been treated. She was discharged on September 15, having normal blood counts, and given 5 days to rest and be ready for the operation scheduled on September 20. Upon admission on September 20, her vital signs were taken and had a normal result. (BP- 110/70 CR-84 RR-19 temp-36.7°C)
b. History of Past Illness: Juana Talion got married at age of 38, quite older than what is usual. Luckily she still got pregnant but two to three months later the fetus was aborted. She never went to the hospital to undergo ‘dilatation and curettage’ after the miscarriage. Instead she regularly had a massage therapy or “hilot”. They never stop trying to have a baby again but then they are not blessed to have one again. One day at age 40, she went to her personal massage therapist or “palahilot”. Her “palahilot” noticed a small lump on her left lower quadrant of the abdomen. She never thought that the lump would go larger but it did, and she also noticed that the lump traveled from the left side to the center portion. This time she went to the Pandan Hospital to have a check up, because of some
I. PERSONAL DATA
Name: Juana Talion
Age: 45 years old Birth Date: May 6, 1976 Address: Caramoran, Cataduanes
Civil Status: Married
Gender: Female Religion: Roman Catholic
Date and time of admission: September 20, 2010 10:30am
Chief complaint: hypogastric mass
Tentative Diagnosis: myoma uteri
Attending physician: Dr. Espinola
II. HEALTH HISTORY
a. History of Present Illness
Juana Talion, was admitted at the EBMC due to a hypogastric mass. She underwent ultrasound examination and found out that she is having a myoma of the uterus. On September 10, she was admitted and scheduled for an operation, but then after the result of her complete blood count was released her physician also found out she is having anemia. The operation was postponed and rescheduled after her anemia has been treated. She was discharged on September 15, having normal blood counts, and given 5 days to rest and be ready for the operation scheduled on September 20. Upon admission on September 20, her vital signs were taken and had a normal result. (BP- 110/70 CR-84 RR-19 temp-36.7°C)
b. History of Past Illness: Juana Talion got married at age of 38, quite older than what is usual. Luckily she still got pregnant but two to three months later the fetus was aborted. She never went to the hospital to undergo ‘dilatation and curettage’ after the miscarriage. Instead she regularly had a massage therapy or “hilot”. They never stop trying to have a baby again but then they are not blessed to have one again. One day at age 40, she went to her personal massage therapist or “palahilot”. Her “palahilot” noticed a small lump on her left lower quadrant of the abdomen. She never thought that the lump would go larger but it did, and she also noticed that the lump traveled from the left side to the center portion. This time she went to the Pandan Hospital to have a check up, because of some