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College of Nursing
Cebu City
HEALTH HISTORY
2. Immunization
3. Hospitalization
This is the
patient’s first
hospitalization
5. Transfusions
Patient did not undergo any transfusions, as verbalized by the mother.
6. Allergies (specify)
Patient doesn’t have any allergies, as verbalized by the mother.
B. Family History
C. Social and Personal History
1. Occupation
Patient does not have an occupation since she’s still 9 months.
2. Number of Children
No children; patient is the only child in the family so far.
5. Diet
Patient was breastfed but whenever the mother is working, the patient is bottlefed
as an alternative for feeding.
6. Type of Family
Patient lives in an extended type of family; her father’s mother is residing in the
family’s house.
D. Review of Systems
Others
III. CURRENT HEALTH PROFILE
9/22/09 CBC
- Hgb 100 g/L F: 120-160 An increase in
- Hct 0.30 F: 0.37-0.47 lymphocyte levels
- Lymphocytes 0.41 0.20-0.35 indicate viral infection.
- Monocytes 0.01 0.02-0.06
2. NCP
3. Drug Study
4. Discharge Plan
PHYSICAL EXAMINATION
A.) General
Patient is seen lying on bed, asleep and dyspneic, w/ IVF of PLR 1000cc @ 36
cc/hr infusing well @ right arm. Initial vital signs were Temp: 36.4°C, RR: 60 cpm, PR:
117 bpm. Patient appeared clean and well groomed.
B.) Skin
Patient’s skin is pinkish white in color, equally colored in all parts, slightly warm
to touch, fair skin turgor, smooth in texture. No lesions, erythema, discolorations and
bleeding noted.
C.) Head
Head appears normocephalic with no lesions or sores noted. Forehead is large and
prominent. Chin is receding. Hair is abundant, well-distributed on scalp, thin and fine in
texture. Anterior fontanelle palpable as a soft spot.
D.)Eyes
Eyes appear symmetrical and clear with no redness or discharges noted. Cornea is
round and proportionate in size on both eyes. Has brown iris and black pupils; PERRLA
direct and consensual on both eyes. Eye movement distinctive: follows across midline,
blinks when penlight is shone on the eyes. Eyebrows equally distributed; slightly curved
eyelids. Tears present upon crying..
E.) Ears
Ears are in symmetrical position; color is the same as that of the whole skin; no
lesions, discharges and deformities noted on both ears, nontender upon palpation. Pinna
on both ears recoils after folding. Hearing distinctive as infant looks at me after sound is
made/talking softly.
F.) Nose
Nose appears symmetrical, located midline; no deformity, flaring, bleeding, and
discharges noted; nontender.
G.) Mouth
Lips are pinkish in color, no sores and lesions noted. No teeth, pink gums with no
bleeding present. Lips moist upon palpation. Tongue in central position with no sores and
bleeding, pink in color. Intact and symmetrical hard and soft palate. Tongue moves
freely; mouth opens evenly when cries.
H.) Neck
Neck appears short, chubby with creased skin folds; no masses, lesions, redness
noted. Head rotates freely using the neck, indicating good muscle tone. Trachea
prominent and in central placement in the midline of neck. Nontender upon palpation;
nonpalpable lymph nodes.
I.) Chest, Heart and Lungs
Chest appears rounded with anterior-posterior and transverse diameters
approximately equal. Patient showed slight heaviness on respiratory effort upon lying on
bed; breathing pattern is irregular with periods of apnea in between respirations;
retraction no present. Chest slightly indraws. Fremitus most palpable on upper thorax
anteriorly and posteriorly when crying. Resonance on selected lung fields (anterior and
posterior) heard on percussion. Crackles heard on selected lung fields (anterior and
posterior) upon auscultation. Regular apical pulse with S1 and S2 heart sounds heard.
Chest nontender upon palpation. Patient had slightly productive cough, sputum appears
sticky, whitish in color.
J.) Abdomen
Abdomen appears slightly protuberant even upon lying on bed, rises and falls as it
is used for respirations; no lesions, sores, redness or bleeding and discharges on
umbilicus are noted; umbilicus midline, inverted. Soft, medium-pitched bowel sound
heard every 15 secondsin all four quadrants on auscultation. Tympanic in all four
quadrants upon percussion, dullness over organs. Nontender on palpation; liver, spleen
and kidneys nonpalpable.
K.) Extremities (upper and lower)
Upper and lower extremities equal in size and bilaterally symmetrical; prominent
subcutaneous fats; warm to touch especially on palms and soles. Legs appeared short and
slightly bowed. No lesions, redness, bleeding, edema, deformities and discolorations
noted on upper and lower extremities bilaterally. Both extremities move symmetrically;
good muscle tone and ROM (complete with some resistance) manifested by flexion and
extension of arms and legs, hands and feet. Fingers and toes soft and smooth, nontender;
nails on fingers and toes intact and smooth, 160° curvature angle, no deformities or
cracks noted; appeared short, capillary refill time on both fingernails and toenails of
about 2 seconds; pink in color with no discolorations noted.