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A Case Study of Patient V

A Case Study of Patient V

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Published by: whiteballerina on Aug 01, 2010
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05/12/2014

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A CASE STUDY OF PATIENT V
At Antipolo City Medical Hospital

In Partial Fulfillment of the Academic Requirements
In Related Learning Experience,
Presented to the College of Nursing
SY 2010-2011

Submitted to:
Vilma S. Cordova, RN
Clinical Instructor
Submitted by:

De Guzman, Michael H.
De Guzman, Monica E.
De Guzman, Rose Mary M.
Dela Cruz, Cherrie Rose A.
Diaz, Jann Christine R.
Dizon, Monica
Ebuen, Bernice Andrea T.
Eledia, Shielamae F.
Embile, Demille Joy U.
Estrella, Airis A.
Factoran, Samantha Jane J.
Figueroa, Sharmaine Nicole J.

BSN 3-1
Group 3
Pamantasan ng Lungsod ng Marikina
College of Nursing
Marikina City
Pamantasan ng Lungsod ng Marikina
College of Nursing
Marikina City
Pamantasan ng Lungsod ng Marikina
College of Nursing
Marikina City
Patient¶s Profile

Name: Villon, Aron John Fernando
Address: Unit II Pagrai Hills, Duhat Road, Antipolo City
Bday: January 20, 2005
Age/sex: 5y/o / M
Religion: Roman Catholic
Father: Arnolfo Villon
Mother: Jocelyn Villon
Attending Physician: Dra. Alberto
Admission date/time: 7/27/10 01:55 am

Present Complaint: Fever, Convulsion, Cough
Past History: 1 week PTA ± onset of cough, resolved for 2 days, given lagundi syrup
1 day PTA ± onset of fever associated with convulsion prompting consult hence subsequently
admitted

Initial VS

PR- 126, RR-34, Temp-38.1
LABORATORY WORK-UP
URINALYSIS

(July 27, 2010; Dra Alberto)
ACTUAL FINDINGS
NORMAL FINDINGS
INTERPRETATION
Physical Examination
Color
Yellow
Transparency
Sl. Hazy
Specific Gravity
1.015
Chemical Examination
Albumin
-
Sugar
-
pH
5.0
Physical Examination
Pus cells
1-2/hpf
RBC
0-1/hpf
Epithelial Cells
Few
Bacteria
Few
HEMATOLOGY
(July 27, 2010)
ACTUAL FINDINGS
NORMAL FINDINGS
INTERPRETATION
HgB
126
140-160g/L
Hct
0.37
0.40-0.54

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