Age : 4 years old Sex : Male Room number : 312 Hospital Number : 271939 Impression : Pneumonia (PCAPc) Attending Physician/s : Dr. Julieta T. Lim Diagnosis : Student Nurse’s Signature: CLINICAL PORTRAIT PERTINENT DATA
ASSESSMENT: Chief Complain:
Fever and cough During first day of care to patient, the patient was awake, conscious and responsive. With IVF #3 D5IMB 500 cc infusing on left hand and on nebulization History of Present Illness: therapy. Noted coughing but non productive. Three days prior to admission patient had onset of fever ranges from 38-39 ºC with non productive cough and was given Paracetamol and symptoms was relief with SIGNIFICANT FINDINGS: good appetite. Two days prior to hospitalization there was a decrease in appetite and also - Persistent coughing but not dyspneic decreased in activities. - Positive crackles on both lung when auscultated - Afebrile Health history of relevant to present Illness: - Decreased appetite - Distended abdomen with flatus On December 5 and 7, 2009 patient was also been hospitalized in the same institution due to same chief complains and was given paracetamol 250/5 mL and cefuroxime. After deveral days of stay in the hospital patient was discharged with a VITAL SIGNS: diagnosis of Upper Respiratory tract Infection.