Professional Documents
Culture Documents
ATENEO DE
CAGAYAN
Relation: Mother
Physician,
2015
I. GENERAL INFORMATION
Time: 11:45 am
Pallor
COLLEGE OF NURSING
NCM 102 RLE
given
Lymphoprolferative Disorder
Occupation: Student
CIty
Cordinez,
Income: None
Dr.
that
consultation.1
the
patient
month
prior
has
to
RR 37 BP 100/60
Temp 37.5oC
O2 Sat 98 HT 104
WT 15.4kg
BMI 14.24
Interpretation of BMI: Normal
II.
PAST
CHILD
ILLNESS
Date
2014
2015
2015
2015
Current Medications
Drug
ency/Route
Diphenyhy 12.5mg/5m
dramine
Indication
TID
8AM
1PM
Paraceta
6PM
250mg/5ml
Symptom
associated
mol
, 4ml, Q4,
atic relief
with
(Biogesic)
PO, PRN
of pain
Relief of
symptoms
ide
blood
perennial
November
for T > or
and
(Benadryl)
transfusion
and
30, 2015
equal to
fever,
37.8C
prophyla
November
seasonal
30, 2015
allergic
xis for
rhinitis
Clindamyc
(Cleocin
75mg/5,
5ml, PO,
QID
8AM
infections
Pedia)
12NN
Pneumon
November
4PM
ia
in
Heart Disease:None
Cancer: Paternal
Nystatin
(Mycostati
n)
l, 5ml, PO,
30, 2015
Epilepsy: None
Dose/frequ
30, 2015
November
children
Severe
8PM
Syrup
(suspensio
n) 1ml,
Swish and
Swallow,
Piperacillin
900 mg IV
Treatment
Drip, Q6,
of severe
Tazobacta
ANST (-)
G-
m (Vigocid)
12 MN 6
infection
November
30, 2015
Orophary
ngeal
Racecado
candidias
tril
is
AM 12
NN 6 PM
10 mg
sachet 1
sachet per
10 ml H20,
PO, TID
and other
susceptibl
e bacteria
Supplem
ent to
oral
(Hidrasec)
8AM
rehydrati
December
1PM
on
1, 2015
6PM
Zinc-
5 ml, PO,
Used for
Sulfate
OD, 6PM
treatment
interaction.
Cyanosis: None
syrup
and
(E-zinc)
preventio
December
n of zinc-
1, 2015
deficienc
Benzydam
TID, 8 AM
y
Relief of
ine
1 PM 6
inflamma
(Difflam
PM
tion in
and spleenomegaly
Spray)
oral
December
mucosa
9, 2015
comfortable clothes
i.Respiration
Objective
Objective
Symmetry: Unequal
Recurrent Pneumonia /
Rhythm: Tachycardia
ii. Circulation
Pulse
Subjective
Carotid: 130
Radial: 129
Extremities:
Popliteal: 130
Temporal: 129
Objective
Femoral: 130
BP
R: Lying: 100/60
present on tongue
Teeth: Clean
present
Varicosities: none
Sitting: 100/60
L: Lying: 100/60
Sitting: 100/60
Heart Sounds:
Rate: 131
clubbing
Hearing: Good
v. Activity-Exercise
Smell: Good
iv. Elimination
Bowel habits:
friends
Disoriented:___
vi. Sleep-Rest
Time:_/_
Place:_/_
Person:_/_
the night
Sleep aids: None
Quality: Good
vii. Sensory-Perceptual
Vision: Good
Alert:_/_
Combative:___
Drowsy:_/__
Stuporous:__
Comatose:___
5
Lethargic:___
Pupil Size/Reaction:
Severity: Severe
Time( Onset, Frequency, Duration):
Safety
Allergies/Sensitivity: None
Right: Normal
Reaction: None
Left: Normal
Blood Transfusion/number:
Posturing: Normal
infusion site
injury
Fractures/Dislocations: None
VII. Pain/Comfort
Subjective Data
Precipitating:
Quality of pain: 9 (pain scale)
Radiating at: infusion site @ (R)
family: 3
rd
Prosthesis: None
X. DEVELOPMENTAL
MILESTONES
(Indicate clients age)
Age
Psychos
Psychos
Cognit
exual
ocial
ive
Infa
playing
since
with
he
clays.
was
sick.
Sch
ool
Age
ncy
Tod
dler
Pre
Anal: the
Autonomy
Preop
sch
patient
VS
eration
ool
is
Shame
al:
already
and
The
potty
Doubt:
patient
trained
Engages
XYZ
in
wants
activities,
to
such as
control
coloring
the
books
chann
and
el
XII. LABORATORY/DIAGNOSTIC
RESULTS
enlargement of abdomen
7
(
2
)
RBC
Hgb
Hct
A. Complete Blood Count
MCV
MCH
November 30, 2015
MCHC
Variables
Remarks
Platelet
WBC
High
Neutrophils
RBC
Low
Lymphocytes
Hgb
Low
Hct
Low
MCV
High
MCH
Normal
Monocytes
MCHC
Low
Eosinophil
Platelet
Low
Basophil
Neutrophils
Normal
ROW-CV
Lymphocytes
High
Monocytes
Eosinophil
Basophil
ROW-CV
Variables
WBC
Variables
WBC
RBC
Hgb
Hct
MCV
MCH
MCHC
December 1, 2015Platelet
Neutrophils
Remarks
Lymphocytes
High
Low
Normal
Normal
High
Low
Monocytes
Low
Eosinophil
Low
Basophil
High
RDW-CV
Normal
Normal
Low
B. URINALYSIS 11/30
Normal
Normal Physical Exam:
Normal
Normal
Normal
High
Color Yellow
Transparency Clear
Low
Normal Chemical Parameter
Normal
Specific Gravity 1.020
High
pH 6.5
Sugar Negative
Protein
December 2,
2015 Negative
RemarksMicroscopic/Urine Floucy
High
Low WBC 6/uL (Normal range: 0-11)
Low RBC High 100/ uL (Normal range:
Low 0-11)
High Epith. Cells FEW/uL (Normal
Normal range: 0-11)
Normal Cast 0/Ul (Normal range: 0-1)
Low BACTERIA PLENTY/uL (Normal
Normal range: 0-111)
Normal
8
BCG
C. XRAY 11/30
Chief Complaint: Fast breathing,
pallor
Hepa(3)
No discrete adenopathy is
identified.
Heart is not enlarged.
Hemidiaphragms and sulci are
intact.
Bony thorax is unremarkable.
DPT
Date
Place
ion
Received
Receiv
Center
mother
mother
Not
Health
remembe
Center
red by
mother
Not
Health
remembe
Center
red by
OPV
mother
Not
Health
remembe
Center
red by
Measles
mother
Not
Health
remembe
Center
red by
remembe
red by
red by
Findings:
Lung fairly aerated. Hazy opacities
are appreciated in both inner lung
zones with prominence of the
interstitial lung markings.
Impression:
Bilateral pneumonia. Concomitant
viral or reactive airways disease
cannot be entirely excluded as well
as interstitial edema.
Not
ed
Health
MR
mother
Not
Health
remembe
Center
9
24