TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING

CLINICAL CASE ANALYSIS

Name of Patient Guerrero, Jairus D Age: 7 years old Gender: Male

Address Purok 6 Mabini, Tarlac Date Admitted 12-02-22

Diagnosis Acute Gastroenteritis (AGE) with moderate dehydration

NURSING HISTORY

Past Health History

Patient Kendrick, a 7-year-old male, has no relevant medical problems. He has no history of previous
hospitalization, injury, or surgery, and he has no food, drug, or other allergies.

Family Health History

Present Medical History

On December 02, 2022, at 8:11 a.m., Patient Kendrick was brought to the Emergency room by his
mother and reported that he has been vomiting for 2 days already and has lost his appetite. The patient is
awake and alert, has no fever but has body weakness, sunken eyes and has dry mucus membrane. It was
reported that their drinking water is from deep well and his last meal was also eaten by the rest of the
family but none of them experienced diarrhea, nausea, or other signs and symptoms. His vital signs are
taken upon admission: Temperature of 36, heart rate of 11 bpm, respiratory rate of 32 cpm, SPO2 of 99%.