Part 1.

Nursing Health History

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Identifying Data/Biographic Data
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Name: Juneira C. Alvarez
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Date of Birth : February 21, 2006
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Age: 3years old
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Sex: Female
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Civil Status: Single
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Address: Nueva Street Purok Sena, Surigao City
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Religion : Roman Catholic
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Health care financing and usual source of medical care:

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Source of Reliability of data gathered:

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Date and time of clinical encounter: April 3, 2019/ 7:40 AM
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Date and time of Admission: April 01, 2019
Admission Data
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Date: April 01, 2019 Time: 9:51 am
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Arrived via: Arrived from home
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Admitting Vital Signs:
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Temperature: 37.9 Pulse Rate: 130
Respiratory Rate: 30
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Weight: 17
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Admitting Physician: Mar Kristian B. Lumen
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Attending Physician: Linda C. Chua M.D
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Impression: Cellulitis lower leg
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Final Diagnosis: Cellulitis left lower extremities
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Chief Complain( CC) or Reason for Seeking
Medical Care: Non bleeding wound at left leg
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History of present illness ( HPI )
Past health History:

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Childhood illness:
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Mumps at age of 1 year old
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Childhood immunization
✔
BCG
✔
DPT
✔
OPV
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Hepatitis A Hepatitis B
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History of hospitalization
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Medical History
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No major problems
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Surgical History
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Patient don’t have any Surgical History
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Accidents and Injuries
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Patient don’t have any history of accidents and injuries
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Medications:
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Non- Prescription Drugs:
Family Health History

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Part 1. ( Narrative Form ) include current health status, age and
if deceased include cause of death.

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Patient’s Grandfather on her mother side 57 years old was
alive and well, no known cause of illness, her Grandmother at
the age of 57 had a Diabetes Mellitus 2 years ago and still alive
and well. Patient’s Father 18 years old have an asthma and still
alive and well, her Mother 18 years old was still alive and well.
Patient have 1 sibling still alive and well, and she is the eldest
in the family.
Summary of the patient’s family history

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Acquired Diseases:
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Alcoholism
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Drug Addiction
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Heredofamilial Diseases:
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Heart diseases
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Hypertension
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Asthma
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Diabetes Mellitus
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Stroke
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Arthritis
History Records

I. Chief Complaints
- Non bleeding wound at left leg
II. Present Illness:
- 3 days prior to admission , patient had a sudden onset of non
bleeding wound at right leg associated of fever and body
malaise.
III. Physical Examination
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IV. Past History: Negative hypertension
Negative Diabetes Mellitus
V. Family History: Negative Hypertension
VI. Impression: Cellulitis Lower Leg

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Attending Physician : Dr. Chua M.D
Medical Records

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Ceftriaxone ( levitrox ) 850 mg q 12h
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Mopiocin Ointment – apply 2x a day after betadine
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Paracetamol 250 mg / 5ml
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¾ Tsp. Q 4h for fever