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112120117_case_study.docx

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I. PATIENT’S PROFILE

A. Biographical Data

Name: Patient X

Age: 1 year old

Sex: female

Status: child

Religion:

Place of Birth:

Birthdate:

Address:

Date interviewed:

Informant:

Date admitted:

Chief Complaints:

Prior to admission, patient has temperature ranging

from 36.3 – 39.5°C, with non-productive cough and vomits in

small amount every after breastfeeding, characterized as

whitish in color that started 3 days PTA.

Admitting Diagnosis:

Final Diagnosis:

B. History of the Patient

1. Present History

It started when she vomits in small amount

(approximately 5 ml) of vomitus after every

breastfeeding, characterized as whitish in color. The

next morning, she had a fever of 38.9°C with non-

productive cough. With these conditions, her parents

decided to sought a doctor, hence, the doctor prescribed

Paracetamol Syrup 5 ml every 4 hours for fever.

After the consultation was done, and the prescribed

medication was taken, the fever went on and off

(temperature ranging from 36.3 – 39.5°C. still the child

vomits in a small amount after every breastfeeding. Since

the child hasn’t shown any progress in her condition, the

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family rushed her to atok district hospital and was

diagnosed to have bronchopneumonia and was admitted.

2. Past Medical History

When she was still 2 months old, the child was

admitted in a health clinic in senepsep, Benguet for 3

days due to her primary complaints of cough and fever.

However, the mother claimed that they were not informed

about the diagnosis of her child’s illness at that time.

No previous accident and surgery had occurred. The

patient has no known allergies to food and drugs.

3. Family History

History of hypertension on both sides of her parents

was present. However, on her father side, they have a

family history of anemia.

4. Social and Environmental History

The patient belongs to the Kankanaey group. The

patient is the 3

child of her parents. They live in a

small house ith two bedrooms. Their place has a cold

climate, thus cough and colds are common. Both parents

are farmers in their town. The patient is always with her

parents wherever they go. Trees and plants surround the

house, and the spaces between houses are at least 100-300

meters away, as approximated by the parents.

5. Immunization History

Immunizations were completed before she reached the

age of 1 year old.

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I. PATIENT’S PROFILE A. Biographical Data Name: Patient X Age: 1 year old Sex: female Status: child Religion: Place of Birth: Birthdate: Address: Date interviewed: Informant: Date admitted: Chief Complaints: Prior to admission, patient has temperature ranging from 36.3 – 39.5°C, with non-productive cough and vomits in small amount every after breastfeeding, characterized as whitish in color that started 3 days PTA. Admitting Diagnosis: Final Diagnosis: B. History of the Patient 1. Present History It started when she vomits in small amount (approximately 5 ml) of vomitus after every breastfeeding, characterized as whitish in color. The next morning, she had a fever of 38.9°C with non-productive cough. With these conditions, her parents decided to sought a doctor, hence, the doctor prescribed Paracetamol Syrup 5 ml every 4 hours for fever. After the consultation was done, and the prescribed medication was taken, the fever went on and off (temperature ranging from 36.3 – 39.5°C. still the child vomits in a small amount after every breastfeeding. Since the child hasn’t shown any progress in her condition, the family rushed her to atok district hospita ...
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