Case Study Patient Profile

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Patient Profile

NAME:Baby T.V
Age: 5 y/o
Sex: Female
Birthdate: 08-19-2007
Religion: Catholic
Nationality: Filipino
Primary language: Tagalog
Day admitted: February 14, 2010

A. Chief concern (narrative of present illness)
2 weeks PTA – “hindi ko alam nagkaroon pala siya ng tonsillitis, nakakakain pa naman kasi siya ng hindi dumadaing” as verbalized by the mother. Client urinates once a day, edematous and was experiencing difficulty of breathing secondary to FLU. The child was brought to a health institution for check up. Series of diagnostic exams were taken and ruled out presumptive Urinary tract infection. The physician prescribed antibiotics and vitamins. 1 week PTA – the mother decided to have second opinion by another health institution but still ruled out UTI. Initial symptoms still exists and prescribed meds are being taken. On the day of admission – came to the emergency room with a chief complaint of facial swelling. Laboratory exams were done, client was diagnosed with Acute glomerulonephritis and was advised to be admitted.

B. Vital Signs (taken 02-18-2010)
T: 36.2cP: 90bpmR: 18bpmBP: 100/70

C. Past history
1. Perinatal and birth history
G3P3, non-hypertensive, non-diabetic, non-asthmatic mother delivery via normal spontaneous delivery with no fetomaternal complications 2. Diet history
▪ Breastfed for 6 months,
▪ eats whatever the mother offers such as chicken, veggies and fried fishes or any kind of dishes. ▪ likes eating junk foods,
3. Immunizations
The client completed her immunizations before 1 year old and therefore considered as Fully immunized child (FIC) 4. Developmental milestones
6 months – “sobrang daldal niya nun” verbalized by the mother 7 months – first eruption of deciduous teeth
1 y/o – walks without support
4 y/o – starts studying; nursery

Gordon’s Functional Health Pattern

A. Functional Health Pattern Assessment
Client is admitted due to the ruled out diagnosis of AGN. This is her first time and it was explained to her properly why based on her age. Home medications were given upon first check up, all are taken orally and client has no allergic reactions to any drugs.

B. Nutritional and Metabolic Pattern
Family eats thrice a day and usually the client eats first. Among her favorite foods are chicken and veggies of any type. Client doesn’t like orange juice and prefers to drink milk or water. Right now, the child’s appetite has been slightly affected because of dietary restrictions. She doesn’t experience any gum and dental problems. C. Elimination Pattern

Client is toilet trained and defecated once or twice a day, usually daytime. Has no problems with urination and wears diapers during night time. No reported changes.

D. Sleep-Rest Pattern
Client sleeps 8hours during the night and 2 to 3 hours after lunch. She sleeps together with her parents in one room with lights off. No experienced sleep disturbances during the client’s stay in the ward but she started to snore upon the first day of confinement. No problems reported.

E. Activity-Exercise Patterns
Client goes to school in the morning and usually watches cartoons during noon time. There are also some restrictions in the type of TV shows being watched. Needs assistance in performing personal hygiene and grooming, e.g brushing teeth, taking a bath, combing hair etc. Feeding: 2

Bathing/ hygiene: 2
Dressing / grooming: 2
Toileting: 2

F. Cognitive-Perceptual Pattern
No hearing difficulty, vision problems and no learning disabilities. Currently enrolled as a nursery student and participates actively in school. She knows how to identify basic colors and shows interest in drawing.

G. Self Perception-Self Concept Pattern
The child takes time to adjust to people whom she met for the first time. Client is a bit of shy, cries when...
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