NURSING CASE STUDY
ADMISSION FINAL DIAGNOSIS
I. HEALTH HISTORY
A. DEMOGRAHIC DATA (BIOLOGICAL DATA)
1. Client’s Initial: J.A.L
2. Gender: Male
3. Age: 3 months and 22 days
4. Religion: Catholic
5. Usual Source of Care: UPHMC
6. Date of Admission: January 13, 2012
7. Admission/Initial Diagnosis: T/C Acute Bronchitis, Intestinal Amoebiasis
B. SOURCE AND REALIBILTY OF INFORMATION
The source of valuable information taken is from patient’s mother, the
patient’s chart records and lab result.
C. REASONS FOR SEEKING CARE OR CHIEF COMPLAIN
o Watery Stool for 1 week
o Dry Cough and colds for 2 days
o Moderate Dehydration
D. HISTORY OF PRESENT ILLNESS OR PRESENT HEALTH
One (1) week prior to admission, patient J.A.L experiences a
watery stool with vomiting. Patient’s mother said that her son don’t have
any fever.
Two (2) days prior to admission, J.A.L already has a dry cough and
colds and experiences a fever.
Night prior to admission, patient J.A.L experienced a 2 episodes of
soft water stool, greenish in color with mucous and blood with foul smell.
On January 13, 2012, patient J.A.L together with his mother, he
was brought to hospital for admission. The attending physician decided to
admit the patient at around 5:00am. Patient was admitted at the room 335 in
the KTU 3rd floor under Dr. Bueno with a initial diagnosis of T/C Acute
Bronchitis, Intestinal Amoebiasis with Moderate Dehydration.
, E. PAST MEDICAL HISTORY OR PAST HEALTH
The patient mother said that J.A.L was born via NSD. He was able to
comply in Expanded Immunization Process. As of now, he was on the 2 nd
dose of Hepa-B Vaccine, DPT, and Oral Polio Vaccine.
F. DEVELOPMENTAL HISTORY
Patient J.A.L is 3 months and 22 days old. He falls under Trust Versus
Mistrust of Erik Erikson Developmental Theory. Erikson’s Developmental Theory
reflects positive and negative aspect of the critical life periods. J.A.L is learning to
trust the health care provider and the student nurse.
G. FAMILY HISTORY
Father Mother
ADMISSION FINAL DIAGNOSIS
I. HEALTH HISTORY
A. DEMOGRAHIC DATA (BIOLOGICAL DATA)
1. Client’s Initial: J.A.L
2. Gender: Male
3. Age: 3 months and 22 days
4. Religion: Catholic
5. Usual Source of Care: UPHMC
6. Date of Admission: January 13, 2012
7. Admission/Initial Diagnosis: T/C Acute Bronchitis, Intestinal Amoebiasis
B. SOURCE AND REALIBILTY OF INFORMATION
The source of valuable information taken is from patient’s mother, the
patient’s chart records and lab result.
C. REASONS FOR SEEKING CARE OR CHIEF COMPLAIN
o Watery Stool for 1 week
o Dry Cough and colds for 2 days
o Moderate Dehydration
D. HISTORY OF PRESENT ILLNESS OR PRESENT HEALTH
One (1) week prior to admission, patient J.A.L experiences a
watery stool with vomiting. Patient’s mother said that her son don’t have
any fever.
Two (2) days prior to admission, J.A.L already has a dry cough and
colds and experiences a fever.
Night prior to admission, patient J.A.L experienced a 2 episodes of
soft water stool, greenish in color with mucous and blood with foul smell.
On January 13, 2012, patient J.A.L together with his mother, he
was brought to hospital for admission. The attending physician decided to
admit the patient at around 5:00am. Patient was admitted at the room 335 in
the KTU 3rd floor under Dr. Bueno with a initial diagnosis of T/C Acute
Bronchitis, Intestinal Amoebiasis with Moderate Dehydration.
, E. PAST MEDICAL HISTORY OR PAST HEALTH
The patient mother said that J.A.L was born via NSD. He was able to
comply in Expanded Immunization Process. As of now, he was on the 2 nd
dose of Hepa-B Vaccine, DPT, and Oral Polio Vaccine.
F. DEVELOPMENTAL HISTORY
Patient J.A.L is 3 months and 22 days old. He falls under Trust Versus
Mistrust of Erik Erikson Developmental Theory. Erikson’s Developmental Theory
reflects positive and negative aspect of the critical life periods. J.A.L is learning to
trust the health care provider and the student nurse.
G. FAMILY HISTORY
Father Mother
