PATIENT'S PROFILE Patients Name: Address: Age: Sex: Birth Date: Birth Place: Religion: Nationality: Civil Status:

Fathers Name: Mothers Name: Admission Date: Time of Admission: Chief Complaint: Diagnosis: Attending Physician: Patient X 306 Brgy. 4 Sto Tomas, Batangas 7 years old Male April 5, 2004 Sto. Tomas, Batangas Roman Catholic Filipino Child Father X Mother X July 30, 2011 5:59 PM Chest pain and Palpitations Myocarditis,Lymphadenitis submandibular area probably streptococcal r/o PKI Dra. Maria Lina Tactacan-Sumang

CLIENT PROFILE Name: Patient X Birthday: April 5, 2004 Address: 306 Brgy. 4 Sto. Tomas, Batangas Religion: Roman Catholic Name of Parents/Guardian: Mr. & Mrs. X Name of Informant: Mr. X Relation to Client: Father Attending Physician: Dra. Maria Lina Tactacan-Sumang Date of Admission: July 30, 2011 Room/Ward#: SP3A # of Days Admitted: _5____ Chief Complaints/s upon Admission: Chest Pain and Palpitations Medical Diagnostic, if any: Myocarditis,Lymphadenitis submandibular area probably streptococcal r/o PKI Weight: 23 kgs Current Education Level: Grade 2 Age: 7 years old Birthplace: Sto. Tomas, Batangas

Name of School: Sto. Tomas Central Elementary School

NURSING HISTORY Past Health History: According to the father of the patient, the patient experienced having health problems such as fever, colds and cough. And on year 2006 the patient was hospitalized due to UTI. The Father also claimed that the patient has no history of accident and injuries, and has no allergies to any foods and drugs but experienced several cases of tonsillitis that started when he was 4 years old. The patient was a fully immunized child and taking in Ceelin Plus and Growee, Dolan if having fever. Present Health History: 1 week and 2 days prior to admission, patient was admitted at Saint Frances Cabrini Medical Center due to mass at submandibular area, medications given were oxacillin and amikacin thru IV. CXR done showed pleural effusion. ECG also done. 2D echo also done showed pericardial effusion and minimal tricuspid and mitral regurgitation. After 5 days of hospital stay patient was discharged with the following medications : co-amoxiclav, ascorbic acid, prevacid, furosemide and kalium durule. He was schedule on July 29, 2011(Friday) for a follow up check up with Dra. Sumang, after the consultation he was then referred to a pediacardio. Morning prior to admission, he was seen by the pedia-cardio and was advise for admission. Last July 30, 2011, 5:59pm patient was admitted at St. Frances Cabrini Medical Center with the chief complaint of chest pain and palpitations. Patients initial diagnosis was myocarditis. Family Health History: According to the father of the patient, the patient has the history of Hypertension and Asthma on their mother side; Arthritis and Ulcer on the father side. And no other hereditary diseases. Social and Lifestyle History The patient loves to drink milk and any flavor of juice. He is also very active and loves playing with his cousins and studying his lessons.

GORDONS 11 FUNCTIONAL HEALTTH PATTERN HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN Before hospitalization: The patient perceived his health in the state of good condition. He manages his health by practicing proper hygiene and eating nutritious food. During hospitalization: He seems to be well taken care of because of the help of the therapeutic personnel and by following the prescribed medications. NUTRITIONAL-METABOLIC PATTERN Before hospitalization: The patient eats 3 times a day and with afternoon snacks after coming from school. According to the father of the patient, he eats meat, fish and also vegetables. He doesnt have any allergies on foods and drugs. His appetite is moderate and usually depends on the food being served. He didnt complain any difficulty in swallowing. During hospitalization: The patient still has good appetite; He is on DAT (Diet As Tolerated) ELIMINATION PATTERN Before hospitalization: The patient does not have any problem on his elimination pattern. He usually urinates 4-5 times a day without any difficulty. He added that the color of his urine is light yellow. He didnt feel any pain in urination. The patient defecates once a day with yellow to brown color. Sometimes however, it is hard in consistency with dark color, which generally depends on what he eats. During hospitalization: The patient urinates 5-8 times a day. The color of her urine is yellow. The patient defecates once every two days. ACTIVITY-EXERCISE PATTERN Before hospitalization: He could perform activities of his daily living. According to him, he often plays with his cousins and this serves as a form of exercise for him.

During hospitalization: His activity was limited lying on bed but the patient is given his bathroom privileges but always feels tired. SLEEP-REST PATTERN Before hospitalization: He has the normal 6-8 hours sleep. He also has his nap time for 1-2 hours a day. Sleeping and watching the television are his form of rest and listening to music. During hospitalization: He has the adequate time of sleep but he is sometimes disturbed because he need to use the comfort room and also disturbed with the nurses that enter the room every now and then. COGNITIVE-PERCEPTUAL PATTERN Before hospitalization: He is normal in terms of his cognitive abilities. He has good memory and reasoning skills. He can easily comprehend on things. In terms of his perceptual pattern, he has no problems with his senses. During hospitalization: He was normal as before in his cognitive and perceptual pattern. He responds clearly and well understood. He has no sensory deficit; He responds appropriately to verbal and physical stimuli and obeys simple commands. SELF-PERCEPTION SELF-CONCEPT PATTERN He sees himself as a person with a good personality. He also describes himself as a typical type of student and child. ROLE-RELATIONSHIP PATTERN Before hospitalization: He has a close relationship with his family. They were two siblings in their family. He was the youngest. During hospitalization: He is very quiet. He seems to be afraid of his father and acts differently whenever his father is around.

SEXUALITY-REPRODUCTIVE PATTERN He is still young for such matters. COPING-STRESS TOLERANCE PATTERN Before hospitalization: He does not fully identify his situations having stress but he always tell her parents when something is wrong. During hospitalization: He verbalizes his feelings only to his family. VALUE-BELIEF PATTERN He is a Roman Catholic. He sometimes goes with his family on Sunday for a mass.

Review of Systems Checklist: General Weight loss Weight gain Fatigue Fever or chills Weakness Trouble sleeping

----------------------------------------------------------------------------------------------------------------Skin Rashes Lumps Itching Dryness Color changes Hair and nail changes -------------------------------------------------------------------------------------------------------------------Head Headache Head injury

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Ears Decreased hearing Ringing in ears (tinnitus) Earache Drainage

-------------------------------------------------------------------------------------------------------------------Eyes Vision Glasses or contacts Pain Redness Blurry or double vision Flashing lights Specks Glaucoma Cataracts

-------------------------------------------------------------------------------------------------------------------Nose Stuffiness Discharge Itching Hay fever Nosebleeds Sinus pain

-------------------------------------------------------------------------------------------------------------------Throat Complete Teeth Swollen Gums

 Bleeding Dentures Sore tongue Dry mouth Sore throat Hoarseness Thrush Non-healing sores -------------------------------------------------------------------------------------------------------------------Neck Lumps Swollen glands Pain Stiffness

-------------------------------------------------------------------------------------------------------------------Respiratory Cough (dry or wet,productive) Sputum (color and amount) Coughing up blood (hemoptysis) Shortness of breath (dyspnea) Wheezing Painful breathing CardiovascularChest pain or discomfort Tightness Palpitations Shortness of breath with activity (dyspnea)

Difficulty breathing lying down (orthopnea) Sudden awakening from sleep with shortness of breath (Paroxysmal Nocturnal Dyspnea)

-------------------------------------------------------------------------------------------------------------------Gastrointestinal Swallowing difficulties Heartburn Change in appetite Nausea Change in bowel habits Rectal bleeding Constipation Diarrhea Yellow eyes or skin (jaundice)

-------------------------------------------------------------------------------------------------------------------Urinary Frequency: More than 5 in a day Urgency Burning or pain Blood in urine (hematuria) Incontinence Change in urinary strength

-------------------------------------------------------------------------------------------------------------------Genital: Male Hernia Penile discharge Sores Masses or pain Erectile dysfunction STDs

-------------------------------------------------------------------------------------------------------------------Vascular-

 Calf pain with walking (Claudication) Leg cramping -------------------------------------------------------------------------------------------------------------------Musculoskeletal Muscle or joint pain Stiffness Back pain Redness of joints Swelling of joints Trauma

-------------------------------------------------------------------------------------------------------------------Neurologic Dizziness Fainting Seizures Weakness Numbness Tingling Tremor -------------------------------------------------------------------------------------------------------------------Hematologic Ease of bruising Ease of bleeding -------------------------------------------------------------------------------------------------------------------Endocrine Head or cold intolerance Sweating

 Frequent urination Thirst (polydypsia) Change in appetite (polyphagia) -------------------------------------------------------------------------------------------------------------------Psychiatric Nervousness Depression Memory loss Stress