Haha

Republic of the Philippines

SOUTHERN LUZON STATE UNIVERSITY

COLLEGE OF ALLIED MEDICINE

Extension & Community Services

Lucban, Quezon

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Morbid Case

Submitted by: Submitted to:

Nikki P. Narte Mrs. Evangeline Mecija

Bryan L. Santayana Instructor

BSN 4-C Group 6

Patient’s Data

Name: Romel Dita Siblings: 4

Age: 3 years old Sex: Male

Religion: Roman Catholic

Date of Birth: November 3, 2006

Address: Adelpa St. Brgy Lita Phase I

Parent/Guardian: Rona Dita

DATE OF VISIT | ASSESSMENT | HEALTH ADVISE/CARE PLAN |

July 30, 2010 | Vital Signs T- 36.9ْC RR- 26 bpm PR- 82 bpm>”Di sya makabangon, kahit makaupo, ganyan na sya simula pagkasilang eh” as verbalized by her mother>conscious & active>irritable at times>with fair body built>with lesions noted on forehead>with whitish sclera and slightly pale conjunctiva>with nasal discharges noted, whitish in color, moderate in amount>with pale and dry lips>with symmetrical chest expansion upon breathing>with clear breath sounds heard on both lung fields upon auscultation>with soft and non tender abdomen>with pinkish nailbeds; capillary refill time of 1-2 secs>with fair skin turgor | Instructed and discussed his parents the following:>proper personal hygiene>teaching him how to read and write>assist in passive ROM exercises>place him in high fowlers when feeding>importance of daily checkups |

August 13, 2010 | Vital Signs T-37.2 RR- 28 bpm PR- 81 bpm>conscious and active>with whitish sclera and slightly pale conjunctiva>no nasal discharges noted>with pale and dry lips>with symmetrical chest expansion upon breathing>with clear breath sounds heard on both lung fields...