Name : Genesis M.

Bravo Date of admission : January 4, 2010

Age : 4 years old Sex : Male Room number : 312 Hospital Number : 271939
Impression : Pneumonia (PCAPc) Attending Physician/s : Dr. Julieta T. Lim
Diagnosis :
Student Nurse’s Signature:
CLINICAL PORTRAIT PERTINENT DATA

ASSESSMENT: Chief Complain:

Fever and cough
During first day of care to patient, the patient was awake, conscious and
responsive. With IVF #3 D5IMB 500 cc infusing on left hand and on nebulization History of Present Illness:
therapy. Noted coughing but non productive.
Three days prior to admission patient had onset of fever ranges from 38-39 ºC
with non productive cough and was given Paracetamol and symptoms was relief with
SIGNIFICANT FINDINGS: good appetite.
Two days prior to hospitalization there was a decrease in appetite and also
- Persistent coughing but not dyspneic decreased in activities.
- Positive crackles on both lung when auscultated
- Afebrile Health history of relevant to present Illness:
- Decreased appetite
- Distended abdomen with flatus On December 5 and 7, 2009 patient was also been hospitalized in the same
institution due to same chief complains and was given paracetamol 250/5 mL and
cefuroxime. After deveral days of stay in the hospital patient was discharged with a
VITAL SIGNS: diagnosis of Upper Respiratory tract Infection.

Temperature = 36.4 ºC V/S during admission:

Pulse rate = 98 bpm
Respiratory rate = 24cpm Diagnostic procedure done:

 Urinalysis

 Complete blood count

o White Blood Cells 30.96 H
Segmenters 37.20 H
o Lymphocytes 14.80 L
o MCV 76.30 L