CASE PRESENTATION:

OBJECTIVES

This case presentation aims to identify and determine the general health problems and needs of the
patient with an admitting diagnosis Swelling of Left Elbow. This case presentation also intends to help
patient to promote health and medical understanding of such condition through the application of the
nursing skills.

Specifications:

 To raise the level of awareness of patient on health problem that he encountered.

 Utilize the nursing process in the management of patient’s health condition and in giving quality
nursing care.
 For the fast recovery of the patient.
 To render nursing care and information to patient through the application of the nursing skills.

INTRODUCTION
Clinical Manifestations:

Sign and Symptoms:

Mode of Transmission:
CLASSIFICATION:

SUSCEPTABILITY, RESISTANCE AND OCCURRENCE

DIAGNOSTIC TEST
HISTORY OF

PREVENTION
DEINITION OF TERMS:
 NURSNG HISTORY AND PHYSICAL ASSESSMENT

A. BIOGRAPHICAL DATA

Hospital: Surigao Medical Center

Ward: Semi- Private Room
Name of the patient: Patient X
Gender: Male
Home Address: Del Carmen, Surigao del Norte
Contact No: 09101416979
Birthday: June 4, 2011
Age: 7 years old
Occupation: None
Status: Single
Birth Place: Surigao City
Nationality: Filipino
Religion: Catholic

B. INITIAL DATA

Mode of Admission: Non ambulatory and assisted with family

Date of Admission: March 18, 2019
Time of Admission: 1:49 PM
Admission Room: TPR 21/ Nurse Station 2
Chief Complaints: Swelling of the Left Elbow
Vital Signs:
Blood Pressure:
Temperature: 36.8
Pulse Rate: 110 bpm
Respiration Rate: 25 cpm
Weight: 25 kgs
Admitting Diagnosis:
Principal Diagnosis:
Admitting Physician: Dr. Catherine C. Jumawan, M.D
Attending Physician: Dr. Frederick G. Sarmen, M.D
HISTORY OF PRESENT ILLNESS/ HOSPITALIZATION AND SURGERY

Medical History

COURSE OF PRESENT ILLNESS

THE MEDICINE’S PRESCRIBE:

1. Ibuprofen 1 tsp. TID

2. Cefuroxime
3. Ondansetron
4. Cefixime