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Ana Elizabeth Ota-ot
A Case Study
B. Medical History
1. Vaccines: Complete
- Has a history of convulsion
- Family history of anemia (mother)
- Family history of high blood ( grandmother)
- Family History of Tuberculosis ( grandfather)
- His mother, she used to smoke cigarettes, eating small amount of
food while pregnant.
C. Socio-economic History
(MOTHER)
-She had lack of education; stopped attending school since 2nd year High
school and no work now.
-His Grandmother Alice, the one who took the full responsibility on Rayven
had inadequate salary since she is only a garbage collector.
-household number is six (4)
D. Nutrition and Diet History
a. Anthropometry
Height: 93 cm weight: 13.2 kg
BMI: 14.19 kg/m²; underweight DBW: 16 kg
Normal BMI range: 18.5-24.9 kg
b. Dietary
-Eat small amount of food
-usually eat the same kind of food
-low supply of nutritious food
Incidence:
P Patient education:
Pre-school
Intervention measures:
In general, incorporating additional foods. Avoid fruit juices,
especially those with added sugar. Juices and other sugary
beverages will fill kids up without providing them with any
energy, fat or protein.
Underweight: Snacks are certainly good and encouraged, but
children should eat them at the table — not mindlessly in
front of the television or computer screen.
Eating several small meals a day
To be able achieve the expected outcomes the following will take place:
Diagnosis
Page5
Based from the case of Rayven, underweight/Stunted is very crucial
and should be given so much time and effort not to worsen the nutritional
status that might lead to other complications.
Undernutrition has many causes and many of us aren’t aware that
lack of nutrients in food (major cause), may lead to a very serious disease.
Patients with this kind of nutritional status should be very aware on their
lifestyles to prevent the manifestation of the disease.
Computation of diet
Conversion:
Diet Distribution:
Ht: 93cm
PRO: 17.5 g
Wt: 13 kg CHON: 250 g
FAT: 45g
DBW: (age in years x 2) + 8
PRO: 17.5 X 4 =70 g
=8+8=16 CHON: 70% (NPC)
4
=16kg = 1330 (.70)
4
TER: (Narins & Weil Formula) = 250 g
=1000+(4x100)
FAT: 1330 (.30) =45 g
=1400 kcal + 500 Kcal 9
Sample Menu
Breakfast
Fruit Banana, 1 pc.
Meat Egg Sandwich
Boiled egg, 1 pc.
Mayonnaise, 2 tsps.
Cereals/ Grains Loaf Bread, 2 pcs.
Beverage Milk, 4 tablespoons (250 ml)
AM snack
Camote cue
Camote, 1 pc.
Sugar, 2 tsps.
Oil, 2 tsps.
Lunch
Meat
Vegetables Sauteed Squash, ½ cup
Tomato, ¼ cup
Oil, 1 tsp.
Cereals/ Grains Rice, 1 cup
Dessert Watermelon, 1 slice
Beverage
PM snack Biko, 1 slice
Supper
Meat
Vegetables Adobong Beans, ¼ cup
Cereals/ Grains Rice, ½ cup
Dessert
Beverage
A. Socioeconomic Profile
Birthday: May 10, 2014
Age: 4years old Birth Order:2
MOTHER FATHER
Age in years as of last birthday: Judie Warry
Occupation:
Educational Attainment: 2nd Year Highschool
C. Health History
Birth weight: 2.2 kg Nutritional Status: normal
If birth weight can’t be recalled, ask assessment of respondent if child was
seemingly overweight or of normal nutriture at birth.
Any health problem at birth? (/) None ( )Yes, please specify: ____________
Immunization: ( /) Completely immunized ( ) Incomplete
Familial Diseases, if any: Tuberculosis
(Indicate cause of death of immediate family members if died before age 60, e. g. parents,
siblings, uncles)
Illnesses the child suffered from during the growing years? Cough and colds
Past hospitalizations (year and diagnosis): Fibril Convulsion
Health Behaviors
What is done when child suffers from an illness?
( ) Home medication, please enumerate ____________________
(/ ) Bring for checkup at health facility
If brought for checkup/ treatment, where?
(/ ) Hospital ( ) Barangay clinic
( ) Private clinic ( ) Municipal health center
( ) Others, e.g. albularyo, please specify _______________
Ask about parents’ nutritional status (including mother/s weight gain during pregnancy)
Mother: wt: _____ ht: _____ BMI: ____________ NS: ____________
Father: wt: _kg ht: ____ BMI: _ ___ NS: __ _
E. Physical Activity
PM SNACK
Location
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