Health History

Demographic (Biographical) Data

Client’s Name: Angelo Gardaya

Gender: Male
Age: 8 years old
Birth Date: December 23, 2002
Birth Place: Dasmarinas Cavite
Marital Status: Single
Race/Nationality: Filipino
Address: Blk. 28 Lot 7 Molino Hms. 2, Salitran 3, Dasmarinas, Cavite, City

Date Admitted: December 22, 2010

Time: 05:26 pm
Doctor Incharge: Dr. Montano
Diagnosis: Fracture closed complete diplaced spinal middle 3 rd femur right

Nursing History

 Few hours prior to consultation, patient fell from the bike where he was eventually hit by his
friend on the right thigh.

Diagnostic Procedure

 CBC c PC- he complete blood count (CBC) is one of the most commonly ordered blood tests. The
complete blood count is the calculation of the cellular (formed elements) of blood. These
calculations are generally determined by special machines that analyze the different
components of blood in less than a minute.
 ESR- The erythrocyte sedimentation rate (ESR) is an easy, inexpensive, nonspecific test that has
been used for many years to help detect conditions associated with acute and chronic
inflammation, including infections, cancers, and autoimmune diseases.
 CRP- Fast and accurate blood tests for detection of inflammation.

 PTT- Partial thromboplastin time (PTT) is a blood test that looks at how long it takes for blood to
clot. It can help tell if you have bleeding or clotting problems.

 Blood Typing- Blood typing is a method to tell what specific type of blood you have. What type
you have depends on whether or not there are certain proteins, called antigens, on your red
blood cells.

 X-Ray- X- examination is painless, fast and easy. The amount of radiation exposure you receive
during an X-ray examination is small.
Medical Management

 Cefalexcin 250mg/5ml- 1 ½ tsp. TID- Cefalexin is used to treat urinary tract infections,
respiratory tract infections, and skin and soft tissue infections.

 Ibupropen 200mg/5ml TID- it is used for relief of symptoms of arthritis, primary dysmenorrhea,
fever, and as an analgesic, especially where there is an inflammatory component.

 Co-Amoxiclav 312.5/5 5ml TID x 7 days- This combination results in an antibiotic with an
increased spectrum of action and restored efficacy against amoxicillin-resistant bacteria that
produce β-lactamase.

 Omeprazole 20mg/ IV OD- is a proton pump inhibitor used in the treatment of dyspepsia, peptic
ulcer disease (PUD), gastroesophageal reflux disease (GORD/GERD), laryngopharyngeal reflux
(LPR) and Zollinger-Ellison syndrome.