II. HISTORY TAKING A.

Patients Profile Name: Arejay Rank: ED/Son Age: 13years old Sex: Male Status: Single/ Child Religion: Roman Catholic Birthday/ Birthplace: 18 December 1998/ Guimba, Nueva Ecija Address: Village Apartment N, Camp Aquino, San Miguel, Tarlac City c/o Tsg Fernando Baligad COC, NOLCOM, PA Chief Complaint: Fever Date/ Time of Admission: 10 1945H January 2012 Type of Admission: Direct; Ambulatory Admitting Diagnosis: T/C Hemorrhagic Cystitis; UTI Date of Discharge: 17 January 2012 Final Diagnosis: Parotitis, bilateral resolved; UTI Attending Physician: Cpt. Rafael Respicio B. Socio- Demographic Characteristics Arejay lives at Village, Camp Aquino, San Miguel, Tarlac with his parents and four siblings. Hes the only boy and the middle child of the family. He lives in a two-storey house owned by the NOLCOM Personnels. He is a first year highschool student at Tarlac National Highschool Annex, San Miguel, Tarlac City, a several kilometres away from home; with great pride and honor. He is supported by his father, a soldier; his mother is a plain housewife. He is an active football player. C. Concept of Health, Illness and Hospitalization Since Arejay is within the vicinity of the camp, he is remarkably oriented to health and illness. He views health as being well and be able to do his tasks normally; while he views illness as being weak and not able to do what hes capable of when hes well. Hospitalization for the patent is impossible at first, because he himself doesnt want to be confined unless it is really needed. Whenever the patient is not feeling well, he consults a physician, but afraid to be confined. D. Common Health Practices at Home When the client gets sick, he immediately tells his parents especially his mother for some remedy. They usually take medicines not prescribed by a physician when they know the common or usual medicine for a specific illness. If they cant managed it by themselves, thats the time theyll go to the nearest hospital, which is Camp Aquino Station Hospital. He is a fully- immunized child and attends dental check up as needed. He takes a bath everyday, washes his hands before and after eating, brushes his teeth every after meal. He takes vitamins; and if hes not feeling well, he immediately tells his mother and asks for remedy.

E. Immediate factor that brought about Illness The client was unaware of his action prior his admission to the hospital. A day prior his admission, he played football and took a bath after the game. The next day, he had a persistent headache in the morning and had a fever in the afternoon. One day prior to admission, the child played football and took a bath after the game and immediately had headache after. The next day he had a headache at the morning followed by a fever in the afternoon with temperature of ... On Wednesday, swelling is noted on the parotid area bilaterally. F. Comprehensive History 1. History of Present Illness It was Monday, 9th of January, a day prior his admission, he played football and took a bath after the game. The next day, Tuesday, he had a persistent headache in the morning and had a fever in the afternoon. With his parents, they had him consulted by a physician at Camp Aquino Station Hospital on 10th of January 2012. He was initially diagnosed with Hemorrhagic Cystitis; UTI. He had laboratory work ups and found out of having UTI through the results. On Wednesday, swelling of the parotid area was noted. He was given Paracetamol to aid fever; Inosoplex to treat his................. 2. Past Medical History The patient had no previous hospitalizations. He had his immunizations of Anti- Measles, Hepa B, OPV, DPT, BCG, Flu and Chickenpox Vaccine. He had no booster doses and Tetatnus Vaccine. When he was still 1 year old, he had asthma. He had a recurrent sinusitis and upper respiratory tract infection specifically cough and colds. He had no known allergy to food and drugs. 3. Family and Social History Grandmother (+) Hypertension

Grandfather (+) Emphysema

Grandfather No known illness

Grandmother No known illness

Father No known illness Patient (+) Asthma (+) Kidney disease

Mother No known illness

Both parents of Arejay have no known illness. But his grandparents on his father side had a history of hypertension and emphysema. Arejay is a passive smoker and never had any alcoholic drinks yet. 4. Nursing History Health Perception- Health Management Arejay perceives health as an important factor in our activities of daily living. Being healthy is a mere fact that were able to do our tasks well. In managing his health, they seek help from a quack doctor before consulting a physician. He is compliant when it comes to taking medicines for him to get well soon. Nutritional- Metabolic His height is 51. His weight is 47 kg. He seldom eats vegetables; he only eats tortang talong and camote tops. He always eats fruits like grapes and banana. His favourite food is Paksiw na Bangus. He drinks for about 1-2 liters of water per day, but often drinks carbonated beverages. He is fond of eating junk foods. Elimination Before he was hospitalized, he was able to void up to 5x per day depending on the amount of water he consumes. He described his urine as yellowish in color and no foul smelling odor. He has regular bowel elimination, usually in the morning. Activity/ Exercise He is a playful child and active as he is. Arejay enjoys playing outdoor games like football with his team. He also loves biking, usually almost every afternoon. He is fond of surfing the net and watching TV shows while at home. He knows how draw. Cognitive- Perceptual Arejay is a first year highschool student. He is one of the top 3 in their class. Hes able to read, write, and hear things correctly and clearly. He can easily understand things that are taught to him. Arejay knows how to speak Ilocano, Tagalog, Kapampangan and English. He is oriented to time, place and person.

Sleep- Rest Arejay has a normal sleep pattern. He consumes 10 hours of sleep everyday. He usually sleeps from 2000H- 0600H. He has no difficulty in sleeping. Role- Relationship He is close with his siblings but not with his parents. He does not keep an open communication with his family. Sexuality/Reproductive

Coping/ Stress

Values belief

Family and social history On his father side, his grandmother is known to have a history of hypertension, while his grandfather was known to have emphysema. There was no noted history of illness on his mother side.

Present illness Condition started one day prior to admission when Arejay experienced headache. He was given two doses of Paracetamol. Few hours prior to admission, the patient had persistent headache followed by fever in the afternoon. From then on, they had consulted at Out Patient service at Camp Aquino Station Hospital, and was given Paracetamol....................

G. Physical Assessment General Survey Overall Physical Appearance: Arejay is tall for his age, dark in complexion, not so neat in appearance; awake on bed, conscious and coherent, weak in appearance, not in CardioPulmonary distress..............

Behaviour: The patient is cooperative......... Height: 51 Weight: 47 kg Communication Pattern: He knows how to speak Ilocano, Kapampangan, Tagalog and English. Vital Signs: Physical Examination Date of Assessment: 10 January 2012 General Appearance: Awake on bed, conscious and coherent, ambulatory, not in cardio- pulmonary distress; weak in appearance. Vital signs taken as follows: BP- 110/70 PR- 72bpm RR- 24cpm Temp- 38.9 Skin: Dark in complexion; warm to touch; flushy cheeks