Pediatric Case Study: Thrombocytopenia

CASE 1- CLINICAL CASE STUDY
CHAPTER 1 ASSESSMENT
A. Nursing Health History
Biographical Information:
Heidi, 5 years old female was born on December 5, 2001 a t Imus, Cavite. Presently residing with her
parents at Zobel Roxas, Malate, Manila. She is currently enrolled in a prep school somewhere
in Malate. She is a Roman Catholic. These data were gathered and confirmed on July 12, 2006 at the
Ospital ng Maynila.
Chief Complaint
"Ilang araw nang mataas ang lagnat nya" , as verbalized by the client's mother.
History of Present Illness
Three days prior to admission, the client experienced high grade fever with a temperature of
40C, sudden loss off appetite and body weakness. The next day (1 day prior to admission), her
mother brought her to the health center. Health care provider did a torniquet test and the
result was positive (+). The health care provider advised the clients mother to bring her
child to the nearest hospital for more thorough work up, and, as advised, the client was
brought to Ospital ng Maynila. CBC (Complete Blood Count) was done. CBC shows that her
platelet count is significantly decreased. Symptoms persist and rashes (petechiae) started to
develop. With the results, the client was admitted at the pediatrics ward.
Past Medical History
a. Gynecologic History
Client's mother experienced menarche when she was 12 years old; consumed 3-4 pads a
day, moderately soaked, without dysmenorrhea. Subsequent menses have been regular; consuming
3-4 pads a day moderately soaked, without dysmenorrhea. OB Score Gravida 2 Parity 2 (2-0-0-2) TPAL.
b. Pre- natal history
Client is the eldest of 2 siblings. The mother never failed to visit the health center for
check up during the entire period of pregnancy. The clients mother had Urinary Tract
Infection during her fifth month of pregnancy, but, has been treated accordingly by an
OB doctor. She was able to receive TT1 and TT2.
c. Intranatal History
Client was born at 40 weeks of gestation, cephalic presentation, via Normal Spontaneous
Vaginal Delivery, by a midwife at their house, without difficulty or complications.
d. Post Natal History
The client received complete doses of BCG, DPT, OPV, Measles and Hepa B
immunizations. She was breastfed up to 6 months old, solid foods were also introduced. Clusivol
syrup was her daily vitamins she has not experienced mumps and other childhood illness.
Client experienced no major injuries, accidents. The present admission is the client's first
hospitalization. Client has no known allergies to food, drugs and other substances.
Family Health History
No heredo-familial diseases.
Social History
Client is the eldest of 2 siblings . At 6 months, she was already able to crawl and speak the
words like "mama" and "papa". She is leaving with her parents at Zobel Roxas, Malate, Manila. The
house is small but made of both wood and concrete cement, located beside a small creek.
However according to the mother, the space is just adequate for the 4 of them. The breadwinner is the
client's father, who is a cook at a canteen near UST, earning 6000 pHp a month. The client's mother
is a house wife, taking care of the client. According to them, the income is just enough for their basic
necessities. The client enjoys playing outside their house with her playmates.
NCM 100 CASE STUDIES (edited 01_28_2011)
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Developmental Theories
Psychosocial theory
According to Erik Erikson's psychosocial theory, at this age, the social task of the child is to
develop initiative versus guilt. Initiative adds to autonomy the quality of undertaking, planning and
attacking a task for the sake of being active and on the move. The child is learning to master the
world around them, learning basic skills and principles of physics. Things fall down, not up. Round
things roll. They learn how to zip and tie, count and speak with ease. At this stage, the child wants to
begin and complete their own actions for a purpose.
Analysis:
In relation to our client, the mother stated that her daughter was trying to do things on her
own. One e x a m p l e o f i t w a s t o r i d e t h e b i c y c l e a l o n e o r c ro s s t h e s t re e t a l o n e ,
a c c o r d i n g t o t h e m o t h e r.
Psychosexual Theory
In psychosexual theory, Freud describes school age as the phallic stage.. In this stage, the primary focus
of the libido is on the genitals. Children also discover the differences between males and females.
Analysis:
In relation to our patient, her mother stated that their child wants to always be with her father anywhere
he goes.
Cognitive theory
According to Piaget's cognitive theory, at the age of between 4 and 7 years, Children
tend to become very curious and ask many questions; begin the use of primitive reasoning. [10] There
is an emergence in the interest of reasoning and wanting to know why things are the way they are.
[10]
Piaget called it the intuitive substage because children realize they have a vast amount of
knowledge but they are unaware of how they know it.
Analysis:
According to the clients mother, Heidi tends to ask many questions and feels as if she always
know the answers.
Moral Development Theory
Kohlberg defines School age in pre-conventional level stage 2, in which child develops
individualism. Child carries out action to satisfy own needs rather than society. Toddler may not obey
request from other people because they do not view their authority as being the same as their
parents' authority.
Analysis:
Mother states that the patient likes to buy candies on her own so they just give money.
Spiritual Development Theory
James Fowier view the school age as an intuitive-projective faith in which children at this age has
no real understanding of spiritual concept. They view faith as magical, inventive, and derived
primarily from significant others or parents.
Analysis:
The mother told us that they used to bring their son to the church, but still the child wasn't
able to know the reason why they go to church. The only thing that the child knows is to behave
inside the church.
B. Physical Examination
A. General Appearance
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The client has a small frame body built. She has an upright posture and a smooth
rhythmic gait. The client is appropriately dressed and well groomed. She has no body odor. She
weighs 24kg and has no obvious physical deformity. Generalized rashes were observed,
dominantly on the clients lower extremities. Mosquito bites were also seen. She is weak
looking. Vital signs are as follows: Temp 38.5 C, HR= 100bpm ; RR= 22 cpm; BP 100/70
mmHg
B. Mental Status
The patient is conscious, coherent but irritable. With mood affect and oriented to place,
time and person. Responds appropriately and slowly in an understandable manner. Uses simple
words to communicate.
C. Skin
The skin is of normal racial tone (brown). Warm to touch, dry and smooth. Elastic and
mobile skin turgor. With generalized rashes and obvious mosquito bite marks.
D. Hair
With black hair at shoulder level, evenly distributed, thin silky and resilient. No infestation and
dandruff seen.
E. Nails
Nail plate shape is convex. Approximately 160 in curvature. Nails are cut short; nail bed color
is pink, capillary refill within 3 seconds upon administration of blanche test. The texture is
smooth.
F. Head and Face
With rounds, normocephalic and symmetrical with frontal, parietal, and occipital prominence . Hair
is evenly distributed. Facial features are symmetrical and so is the facial movement. The clients skin is
flushed.
G. Eyes
Thin eyebrows and eyelashes are evenly distributed and symmetrical. Skin surrounding the
eyes is intact without any discoloration, lids close symmetrically with 15-20 blinks/min. The sclera is
white, palpebral conjunctiva is shiny, smooth and pinkish while bulbar conjunctiva is clear. No edema
or tenderness on the lacrimal glands. The pupils are equally round (2-3mm) in diameter and
reactive to light and accommodation. Both eyes are coordinated; move in unison w/ parallel alignment
(8 ocular movements. She is able to recognize objects that are 20 feet away from her.
H. Ears
Auricle is in normal racial tone (brown in color), symmetric and elastic. Symmetrical and aligned
with outer canthus of the eye, about 10 degrees from vertical view. Upon palpation, auricles are mobile,
firm and non tender. Pinna recoils when folded. Using an otoscope, the tympanic membrane has semitransparent and pearly gray membrane.
I. Nose
With symmetrical and straight nares. Without discharge, flaring and uniform in color. Air
moves freely through the nares as the client breathe. Nasal mucosa is pink. Nasal septum is intact
and at the midline. Nasal sinuses are non tender. No epistaxis (nose bleeding) noted.
J. Mouth and Oropharynx
Lower and upper lips has uniform pink color. Soft, dry and smooth in texture and able to
purse lips. Inner lips and buccal mucosa is pink, moist, smooth, soft and elastic. Have 12 incomplete
milk teeth. The tongue is at the midline. Pink in color with smooth lateral margins, no lesions and
moves freely w/o tenderness. Salivary glands intact, pinkish in color without any lesions. With light
pink colored hard and soft palate positioned in the midline with smooth posterior wall. Tonsils and uvula
are not inflamed. Gum bleeding noted.
K. Neck
Neck muscles are equal in size. Head is in the center. Head movement has coordinated
movement, smooth and without any discomfort. There is equal muscle strength 5/5 and has palpable
lymph nodes (pre auricular). Trachea is in midline. Thyroid gland is not palpable but ascends during
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swallowing.
L. Breast and Axilla
Skin is smooth, breast are flat. No masses palpated. Nipples are pink and symmetrical.
M. Chest and Lungs
Shape is AP to transverse diameter has a ratio 2:1, chest expansion is symmetrical. Skin is
intact with uniform color and temperature. No tenderness and masses upon palpation. With bilateral
symmetry of vocal tactile fremitus. Resonance is heard over the lung thorax. Diaphragmatic excursion is 3
mm. Costal angles is 80 and the ribs is 45. Upon auscultation, Bronchial (trachea) sounds
bronchovesicular (main bronchi) sound.
N. Heart
There are no masses and lesions in the skin. Here is palpable pulsation at the left ICS (5 th ) MCL; in an
area of 1-2 cm in diameter. Carotid pulse is bounding regularly synchronous w/ S1. Apical and radial
pulse has equal rate and rhythm.
O. Abdomen
The skin is uniform and the skin is unblemished. The shape is protuberant. There is symmetric
movement caused by respiration. Bowel sound is 3/min and without arterial bruit and friction rub. No
tenderness. The bladder is not distended. Liver and spleen are not palpated.
P. Musculoskeletal system
The muscles have equal size and both sides of the body. There are no contractures or
fasciculation present. Muscles are firm, smooth with coordinated movement. Bones does not have any
deformity, tenderness or Swelling.
Q. Genital
No public hair present.
CASE 2 COMMUNITY CASE STUDY

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PERSONAL DATA
Viktoria is a 4-year-old girl who resides at # 129, Palangue 3, Naic, Cavite. She was
born last January 1, 2008. She is a Filipino, a Roman Catholic and she is not yet studying. Their
source of Health Care is the Health Center near their house. The date of interview was January 26,
2011 at the client's house.
CHIEF COMPLAINT
"May ubo po ako," as verbalized by the client.
PRESENT HEALTH STATUS
Three days prior to the day of interview, the client had cough and cold. Her mother said
that her daughter had difficulty in breathing. Sometimes the coughs continuously occur within
three minutes. Her mother also said that maybe she got cough and cold because of her
playmate that has this illness. Her mother claimed that she gave the client Paracetamol as her
medication. She also claimed that her daughter takes Ceelin everyday as her Vitamins.
FAMILY HISTORY
There is no heredofamilial disease noted.
SOCIAL HISTORY
The client is not going to school yet. She enjoys watching cartoons and playing with
their neighbors.
PAST HISTORY
Prenatal
The client's mother reported that she took ferrous sulfate when she was pregnant. There
was no exercise done. The mother didn't drink any milk. She does not smoke nor drink alcoholic
beverages. She said that the pregnancy was planned. She gained weight during the pregnancy
but she forgot how much she gained during the pregnancy.
Natal
She gave birth to the client around 8:30 in the morning last January 1,2009 . Client was
delivered through NSVD and a cephalic presentation. Her grandmother was the one responsible for
the delivery of the baby at their parent's house of the client.
Postnatal
The client's birth weight was 3.5 kilograms. There were no complications after the delivery
and there were no illnesses present. She had a weak cry. She was breastfed. Her mother said that
the client always cries whenever she is hungry and wants to sleep. Sometimes the client's mother
sings to help the client sleep. The client was healthy generally according to her mother.
Nutrition
The client loves to eat chicken whether it is fried or cooked in different meal. She eats
four times a day, which includes breakfast, lunch, merienda and dinner. Sometimes she only eats
rice without any viands. She loves to eat biscuits or any snacks whenever she doesn't do anything
or anytime of the day. The client loves to drink milk from the bottle while watching
cartoons,however, according to the mother, the client cant tolerate sucking on the
bottle at present because shes having a hard time breathing due to the clogged
nostrils.
REVIEW OF SYSTEM
Growth and Developmental Theories (1-3 years old)
Psychosocial Theory (Erik Erickson)
,
According to Erik Erikson's psychosocial theory, at this age, the social task of the child is to
develop autonomy versus shame and doubt. This is important to the child's development in ability
to balance between love and have, cooperation and willfulness, freedom of expression or
suppression. If the child develops autonomy, they are practicing more on self-government or
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independence, like they want to do everything on the ir ow n. O n the othe r si de, w hen they
deve lop shame and doubt;
Analysis
In relation to our client, the mother stated that her daughter was trying to do things on her
own. One 'example of it is when the child is trying to stand on her own; her mother just let her do
it, for her to become independent on what she is doing.
Psychosexual Theory (Sigmund Freud)
In psychosexual theory, Freud describes toddler as the anal stage. In this stage, children have
widened interest and mainly focused on their anal region. The children find pleasure in controlling
and expelling feces, and provide a sense of control. The process of toilet training is regarded as the
solution of this conflict.
Analysis
In relation to our client, her mother stated that they were trying to toilet train their daughter.
However client in some instances client defecates anywhere on her cloth diaper (lampin).
Cognitive Theory (Piaget)
According to Piaget's cognitive theory, at the age of 12-18months, the children is under the
stage of tertiary circular reaction in which instead of reproducing accidental events, the child
chooses to vary them thereby finding new solution to old problem. In relation to our client, the
mother verbalized that the client is having fun playing toys that has a diff erent colors and shape.
She tries to put the right shape that was the same as the hole in the box. This kind of toy helps the
child develop his problem.
Analysis
According to the mother, the client likes to play rubic's cube toy and has different shapes and
colors of toys.
Moral Developmental Theory (Kohlberg)
Kohlberg defines toddlerhood in pre-conventional level Stage 2, in which the child develops
individualism. Child carries out action to satisfy own needs rather than society. Toddler may not obey
request from other people because they do not view their authority as being the same as their
parents' authority.
Analysis
Mother states that the client likes to buy candies on her own so they just give her money.
Spiritual developmental Theory (Fowler)
James Fowler view the toddlerhood as intuitive projective faith, in which children at this age
has no real understanding of spiritual concept. They view faith as magical, inventive, and derived
primarily from significant others or parents.
Analysis
The mother told us that they used to bring their daughter to the church, but still the child
wasn't able to know the reason why they go to church. The only thing that the child knows is to behave
inside the church.
B. PHYSICAL ASSESSMENT
A. General Appearance
The client has a small frame body built. She has an upright posture and a smooth
rhythmic gait. The client is appropriately dressed and is not well groomed. Pungent odor was
noted. She weighs 15 kg and has no obvious physical deformity. The client is wearing a
sando and a soaked cloth diaper (lampin) Rashes on the perianal area was seen and
itchiness was noted. Vital signs are as follows: Temp 38.2 C, HR= 104bpm ; RR= 28cpm;
BP 100/70 mmHg
B. Mental Status
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The patient is conscious, coherent and cooperative With mood affect and oriented to place,
time and person. Responds appropriately and slowly in an understandable manner. Uses simple
words to communicate.
C. Skin
The skin is of normal racial tone (brown). Warm to touch, dry and smooth. Elastic and
mobile skin turgor. With rashes on the perianal area.
D. Hair
With shoulder length black hair, evenly distributed, thin silky and resilient. No infestation and
dandruff seen.
E. Nails
Nail plate shape is convex. Approximately 160 in curvature. Nails are cut short; nail bed color
is pink, capillary refill within 3 seconds upon administration of blanche test. The texture is
smooth.
F. Head and Face
With rounds, normocephalic and symmetrical with frontal, parietal, and occipital prominence . Hair
is evenly distributed. Facial features are symmetrical and so is the facial movement.
G. Eyes
Thin eyebrows and eyelashes are evenly distributed and symmetrical. Skin surrounding the
eyes are intact without any discoloration, lids close symmetrically with 15-20 blinks/min. The sclera is
white, palpebral conjunctiva is shiny, smooth and pinkish while bulbar conjunctiva is clear. No edema
or tenderness on the lacrimal glands. The pupils are equally round (2-3mm) in diameter and
reactive to light and accommodation. Both eyes are coordinated; move in unison w/ parallel alignment
(8 ocular movements. She is able to recognize objects that are 20 feet away from her.
H. Ears
Auricle is in normal racial tone (brown in color), symmetrical and elastic. Symmetrical and
aligned with outer canthus of the eye, about 10 degrees from vertical view. Upon palpation, auricles
are mobile, firm and non-tender. Pinna recoils when folded. Using an otoscope, the Tympanic
membrane has semi-transparent and pearly gray membrane. There is presence of cerumen in
the external canal and the client can respond to whispered voice.
I. Nose
With symmetrical and straight nares. With greenish nasal discharge. Nasal flaring was
observed. There is difficulty in the clients breathing pattern due to the nasal discharges . Nasal
mucosa is pink. Nasal septum is intact and at midline. Nasal sinuses are non-tender. Client has difficulty
recognizing the smell of coffee.
J. Mouth and Oropharynx
Client coughs from time to time. Outer lips has uniform pink color. Soft, dry and smooth in
texture and able to purse lips. Inner lips and buccal mucosa is pink, moist, smooth, soft and
elastic. Have 12 incomplete milk teeth. The tongue is at the center. Pink in color with smooth lateral
margins, no lesions and move freely without tenderness. Salivary glands are intact, pink in color
without any lesions. With light pink colored hard and soft palate positioned in the midline with
smooth posterior wall. Tonsils and uvula are inflamed.
K. Neck
Neck muscles are equal in size. Head is in midline. Head movement is coordinate, smooth
and without any discomfort. There is equal muscle strength with a grade of 5/5 and has palpable
lymph nodes in the pre auricular area. Trachea is in the midline. Thyroid gland is not palpable but
ascends during swallowing.
L. Breast and Axilla
Skin is smooth, breasts are flat. No masses palpated. Nipples are pink in color, dry symmetrical.
Brown color axilla.
M. Chest and Lungs
Shape is AP io transverse diameter has a ratio of ratio 2:1, chest expansion is symmetrical.
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Skin is intact with uniform color and temperature. No tenderness and masses upon palpation.
With bilateral symmetry of vocal tactile fremitus. Crackles (halak) were heard and she uses
accessory muscle to aid in breathing.
N. Heart
There are no masses and lesion in the skin. Heart has palpable pulsation at the left ICS (5th) MCL;
in an area of 1-2 cm in diameter. Carotid pulse is bounding regularly synchronous with Sl. Apical and
radial pulse has equal rate and rhythm.
O. Abdomen
The skin is uniform and the skin is unblemished. There is symmetric movement caused by
respiration. Bowel sound is 3/min and without arterial bruit and friction rub. No tenderness. Liver,
bladder and spleen are not palpated
P. Musculoskeletal System
The muscles have equal size in both sides of the body. There is no contractures or
fasciculation present. Muscles are firm, smooth with coordinated movement. Bones does not
have any deformity, tenderness or swelling.
Q. Genital
No pubic hair present. Rashes on the labia majora extending to the buttocks were
noted.
C. DIAGNOSTIC PROCEDURE
No diagnostic procedure done to the client
CASE 3 - CLINICAL CASE STUDY

A. NURSING HEALTH HISTORY
Personal Data
Name: Jeremy
Age: 15 years old
Sex: Male
Race: Fiipino
Religion: Iglesia ni Cristo
Birth Date: March 27, 1994
Birth Place: Tarlac
Present Address: Unit E-3 Bldg 10, Ilang- Ilang St. Sta. Mesa, Manila
Provincial Address: Anonas St. Panique, Tarlac
Usual Source of Health Services: Capitol Medical Center
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Date of Interview March 30, 2008 at 7: 00 am

Chief Complaint
"Nahihiya na ako kasi hindi pa ako tuli, takot kasi ako maoperahan", as verbalized by the client.
1 day prior to surgery, clients parents decided to bring their child in Capitol Medical Center for
circumcision Jeremy was brought then the next day for surgery at 10 am on March 31, 2008, .
Past Medical Illness
Client claims that he has no history of hospitalization but had a chicken pox when he was 9 years old
that was treated at home. His mother reported that Jeremy had the following immunization: BCG, DPT3, HepaB3,
OPV3, and MMR before he reached 10 years of age.
Family History
Client's parents denied for any hereditary disease. (Genogram not applicable)
Social History
Client Jeremy is the only child in the family, living with her father and mother in Sta. Mesa,
Manila. Jeremy verbalized `Hindi na magkakaanak si Mama pero ok lang kasi masaya na kaming tatlo sa bahay_'
They have an open communication with each other and with harmonious family living pattern. They have an
adequate space at 3rd floor of a condo unit type. Both his parents are working as government
employees in their City. Health Centers/ Hospitals are accessible such as Ospital ng Sampaloc, Capitol Medical
Center and De Ocampo Medical Hospital.
Nutritional Data
Breakfast Fried Rice
Boiled Egg
Bacon
Milk
1
1
3
1
Snacks
Cake
1 slice
Lunch
Steamed Rice
Pork Sinigang
Steamed Rice
Chopseuy
1
1
1
1
cup
piece
strips
glass
High in Carbohydrates with

High in Protein and Fats
High in calcium
Fats
Dinner
cup
serving
cup
serving
High in Calories
Carbohydrates
High in Protein
High in Carbohydrates
High
in
Vitamins
Minerals
and
REVIEW OF SYSTEMS
Growth and Development
Psychosexual Theory by SIGMUND FREUD
Client is a 15 years old male. He is on the Genital stage. The ego in the genital stage is well-developed. It
uses secondary, process thinking, which allows for symbolic gratification. This symbolic gratification
may include the formation of love relationships, development of families, or acceptance of
responsibilities associated with adulthood
Analysis:
In relation to the patient, he is now adjusting from adolescent ot adulthood changes. His
parents are supportive but keeping their childs privacy. Client's mother verbalized Ayaw pasabi sa girlfriend nya
na nandito kami ngayon, nahihiya".
Psychosocial Theory by ERIC ERICKSON
Client is in Identity vs role confusion Stage. The adolescent is newly concerned with how they
appear to others. As they make the transition from childhood to adulthood, adolescents ponder the
roles they will play in the adult world. Initially, they are apt to experience some role confusion- mixed
ideas and feelings about the specific ways in which they will fit into society- and may experiment
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with a variety of behaviors and activities.

Analysis:
In relation to the patient, Jeremy is always getting into a fight because his classmates get to tease him the
uncut kid. He tend to feel that he doesnt belong because most of his male classmates have already been circumcised.
Cognitive Theory by JEAN PIAGET
Jeremy is in the Formal Operation Phase. During concrete operation They can solve concrete problems.
Formal operation Phase describes that child uses rational thinking, reasoning is deductive and futuristic. (Kozier
and Erb ed pg 357, 2008)
Analysis:
Client demonstrated logical reasoning when assessed about the concepts such as time, money
and application of addition and subtraction. This implies that the client acquires knowledge from his formal education
and applies it to the real situation of life.
Moral Development by LAWRENCE KOHLBERG
Most of the adolescent is spent in the Conventional Phase. Behavior is based on familial and peer
group beliefs, and conformity the norm is common. Following school regulations, respecting teachers, and viewing justice
as a means of fair play are all important
Analysis:
He has good relationship with his fiends 'Sa bahay minsan kumakain mga classmates ko lalo na
pag gumagawa kami ng project.
Spiritual Development by JAMES FOWLER
Jeremy is in the Synthetic conventional stage wherein faith is characterized by conformity.
The process by which an individual's attitudes, beliefs, and behaviors are influenced by what is
conceived to be what other people might perceive. This influence occurs in both small groups and
society as a whole, and it may be the result of subtle unconscious influences, or direct and
overt social pressure .
Analysis:
Client is a member of Iglesia ni Cristo who attends worship service every Thursday without
fail. He is also an active officer in their church as a member of their choir. He believes that words of God written
in the bible must be obeyed in order to be saved from the Day of Judgment.
B. PHYSICAL ASSSESSMENT
(03/30/08 P.A. done before and after surgery)
A. GENERAL APPEARANCE
Client has a small body built with an upright posture. He is appropriately dressed. Client has neither body
odor nor bad breath odor. No obvious physical deformity. His height is 4'11' and weighs 90 lbs obtained on
the day of surgery. Vital signs: T-36.5 C(axilla), RR 24cpm, PR 110 bpm, BP- 1 00/80 mm/Hg
(done after circumcision)
Vital Signs: 37.4 C, RR-22cpm, PR 77bpm, BP- 100/80mmHg
Looks weak with discomfort
With surgical bandage on the perineal area, clean and dry
B. MENTAL STATUS
The client is conscious and coherent, with good affect, oriented to date, time, person, and
place. He looks nervous due to impending surgery but answers questions appropriately. Uses simple words.
> conscious, coherent and Irritable
C. SKIN
The client's skin is of normal racial tone, which is brown, has warm temperature except palm,
which is cold to touch. Client's skin is smooth and has good skin turgor. No lesions noted and hair is fine that is evenly
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distributed.
> clients skin is warm to touch, has a smooth texture and skin turgor is elastic and
mobile
D. HAIR
With black hair, straight barber's cut, evenly distributed. No infection or infestation and dandruff
seen. Pubertal hair starts to grow.
> pubertal hair shaved off
E. NAILS
The clients nail plate shape is concave 1600. it has a smooth texture, pinkish nail bed.
Capillary refill exceeds 30 seconds. No presence of Beaus line.
>capillary refills within 3 seconds upon doing the blanche test
F. HEAD AND FACE
The client's skull is proportionate to his body size and has a smooth texture. The scalp is nontender and white. Hair is equally distributed, thin and is free from any infestations. No presence of nodules or
masses noted. The face as well as the facial movements is symmetrical. Head has a hard
consistency.
>Facial grimace observed
G. EYES
The client's eye condition is straight normal and eyebrows are thick. He has equal distribution
of eyelashes. The eyelids has no discharge and close symmetrically. He has a bilateral blink response. Eyeballs
are symmetric and firm. Bulbar and palpebral conjunctivas are clear. Pupils are equally reactive to light and
accommodation. Lacrimal apparatus are moist.
H. EARS
Client's auricle are of normal racial tone, whitish is brown, same with the color of the face, symmetrical in
size and position. The alignment of pinna is in line with the outer canthus of the eye. It is elastic and
nontender. Pinna recoils when folded. Theres presence of some cerumen, which is light brown in the
extemal meatus. Absence of discharge and there no swelling or redness observed.
I. NOSE
The patient's extemal nose is of normal racial tone color, brown, the same as with the face, septum at
midline, nares are symmetrical. Pink nasal mucosa, nares both patent and nasal cavity is moist. Sinuses are
nontender.
J. MOUTH AND OROPHARYNX

The patient's lips are symmetrical and dry. Buccal mucosa is dry. The tongue is at midline, moves freely,
rough and pink. Client's permanent tooth has erupted. Gums are pink, tonsils are not inflamed.
K. NECK
The client's neck muscles are equal in size. Preauricular, post auricualar, cervical, and supraclavicular
lymph nodes are not palpable. Trachea is at midline of neck with no deviation noted and thyroid gland is not
palpable.
L. BREAST AND AXILLA
There no masses palpated. Nipples are light brown in color, dry and symmetrical. The axilla is color
brown, dry and presence of hair starts to grow.
M. CHEST AND LUNGS
The client's chest is of normal racial tone, brown color. Lung shape is AP lateral ratio of 1:2.
Lung expansion is symmetrical anterior to posterior. Fremitus is found to be symmetrical and
decreasing in both sides. Vesicular, bronchial, and bronchovesicular breath sounds are heard. He has a regular
breathing pattern. Resonance was heard upon percussion. The costal angle of the client is 45 degrees. Aortic valve sound
was heard at the 2" d right intercostals space, pulmonic valve sound was auscultated ant 2" d left intercostals space;
mitral valve was heard at the 5'' midclavicular line, tricuspid valve sound was heard at the 4h right intercostals
space. Apical pulse has a rhythm that is regular with 80bpm; during the interview client's HR was 110 due to anxiety
Page 11
for the impending surgery- No murmurs were heard.

N. HEART
The client's apical pulse is equal in rate and symmetrical with regular rhythm and strength. HR-80 bpm,
however it was only observed to be increased during the interview but it was reassessed after 15 minutes
and the result went back to 80 bpm. The apical and radial pulse has equal rate and rhythm.
O. ABDOMEN
The client's abdomen is of normal racial tone color that is brown, flat contour and with symmetrical
abdominal movements. i t has a hyperactive bowel sounds which is 25 bowel sounds per minute, Bladder is not
distended. Liver is not palpable. Upon percussion, tympany was heard. Muscle guarding is nort present
> normal bowel sounds heard
P. UPPER EXTREMITIES
The client's motor strength is 5/5. Client can move his extremities freely. She has no physical deformity.
Bronchial and radial pulse is present. Lymph nodes are not palpable. No inflammation noted.
Q. LOWER EXTREMITIES
The client's motor strength is 5/5. He needs assistance in moving. Neither lesions nor physical
deformities observed. Dorsalis pedis, posterior tibial and inguinal pulses are present. Lymph nodes are not
palpable.
R. GENITALIA
Pubic hair starts to grow. There is no presence of lesions. Penis is not yet circumcised.
>Pubic hair shaved off, upon the removal of sterile dressing and elastic bandage,
(for assessment
purposes), sutures sorrounding the glans penis are present. The
glance penis is slightly swollen and bruises on the shaft to the scrotum are starting
to develop. Redness on the area was also seen.
S. RECTUM AND ANUS
The client's rectum and anus is patent. Gluteal folds are symmetric. Active anal reflex.
CASE 4 - COMMUNITY CASE STUDY

1. Personal Data
The client is J. C. 15 y/o male client. He is Filipino and was baptized as a member of the Roman
Catholic Church. He was born on March 27, 1994 in Batangas. He is the only child of Mr. and Mrs.
N.C. He is presently residing with his parents in Sta. Mesa, Manila. The usual source of health
services of his family is in Barangay Health Center & Sto. Thomas Medical Hospital The interview
was conducted last April 14, 2008 at 7:00 am.
2. Chief Complaint
"Nahiya na ako kasi di pa ako tuli, takot kasi ako maoperahan", as verbalized by the client.
3. History of Present Illness
1 day prior to circumcision, client's parents decided to bring their child in Barangay clinic for
a free Operation tuli conducted by medical volunteers . J.C. was brought then the next
day for circumcision at 10 am on April 4, 2008.
Page 12
4. Past Medical Illness

Client claims that he has no history of hospitalization but had a chicken pox when he was 9
y/o that was treated at home. His mother reported that J.C. had the following immunization: BCG1,
DPT3, HepaB3, OPV3, and MMR before he reached 10 years of age.
5. Family History
Client's parents denied for any hereditary disease.
6. Social History
Client J. C. is the only child in the family, living with her father and mother in Sta. Mesa, Manila
J.C. verbalized "Hindi na magkakaanak si Mama pero ok lang kasi masaya na kaming tatlo sa bahay".
They have an open communication with each other and with harmonious family living pattern.
According to J.C.,Their house is small but made of concrete cement and is spacious
enough for them. Both his parents are working as government employee in their City.
Health center / hospital are accessible such as Barangay Health Clinic in San Roque & Sto. Thomas
Medical Hospital. According to J.C. they also believe in the practice of the herbularyos and
also believes in superstitions.
7. Nutritional Status
The client tolerated food well; he did not experience or exhibit any eating problems.
24-hour food recall as follow:
Breakfast
Snacks
Lunch
Dinner
Fried rice
Boiled eggs
Bacon
milk
Cake
Steamed rice
Pork Sinigang
Steamed rice
Chopsuey
1
1
3
1
1
1
1
1
1
cup
piece
strips
glass
slice
cup
serving
cup
serving
High in carbohydrates with fats

High in protein
High in protein & fats
High in calcium
High in calories
Carbohydrates
High in Protein
High in carbohydrates
High in vitamins and minerals
Growth and Development

Psychosexual Theory by SIGMUND FREUD
Client is a 15 years old male. He is on the Genital stage. The ego in the genital stage is well-developed. It
uses secondary, process thinking, which allows for symbolic gratification. This symbolic gratification
may include the formation of love relationships, development of families, or acceptance of
responsibilities associated with adulthood
Analysis:
In relation to the patient, he is now adjusting from adolescent ot adulthood changes. His
parents are supportive but keeping their childs privacy. Client's mother verbalized Ayaw pasabi sa girlfriend nya
na nandito kami ngayon, nahihiya".
Psychosocial Theory by ERIK ERICKSON
Client is in Identity vs role confusion Stage. The adolescent is newly concerned with how they
appear to others. As they make the transition from childhood to adulthood, adolescents ponder the
roles they will play in the adult world. Initially, they are apt to experience some role confusion- mixed
ideas and feelings about the specific ways in which they will fit into society- and may experiment
with a variety of behaviors and activities.
Analysis:
In relation to the client, J.C. is now on the third year high school and has verbalized
that he wants to have a circumcision because he wants to get taller.
Cognitive Theory b y JEAN PIAGET
J.C. is in the Formal Operation Phase. During concrete operation They can solve concrete problems.
Formal operation Phase describes that child uses rational thinking, reasoning is deductive and futuristic. (Kozier
Page 13
and Erb ed pg 357, 2008)

Analysis:
Client demonstrated logical reasoning when assessed about the concepts such as time,
money, and application of addition and subtraction. This implies that the client acquires knowledge
from his formal education and applies it to the real situation of life.
Moral development by LAWRENCE KOHLBERG
Most of the adolescent is spent in the Conventional Phase. Behavior is based on familial and peer
group beliefs, and conformity the norm is common. Following school regulations, respecting teachers, and viewing justice
as a means of fair play are all important
Analysis:
Client has no records of misbehavior on their class. He has also a good relationship with his
friends. "Sa bahay minsan kumakain mga classmates ko lalo na pag gumagawa kami ng project," client
reported.
Spiritual Development by JAMES FOWLER
J.C. is in the Synthetic conventional stage wherein faith is characterized by conformity. T he
process by which an individual's attitudes, beliefs, and behaviors are influenced by what is conceived
to be what other people might perceive. This influence occurs in both small groups and society as a
whole, and it may be the result of subtle unconscious influences, or direct and overt social pressure .
Analysis:
Client is a member of the roman catholic church who attends worship service every Sunday
without fail. He is also an active officer in their church as a member of the choir. He believes that
words of God written in the bible must be obeyed in order to be saved come the Day of Judgment.
A. GENERAL APPEARANCE
Client has a small body built with an upright posture. He is appropriately dressed. Client has neither body
odor nor bad breath odor. No obvious physical deformity. His height is 4'11' and weighs 90 lbs obtained on
the day of surgery. Vital signs: T-36.5 C(axilla), RR 24cpm, PR 110 bpm, BP- 1 00/80 mm/Hg
Vital Signs: 37.4 C, RR-22cpm, PR 77bpm, BP- 100/80mmHg
With herbs wrapped in a handkerchief and wrapped on his head
Looks weak with discomfort, still chewing bayabas leaves
With elastic bandage on the perineal area, clean and dry
B. MENTAL STATUS
The client is conscious and coherent, with good affect, oriented to date, time, person, and
place. He looks nervous due to impending surgery but answers questions appropriately. Uses simple words.
> conscious, coherent and Irritable
C. SKIN
The client's skin is of normal racial tone, which is brown, has warm temperature except palm,
which is cold to touch. Client's skin is smooth and has good skin turgor. No lesions noted and hair is fine that is evenly
distributed.
> clients skin is warm to touch, has a smooth texture and skin turgor is elastic and
mobile
> herbal oil is applied on the clients back, arms and legs by the mother
D. HAIR
With black hair, straight barber's cut, evenly distributed. No infection or infestation and dandruff
seen. Pubertal hair starts to grow.
Page 14

> pubertal hair shaved off
E. NAILS
The clients nail plate shape is concave 1600. it has a smooth texture, pinkish nail bed.
Capillary refill exceeds 30 seconds. No presence of Beaus line.
>capillary refills within 3 seconds upon doing the blanche test
F. HEAD AND FACE
The client's skull is proportionate to his body size and has a smooth texture. The scalp is nontender and white. Hair is equally distributed, thin and is free from any infestations. No presence of nodules or
masses noted. The face as well as the facial movements is symmetrical. Head has a hard
consistency.
>Facial grimace observed
G. EYES
The client's eye condition is straight normal and eyebrows are thick. He has equal distribution
of eyelashes. The eyelids has no discharge and close symmetrically. He has a bilateral blink response. Eyeballs
are symmetric and firm. Bulbar and palpebral conjunctivas are clear. Pupils are equally reactive to light and
accommodation. Lacrimal apparatus are moist.
H. EARS
Client's auricle are of normal racial tone, whitish is brown, same with the color of the face, symmetrical in
size and position. The alignment of pinna is in line with the outer canthus of the eye. It is elastic and
nontender. Pinna recoils when folded. Theres presence of some cerumen, which is light brown in the
extemal meatus. Absence of discharge and there no swelling or redness observed.
I. NOSE
The patient's extemal nose is of normal racial tone color, brown, the same as with the face, septum at
midline, nares are symmetrical. Pink nasal mucosa, nares both patent and nasal cavity is moist. Sinuses are
nontender.
J. MOUTH AND OROPHARYNX

The patient's lips are symmetrical and dry. Buccal mucosa is dry. The tongue is at midline, moves freely,
rough and pink. Client's permanent tooth has erupted. Gums are pink, tonsils are not inflamed.
K. NECK
The client's neck muscles are equal in size. Preauricular, post auricualar, cervical, and supra davicular
lymph nodes are not palpable. Trachea is at midline of neck with no deviation noted and thyroid gland is not
palpable.
L. BREAST AND AXILLA
There no masses palpated. Nipples are light brown in color, dry and symmetrical. The axilla is color
brown, dry and presence of hair starts to grow.
M. CHEST AND LUNGS
The client's chest is of normal racial tone, brown color. Lung shape is AP lateral ratio of 1:2.
Lung expansion is symmetrical anterior to posterior. Fremitus is found to be symmetrical and
decreasing in both sides. Vesicular, bronchial, and bronchovesicular breath sounds are heard. He has a regular
breathing pattern. Resonance was heard upon percussion. The costal angle of the client is 45 degrees. Aortic valve sound
was heard at the 2" d right intercostals space, pulmonic valve sound was auscultated ant 2" d left intercostals space;
mitral valve was heard at the 5'' midclavicular line, tricuspid valve sound was heard at the 4h right intercostals
space. Apical pulse has a rhythm that is regular with 80bpm; during the interview client's HR was 110 due to anxiety
for the impending surgery- No murmurs were heard.
N. HEART
The client's apical pulse is equal in rate and symmetrical with regular rhythm and strength. HR-80 bpm,
however it was only observed to be increased during the interview but it was reassessed after 15 minutes
and the result went back to 80 bpm. The apical and radial pulse has equal rate and rhythm.
O. ABDOMEN
Page 15
The client's abdomen is of normal racial tone color that is brown, flat contour and with symmetrical
abdominal movements. i t has a hyperactive bowel sounds which is 25 bowel sounds per minute, Bladder is not
distended. Liver is not palpable. Upon percussion, tympany was heard. Muscle guarding is nort present
> normal bowel sounds heard
P. UPPER EXTREMITIES
The client's motor strength is 5/5. Client can move his extremities freely. She has no physical deformity.
Bronchial and radial pulse is present. Lymph nodes are not palpable. No inflammation noted.
Q. LOWER EXTREMITIES
The client's motor strength is 5/5. He needs assistance in moving. Neither lesions nor physical
deformities observed. Dorsalis pedis, posterior tibial and inguinal pulses are present. Lymph nodes are not
palpable.
R. GENITALIA
Pubic hair starts to grow. There is no presence of lesions. Penis is not yet circumcised.
>Pubic hair shaved off, upon the removal of sterile dressing and elastic bandage,
(for assessment
purposes), sutures sorrounding the glans penis are present. The
glans penis is slightly swollen and bruises on the shaft to the scrotum are starting
to develop. Redness on the area was also seen.
S. RECTUM AND ANUS
The client's rectum and anus is patent. Gluteal folds are symmetric. Active anal reflex.
CASE 5 - COMMUNITY CASE STUDY

Personal Data
The client is Mr. Yu a 22 ylo male, born on April 22, 1986 and was baptized in a Roman Catholic Church.
He is presently residing at Sta. Cruz, Sto. Tomas, Batangas. He is the third among the 7 siblings. His mother stays
at home as a plain housewife while his father died when he was still young. He works as a construction worker and earn
for the entire family as the sole breadwinner.
Chief Complaint
"Masakit ang katawan ko at nanghihina ako" as verbalized by the client.
Past Medical Illness
Patient has no known allergies on food or medications. As far as he could remember, he was
on his 3rd grade when he completed all his vaccines. The client has undergone circumcision and
tooth extraction as the only form of surgery.
There are no known heredofamilial diseases in the family.
Social History
According to the client, he is working as a construction worker from Mondays through Fridays
at 4 o'clock in the morning until 12 o'clock in the midnight depending on the given schedule to him.
He also works as a welder every Saturday. He usually sleeps at around 1 am and wakes up at around
3:30 am. The patient states that he rest during Sundays but spends most of his time with his friends drinking
Red Horse until they will get drunk. He does not engage to any form of gambles. Everyday the client smokes 3
sticks of cigarettes every after meals.
Review of Systems
Page 16
PSYCHOLOGICAL
The client assesses himself as a very hardworking person with a happy lifestyle but is not that
contented. He is not feeling alright today because his entire body is aching and he is feeling very weak. When
people discriminate him and his family, he gets mad. He values his family the most. He is the sole
breadwinner of the family. According to him, he earns 5000 Php every 15th of the month but it is not enough to feed
8 mouths three times a day and he sends three siblings to school. His mother and his eldest brother
are the ones who make decisions at home. He is not active in barangay meetings and does not want to be a part of
it. They utilize the community health center, when a member of the family is sick. The client has no difficulty in hearing
and vision. He is complaining of body pain and he is so weak and tired. He drinks alcoholic beverages to manage
his stress, along with his "barkadas". According to him, if his two elder brothers will also work and help
the family, he will not get stressed. The client wants his younger siblings to finish their study and have a
stable job. He wants to have someone to love (girlfriend) but he knows it is difficult. The family cares about
everything, especially on their health, but for him, they won't be able to afford the expenses when a
member of the family gets sick. The client is a Roman Catholic and also believes in superstition.
ELIMINATION
The client defecates once a day, every morning. He doesnt experience any discomfort or
pain. He urinates four times a day with approximately 630 cc and does not perspire excessively. Going to work
is his daily routine.
REST
The client sleeps at 1:00 am and wakes up at around 3:30 am every day; he does not have
enough sleep and rest. He only rest during Sundays but spends most of his time drinking and chatting with his
friends.
SAFE ENVIRONMENT
The client lives in Sta. Cruz, Sto Tomas Batangas. The place is very peaceful and clean, and has been
awarded as one of the CLEANEST COMMUNITY in the country. According to the client, he gets tired
easily. He puts pillows under his head and back to be able to breathe easier because its easier for him
to breathe when seated. He often eats vegetables because according to the client it is cheap.
Sometimes, when he has a lot of work to do and when he doesn't have money to buy food, the client skips his meals and
he does not take any vitamins.
24 Hour Dietary Recall
Meal
Food Quantity
Breakfast
2 cups of rice
I medium sized tuyo
2 cups of rice
I small can of
sardines
2 cups of rice
1 serving of
vegetables(pakbet)
Lunch
Dinner
Fluid Quantity
1 cup of coffee
2 glasses of water
2 glasses of water
Biochemical Appraisal
Rich in carbohydrates
Rich in Proteins
Rich in Carbohydrates
Rich in Proteins
Rich in Calcium
Rich in Carbohydrates
Rich in Fiber and Vitamins
a. General Appearance
The client has a medium frame body built. He has an upright posture and walks with a smooth
rhythmic gait. He looks very weak and tired. He is appropriately dressed but is in need to be
reminded about proper hygiene. No obvious physical deformities but there are noted insect bites.
Vital signs:
Temp = 37.0 'C
CR= 85 bpm
RR = 20 cycles per minute
BP= 120/80
b. Mental Status
He is conscious and coherent. The client is oriented to time, place and person.
c. Skin
The client's skin is dark brown in color. His temperature is warm and is smooth to touch. His skin turgor is
elastic and mobile. His hair is evenly distributed.
Page 17
d. Hair
The client's hair color is black, thick and evenly distributed. No noted infection or infestation on
his head but flakes was observed.
e. Nails
The client's nail bed is yellowish in color. He has convex 160 but long and dirty finger nails. The capillary
refill within three seconds, upon administration of blanche test and texture is smooth.
f. Head and Face
The client's skull is proportionate to his body size. H e has a symmetrical face and it moves easily
g. Eyes
He has straight normal eyes with white sclera and his pupils are 2-3 mm in diameter. Blink
response is present and there are no observed fallen eyelashes or eyebrows. His eyeballs are symmetrical
and firm. He is able to see objects 20 feet away. His conjunctiva is pale and has moist lacrimal apparatus.
h. Ears
The client has normal ear tone. Pinna recoils when folded, it is elastic and non tender. Some
cerumen was noted on the external and he can respond to normal voice.
i . Mouth and Oropharynx
He has pale symmetrical lips. His tongue rest in the midline, uvula is in the midline. Oral
mucosa is pink. Hard and soft palate are intact and his tonsils are not inflamed. Present gag reflex
was observed and teeth are complete.
j. Nose
The client's external nose has a normal racial tone. The septum rest s at the midline and his
nostrils are both patent. There are no nasal secretion observed and sinuses are not tender.
k. Neck
The client has a strong neck muscle. Lymph nodes are not palpable as well as the thyroid
gland. Trachea is at the midline.
I. Breast and Axilla
He has a flat symmetrical breast. There are no masses observed and palpated.
m. Chest and Lungs.
The client has regular breathing pattern. Both anterior and posterior lung expansions are
symmetrical. During auscultation, normal breath sounds were heard. He does not use accessory muscle.
n. Abdomen
The client has a normal racial tone abdomen. It is flat. Bowel sounds were heard and it is within
normal range. His bladder is not distended.
o. Upper and Lower Extremities
The client's muscle is strong and firm. At present, muscle tone is poor. Peripheral pulses are
present and there are no palpable lymph nodes.
p. Genitals
This part was not assessed.
C. Diagnostic Procedure Not applicable
Page 18
CASE 6 -- CLINICAL CASE STUDY

ASSESSMENT
NURSING HEALTH HISTORY
Personal Data
Ms. Y is a 26 year old female. She lives at Las Pinas City. She stands 5'4" tall and weighs 115
pounds. Ms. Y is the eldest among 4 siblings. The client's father is a retired accountant while her
mother is a college professor in a prestigious university. She is a Roman Catholic and was born on
February 22, 1971. She is a call center agent in Ortigas.
Chief Complaint
"I feel so weak and wobbly that I can't get up from bed to go to work" as verbalized by the
client.
The client has been reporting to work from 12mn to 8am a week prior to admission. Ms. Y
gets home by 10am and does household chores. She was able to get some sleep at around 5pm and
wakes up at 8pm to prepare for work.
The client experienced lingering headaches 2 days prior to admission. She was relieved by a
pain reliever which she has been taking every 4 hours 1 day prior to admission.
4 hours prior to admission, she felt body weakness and headache which prompted her to seek
consultation at Las Pinas Doctor Hospital.
Upon admission, her body temperature is 37.8 C and appears to be pale and weak.
Ms. Y has no known food or medication allergies. As far as she can remember, she has
completed all her vaccines when she was in grade 3. She had undergone appendectomy when she
was a 3r d year high school student.
There is no heredo-familial disease from both parents according to Ms. Y.
Social History
Ms. Y has irregular working hours as a call center agent, depending on the schedule given to
Page 19
her. She reports to work from 11 pm to 7am of the next day most of the time. She helps with the
household chores first when she gets home from work and cooks lunch for her father. She goes to
sleep the earliest at 3pm. She needs to wake up at 7pm to start preparing for work. She needs to
allot 2 hours of travel time going to her workplace.
Review of Systems
PSYCHOLOGICAL
The client says she is a very hardworking person. She is happy with her life even though she is
single. She feels really very weak.
Ms. Y values her family the most, She works and earn for herself and she helps in the
finances of their family. She sends her 2 nieces to a public school. Her parents shares in decisionmaking for their family. She earns 18000 PHP every payday.
She is an active lector of their Parish Church. She serves every Sunday mass and holy days of
obligation. They immediately bring their family member to the hospital for consultation when someone
of their family member is sick.
She has no hearing and visual difficulty. She just feels so weak and tired.
She manages stress by going out with friends, barhopping or hanging out with them the
whole night. She simply enjoys conversation with her friends though she is not an alcohol drinker.
She had several boyfriends but she havent found the right one yet. She is in a relationship
with a co-call center agent at present. They had been together for 6 months already.
Their family pays particular attention to one's health that they take vitamin supplements
regularly and immediately seeks consultation as soon as they get to feel something unusual in their
system. All of their family members have health insurance.
ELIMINATION
MS. Y urinates four to five times a day with approximately 550 cc. She does not experience any pain
or discomfort. She defecates once a day, every morning. The client doe not perspire excessively.
REST AND ACTIVITY
She rests during her day off only which is one day within a week. She spends her whole day
chatting with her friends in the internet. She approximately gets a minimum sleep of 4 hours a day.
SAFE ENVIRONMENT
Ms. Y lives in an exclusive subdivision in Las Pinas. The place is peaceful and safe.
OXYGENATION
Ms. Y gets tired easily according to her. It is easier for her to breathe when seated. She puts
pillows under her head and back to be able to breathe easier.
NUTRITION
She often eats vegetables because she wants to maintain her body figure. She sometimes
skips meal when she has a lot of work to do. She takes vitamin supplements and Stresstabs regularly.
24 hour diet recall
Dinner: She bought McChicken Sandwich meal with a Large Fries and Coke and ate it inside the
taxi on her way to work.
Breakfast: She was not able to eat breakfast because she gets home almost lunch time
already and she gets pre-occupied with the household chores.
Lunch: She had small bowl of a vegetable salad.
PHYSICAL ASSESSMENT
General Appearance
She has a medium frame boy built and has an upright posture. She walks with a smooth
rhythmic gait. She looks weak and tired. She is appropriately dressed and well groomed. She has no
obvious physical deformity. There is presence of insect bites. She stands 5'4" tall and weighs 115 pounds.
She has the following vital signs: temperature is 37.8 C, respiratory rate of 20 breaths per minute,
cardiac rate of 85 beats per minute and her blood pressure is 120/80.
Mental Status
She is conscious and coherent. She is well- oriented of the time, place and person she is with.
Page 20
Skin
She has a brown skin color. Skin is warm and smooth to touch, turgor is elastic and mobile and
hair is evenly distributed.
Hair
She has a black and shiny hair. Her hair is thick and evenly distributed. There are no infestations
and infections present on her head but there is a presence of flakes in her scalp.
Nails
Ms. Y has pale nail beds. Her nails are long and have a blue nail polish on it that's why
capillary refill is not observed. Her nail plate shape is convex 160 and has a smooth texture.
Head and Face
Her skull is proportionate to her body size. Her face is symmetrical and her face moves easily.
Eyes
She has straight normal eyes. There are no fallen eyelashes or eyebrows observed and blink
response is present. Eyeballs are symmetrical and firm. Her sclera is white and pupils are 2-3 mm in
diameter. The client is able to see objects clearly that are 20 feet away. She has pale conjunctiva and moist
lacrimal apparatus.
Ears
Her ears are of normal racial tone. The pinna recoils when folded. It is elastic and non-tender.
There is presence of some cerumen on the external canal. She responds to whispered voice.
Mouth and Oropharynx
Her lips are symmetrical but pale. Her tongue rests at midline. Oral mucosa is pink in color.
Her hard palate and soft palates are intact. The uvula is located in the midline and her tonsils are
not inflamed. Her gag reflex is present and she has a complete teeth.
Nose
Her nose is of normal racial tone. Septum is located in the midline and her nostrils are both
patent. Sinuses are not tender and there are no nasal secretions.
Neck
The client has a strong neck muscles. Trachea is located in the midline. Thyroid gland and
lymph nodes are not palpable.
Breast and Axilla
She has asymmetrical breasts and no masses observed and palpated.
Chest and Lungs
She has regular breathing pattern. Lung expansion is symmetrical both in anterior and
posterior. Normal breath sounds are heard on auscultation. She does not use accessory muscle when
breathing.
Abdomen
She has a normal racial tone abdomen and is flat. Bowel sounds were heard and is within the
normal range. Her bladder is not distended.
Upper and Lower Extremities
She has strong and firm muscles. Her muscle tone at present is poor. Lymph nodes are not
palpable and peripheral pulses are present.
Genitals
This part was not assessed.
Page 21
CASE 7 -- CLINICAL CASE STUDY

Personal Data
Ms. Sy, 65 years old, Female residing at Quiapo, Manila. She is single, Filipino citizen and a
Roman Catholic believer. Her usual source of healthcare is at Ospital ng Maynila.
Chief Complaint
"I noticed a significant delay on my bowel, and I don't know why?" as claimed by the client.
Five days prior to consultation, the client noticed a delay on her bowel habits. The client cannot
remember the exact date when the symptoms started. But according to her it started gradually since
she turned 60 years old. There is no associated symptoms or aggraviating factors related to her
symptom. On the day of consultation, the client suddenly worried about her change in bowel habit,
which prompted to consult. She was examined at Ospital ng Maynila, Out patient department.
Ms. Sy has a complete immunization when she was a child. Common illness include fever, flu,
then cough and colds which is usually relieved at home. She never experienced any injuries. No
records of hospitalization and she does not take any form of medications.
Family History
No heredofamilial disease such as asthma, diabetes, hypertension, alcoholism, tuberculosis etc.
Social History
She lives alone in her house and believe in the effects of herbal medications she does not have
any superstitious belief that can affecther health status. Ms. Sy finished her primary education in
Cebu and used to work as a sewer, even up to the present. According to her she never had any
conflicts with her neighbor. She also receive monthly pension from SSS and Philam Life.
Review of Systems
Pyschological
The client views herself as a simple person gifted with a peaceful life. Even though she lives
all alone by herself she thinks that it is good enough for her. Sometimes she feels lonely when
listening to love songs since she never had a chance to get the best man for her. She also prefers
to be alone for some time and does not want to socialize when she is sad since most of her
neighborhood have their own family.
Elimination
The client urinates 5-6 times a day in scanty amounts with yellowish color without any
Page 22
discomfort. She defecate 2 times a week, color brown in scanty amount and hard. According to her
this is not her usual characteristic of her bowel. She feels incomplete every time she defecates as
if she wants to excrete more. She does not perspire a lot.
Rest and Activity
She used to watch television and listen to the radio when she gets tired. Her usual Activity of
Daily Living includes cleaning her house, doing the chores and gardening. But for the last month she
had lessened her activity and prefers to stay inside her house because of glare on lights.
Safe Environment
Ms. Sy feels secure in her place since the Barangay Hall is just adjacent to her house.
According to her she seldom hear some trouble in their place since the Barangay Tanods are very
active. She lives in a house made of concrete material. She has no allergies to food, drugs and
environment.
Oxygenation
She does not have any signs of respiratory distress and never had symptoms of difficulty of
breathing.
Nutrition
The client used to eat root crops and tomato from her garden since this is one of her
favorite foods. She seldom drinks water and would prefer to have nganga in her mouth all day long.
She also verbalized, "Gusto ko nga matuto magluto at kumain ng masusustansyang pagkain eh, para
libangan na rin, as verbalized by the client.
24 Hour Diet Recall
Breakfast: 1 Pandesal, 1 cup of coffee
Lunch:
1 cup rice, 1 tilapia,
1 glass of water
Dinner: 1 cup rice, 1 tinapa,
1 glass of water
B. Physical Examination
GENERAL APPEARANCE
The client has small body built, thin with stooped posture and coordinated body movement.
She is appropriately dressed, neat without body odor. No obvious signs of physical deformity or
illness noted. Her vital signs are: temperature= 36.1 OC (axilla), PR=65 bpm, RR= 17cpm, BP=
110/80mmHg. Clients height is 147cm and weighs 90 lbs.
MENTAL STATUS
She is conscious, coherent and cooperative with good aff ection. Oriented to time, place,
date and person. She responds appropriately and slowly in an understandable manner. Uses
simple words in communicating.
SKIN
Clients skin color is light to deep brown, uniform in color with prominent veins on the arms
and toes. Sagging and wrinkling were noted. Brownish, circular age spots (lentigo senilus) was
noted on the volar area of both arms ranging from 1-2cm width. Skin temperature is warm within
normal range. Decreased skin turgor is noted. There are no lesions and fine white hairs are evenly
distributed all over the body.
HAIR
With white, straight hair at shoulder level, evenly distributed, thin silky resilient. No
infection/manifestation and dandruff seen. Absence of nasal, ear, eyebrow and axillary hair coarse is
noted.
NAILS
The nail plate had 160 angle, smooth texture, and pinkish with longitudinal ridges.
Epidermis is intact, capillary refills within 3 seconds.
HEAD AND FACE
Page 23
With round normocephalic and symmetrical with frontal, parietal and occipital prominence.
Hair is evenly distributed, head contour is smooth with uniform consisteny; without nodules or
masses. With symmetrical facial movements and features. Wrinkles are also present.
EYE
Thin eyebrows and eyelashes are evenly distributed and symmetrical. Skin surrounding the eyes
is intact without any discoloration; lids close symmetrically with 15-20 blinks per minute. The sclera
is white, palpebral conjunctiva is shiny and pinkish while bulbar conjunctiva is clear. No edema or
tenderness on the lacrimal glands. Opaque white ring around the iris (arcus senelis) is noted. There
is some opacity present on the lens. The pupils are equally round (3-4mm) and reactive to light
and accommodation. When looking straight ahead, client has difficulty in recognizing objects in the
periphery. Both eyes are coordinated; move in unison with parallel alignment (8 ocular
movements). The client is unable to read font 12 of printout and has a vision of 20/100. Glaring into
lights is one of her concerns.
EAR
The auricles are brown in color, symmetrical and aligned with outer canthus of eye, about 10
from vertical view. Upon palpation, auricles are mobile, firm and non-tender; pinna recoils after it is
folded. Using an otoscope, distal 3~d contains thin hair follicles and glands; semitransparent and
pearly gray tympanic membrane. The client has diffi culty in responding to normal voice and
negative for watch tick test. Normal for Rinnes and Webers test
NOSE
With symmetrical and straight nares, without discharge, flaring and uniform in color. Air
moves freely through the nares as the client breathe. Nasal mucosa is pink, clear without any
lesions. Nasal sinuses are non-tender. (deleted cant recognize coffee)
MOUTH AND OROPHARYNX
Outer lips has uniform pink color, soft, dry, smooth in texture and able to purse lips. Inner lips
and buccal mucosa is pink, moist, smooth, soft, glistening and elastic. She has 32 smooth and intact
dentures, moist and firm. The tongue is . at the center, pink color, with smooth lateral margins, no
lesions, raised papillae, moves freely without tenderness and nodules. Absence of papillae is
noted. Salivary glands is intact, pinkish in color without any lesions with light pink hard and soft
palate positioned in the midline with smooth posterior wall. Tonsils and uvula is not inflamed. Gag
reflex is present.
NECK
Muscles are equal in size, head is in the center. Head movement is coordinated, smooth
without discomfort. There is equal muscle strength and non-palpable lymph nodes. The trachea is
in the midline. Thyroid gland is not palpable but ascends during swallowing.
BREAST AND AXILLA
With brown, saggy,asymmetrical with fine glandular texture. There are no masses palpated.
Nipples are pinkish in color, dry and symmetrical. The axilla is color brown, dry without hair.
CHEST AND LUNGS
The anteroposterior to transverse diameter is in ratio of 2:1. with symmetrical chest
expansion and kyphotic spine. Skin is intact with uniform color and temperature. No tenderness and
masses upon palpation. With bilateral symmetry of vocal and tactile fremitus. Resonance is heard
over the thorax. Diaphragmatic excursion is 3cm. Costal angle is 80 and the ribs are 45. Upon
auscultation, bronchial (trachea) sounds, bronchovesicular (main bronchi) sound and vesicular
sounds (terminal bronchi) were heard.
HEART
There are no masses and lesions in the skin. There is palpable pulsation at the left ICS
(5th) MCL; in an area of 1-2 cm in diameter. The carotid pulse is bounding regularly synchronous
with S1. The apical and radial pulse has equal rate and rhythm. Systolic murmur was heard during
auscultation.
ABDOMEN
The color is uniform and the skin is unblemished. There are symmetric movements caused by
respiration. Aortic pulsations were also noted at the epigastric' area. Bowel sounds is 3/min
Page 24
without arterial bruits and friction rub. Tympanic sounds were heard during auscultation. No
tenderness, relaxed abdomen with smooth, consistent tension. The liver, bladder and spleen are not
palpable.
The muscles have equal size on both sides of the body. There are no contractures or
fasciculation present. Muscles are firm, smooth with coordinated movements and equal strength
on both sides of the body. The bones do not have any deformities (rlt injury), tenderness or swelling.
Joints move easily .There are no signs of tenderness, swelling, crepitation of the joints.
CASE 8 COMMUNITY CASE STUDY

A. NURSING HEALTH HISTORY
Personal Data:
Ms. Sy is a 65 years old, female, and residing at Quiapo, Manila. She is single, a Filipino
citizen and a Roman Catholic believer. Her usual source of health care is at the Barangay Health
Center.
Chief Complaint:
"My joints are painful and it seems so hard to move especially when I get stuck in one
position and I don't know why."
History of Present Illness:
The client cannot remember the exact date when the symptoms started. But according to her
it started gradually since she turned 60 years old. The symptoms seem to worsen especially when
it's cold at night.
Ms. Sy had a complete immunization when she was a child. Common illnesses include fever, flu,
then cough and colds, which are usually relieved at home. She never experienced any injuries. No records
of hospitalization and she does not take any form of medication.
Family History
No heredofamilial diseases such as asthma, diabetes, hypertension etc.
Social History
She lives alone in her house and believes in the eff ects of herbal medications. She does
not have any superstitious belief that can affect her health status. Ms. Sy finished her primary
education in Cebu and used to work as a sewer, up to present. According to her, she never had any
conflicts with her neighbor. She also receives monthly pension from SSS and Philamlife.
REVIEW OF SYSTEMS
Psychological
The client views herself as a simple person, gifted with a peaceful life. Even though she lives
all alone by herself, she thinks that it is good enough for her. Sometimes she feels lonely when
listening to love songs since she never had a chance to meet the man if her life. She also prefers to be
alone for some time and does not want to socialize when she is sad since most of her neighbor have
their own family.
Elimination
The client urinates 5-6 times a day scanty in amount, yellowish color with no accompanying
discomfort. She defecates 2 times a week, brown in color, scanty in amount and is hard. According to
her, this is the usual characteristic of her bowel. She perspires a lot.
Rest and Activity
She used to watch television and listens to the radio whenever she gets tired. Her usual
activities of daily living Include cleaning her house, doing the chores and gardening. She expresses
Page 25
concern like learning simple exercises that she can do inside the house but she does not know
where or who to seek information.
Safe Environment
Ms. Sy feels secure in her place since the Barangay Hall is just adjacent to her house. According
to her, she seldom hears troubles in their place since the Baranggay Tanods are very active. She lives in
a house made of concrete material. There are no allergies to food, drugs and to the environment.
Oxygenation
She does not have any signs of respiratory distress and never had symptoms of difficulty in
breathing.
Nutrition
The client used to eat root crops and tomatoes from her garden since these are her favorite foods.
She seldom drinks water and would prefer to have "nganga" in her mouth all day Iong. Client verbalized
"Gusto ko nga matuto magluto at kumain ng masusustansyang, pagkain eh, para libangan na rin."
24-Hour Diet Recall:
Breakfast: 1 pandesal, 1 cup of coffee
Lunch: 1 cup of rice, 1 tilapia, 1 glass of water
Supper: 1 cup of rice, 1 tinapa, 1 glass of water
B. PHYSICAL EXAMINATION
General Appearance
The client has small body built, thin, with stooped posture and coordinated movement. She
is appropriately dressed, neat, without body odor. No obvious signs of physical deformity or illness
noticed. Client's height is 4'9" and weighs 901bs.
Her vital signs:
Temperature= 36.1'`C
PR= 65 beats per minute
RR= 17 cycles per minute
BP= 110/180 mmHg
Mental Status
She is conscious, coherent and cooperative with good affect oriented to time, place, date and
person. She responded appropriately and slowly in an understandable manner. She used simple
words in communicating.
Skin
Client's skin color is light to deep brown, uniform in color with prominent veins on the arms
and toes. Sagging and wrinkling were noted. Brownish, circular "age spots" (lentigo senilus) was
noted on the area of both arms ranging from 1-2cm width. Skin temperature is warm within normal
range. Decreased skin turgor is noted. There are no lesions and fine white hairs are evenly distributed
all over the body.
Hair
With white, straight hair at shoulder level, evenly distributed, thin, silky and resilient. No
infection/infestation and dandruff seen. Absence of nasal, ear, eyebrow and axillary hair coarse is noted.
Nails
The nail plate has 160 angle smooth texture, and pinkish w/ longitudinal ridges. Epidermis is intact,
capillary refills within 3 seconds.
Head and Face

She has round normocephalic and symmetrical w/ frontal, parietal and occipital prominence. Hair is
evenly distributed; Head contour is smooth w/ uniform constituency; without nodules or masses and
with symmetrical facial movements and features.
Page 26
Eyes
Thin eyebrows and eyelashes are evenly distributed and symmetrical. Skin is intact w/o any
discoloration; lids close symmetrically w/ 15-20 blinks/min. The sclera is white, palpebral conjunctiva is
shiny smooth and pinkish, while bulbar conjunctiva is clear. No edema or tenderness on lacrimal
glands. Opaque white rings around the iris (arcus senilis) is noted. There are some opacities present
in the lens. The pupils are equally round (5mm) and reactive to light and accommodation. When
looking straight ahead, client has difficulty in recognizing objects in the periphery. Both eyes are
coordinated; moves in unison w/ parallel alignment (8 ocular movements). The client is unable to read
font 12 of printout and have a vision of 20/100. Glaring into lights is one of her concern.
Ears
The auricles are brown in color, symmetrical and aligned w/ outer canthus of eye, about 10'
from vertical view. Upon palpation, auricles are mobile, firm and not tender; pinna recoils after it is
folded. Using an otoscope, distal 3 rd contains thin hair follicles and glands; semi-transparent
and pearly gray tympanic membrane. The client has diffi culty in responding to normal voice and
negative for watch tick test. Normal for Rinne's and Weber's test.
Nose
She has symmetrical and straight nares, without discharge, fl aring and uniform in color. Air
moves freely through the nares as the client breathe. Nasal mucosa is pink and clear without any
lesions. Nasal septum is intact and in midline. Nasal sinuses are non-tender. The client had
difficulty in recognizing the smell of coffee.
Mouth and Oropharynx
Outer lips have uniform pink color, soft, dry, smooth in texture and able to purse lips. Inner lips
and buccal mucosa is pink, moist, smooth, soft, glistening and elastic. She had 32 smooth and intact
dentures, moist and firm. Absence of papillae is noted. Salivary glands are intact, pinkish in color w/o any
lesions. Light pink hard and soft palate and are positioned in the midline w/o smooth posterior wall.
Tonsils and uvula is not inflame0. Gag reflex is present.
Neck
Neck muscles are equal in size; head is at the center. Head movement is coordinated, smooth
w/o discomfort. There is equal muscle strength and non- palpable lymph nodes. The trachea is in
the midline. Thyroid gland is not palpable but ascends during swallowing.
Breast and Axilla
With brown, flat, symmetrical w/ fine glandular texture. There are no masses palpated. Nipples
are pinkish color, dry and symmetrical. The axilla is brown in color, dry, w/o hair.
Chest and Lungs

The anteroposterior to transverse diameter is 2:1 ratio. She has a symmetrical chest
expansion and a kyphotic spine. Skin is intact, with uniform color and temperature. No tenderness
and masses upon palpation. She has bilateral symmetry of vocal and tactile fremitus. Resonance is
heard over the thorax. Diapragmatic excursion is 3cm. Costal angle is 80, and the ribs is 45. Upon
auscultation, bronchial (trachea) sounds, bronchovesicular (main bronchi) sound and vesicular sounds
(terminal bronchi) were heard.
Heart
There are no masses and lesions in the skin. There is palpable pulsation at the left ICS
(5th) MCL; in an area of 1-2 cm in diameter. The carotid pulse is bounding regularly synchronous
with S1. The apical and radial pulse has equal rate and rhythm. Systolic murmur was heard during
auscultation.
Abdomen
The color is uniform and the skin is unblemished. There are symmetric movements caused by
respiration. Aortic pulsations were also noted at the epigastric' area. Bowel sounds is 3/min
without arterial bruits and friction rub. Tympanic sounds were heard during auscultation. No
tenderness, relaxed abdomen with smooth, consistent tension. The liver, bladder and spleen are not
palpable.
Page 27

Muscles are firm, smooth with coordinated movements and equal strength on both sides of
the body. The clients fingers have swollen joints. Stiffness on the joints on the clients hands were
noted. Patient claimed that the bones and joints on her hands, legs and feet are painful. Crepitations on
the joints were also present.
Page 28

Pediatric Case Study: Thrombocytopenia

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CASE 1- CLINICAL CASE STUDY

NCM 100 CASE STUDIES (edited 01_28_2011)

CASE 2 COMMUNITY CASE STUDY

NCM 100 CASE STUDIES (edited 01_28_2011)

CASE 3 - CLINICAL CASE STUDY

Date of Interview March 30, 2008 at 7: 00 am

High in Carbohydrates with

with a variety of behaviors and activities.

J. MOUTH AND OROPHARYNX

for the impending surgery- No murmurs were heard.

CASE 4 - COMMUNITY CASE STUDY

4. Past Medical Illness

High in carbohydrates with fats

Growth and Development

and Erb ed pg 357, 2008)

(done after circumcision)

J. MOUTH AND OROPHARYNX

CASE 5 - COMMUNITY CASE STUDY

NCM 100 CASE STUDIES (edited 01_28_2011)

CASE 6 -- CLINICAL CASE STUDY

NCM 100 CASE STUDIES (edited 01_28_2011)

CASE 7 -- CLINICAL CASE STUDY

CASE 8 COMMUNITY CASE STUDY

Head and Face

NCM 100 CASE STUDIES (edited 01_28_2011)

Chest and Lungs

NCM 100 CASE STUDIES (edited 01_28_2011)

Upper and Lower Extremities

NCM 100 CASE STUDIES (edited 01_28_2011)

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