Name: Patient JJG Age: 2 years old Gender: Male Birthday: October 7, 2009 Birthplace: Bitas, Cabanatuan City

Marital status: Single Address: Mabini Homesite, Cabanatuan City Phone number: 09202835545 Educational level: not applicable Occupation: not applicable Race or ethnic background: not applicable Religion: Roman Catholic Nationality: Filipino Citizenship: Filipino Language spoken: tagalong Source of information: mother Reliability: not applicable

Initial Diagnosis
ALL Pre-B - June 6 2012 ALL Pre-B - June 15 2012 ALL Anemia leucopenia thrombocytopenia secondary to chemotherapy June 5 2012

Final Diagnosis
ALL Pre-B -June 6 2012-June 7 2012 ALL Pre B S/P Chemotherapy - June 15 2012-June 17 2012 ALL Pre b, SP PRBC transfusion, SP IV chemotherapy day 48 - July 05 2012- July 06 2012 ALL Pre B S/P PRBC and platelet transfusion - July 08 2012July 09 2012

History of present illness

June 6 2012 With chief complaint: for chemotherapy 2 times diagnosed ALL pre-B Patient came in for 3rd cycle of chemo treatment June 15 2012 With chief complaint : swelling of lower extremities July 5 2012 Diagnosed with ALL on methotrexote intrathecally on if up today, repeat CBC anemia leucopenia thrombocyte Admitted add for blood transfusion. July 8 2012 Chief complaint: hematoma, lower lip Diagnosed case of ALL on methotrexate treatment, packed RBC 2 days ago discharged insert fully, Few hours PA, patient was noted with hematoma on lower lip. Advised ad.

Physical Examination
June

6 2012 General Appearance: ambulatory; irritable EENT: pink PC(pink conjunctiva), AS(anicteric sclerae) Chest and lungs: SCE(symmetrical chest expansion), CBS(clear breath sounds) Heart: Ap(adynamic precordium), NRRR(normoactive bowel sounds) Abdomen: Soft, NABS Extremities: pulses full and equal Clinical impression: ALL pre B

Physical Examination
June

15 2012 General Appearance: F/N, F/P EENT: (-) CLAD(cenical lymphadenopathy) Chest and Lungs: CBS, EUE Extremities: (-) swelling

Physical Examination
July

5 2012 General appearance: ambulatory Skin: (+) Pallor Chest and lungs: SCE, CBS Heart: AP.AB Abdomen: Soft NABS

Physical Examination
July

8 2012 General Appearance: Ambulatory, coherent EENT: pale PC AS (+) hematoma lower lip Chest and lungs: SCE and CBS Heart: Ap, ARRR Abdomen: non-distended, non-intended Extremities: pulses full and equal Clinical impression: ALL

COURSE in the WARD

June 1, 2012 Received a 2 year old boy brought by her mother. The patient was seen and examined by Dr. Mendoza with orders made and carried out. For intrathecal chemotherapy by Dr. Mendoza, consent was signed. Intrathecal chemotherapy done. To ward per wheelchair cuddled by the mother with on going IV fluid of D.5 0.3 NaCL 500ml. Present IV fluid was consumed and shifted to a heplock aseptically. The patient is pale in appearance and irritable when approached. Vital signs monitored and recorded.

COURSE in the WARD

June 6 2012 Admitted to E.R, the patient was cuddled by the mother conscious and coherent. Attended by ROD Dr. Uy with on going IV fluid of D5 0.3 NaCL 500ml connected to volumetric tube/chamber. The patient was weak in appearance. Added L-aspanagenase 3525 unit in 100ml of D5 was started. Encouraged mother to avoid environmental hazanious, rest and comfort promoted. L- aspanegenase 3525 unit in 100ml of D5 consumed and removed aseptically. Take home instructions, instructed to the mother and went home with relatives.

COURSE in the WARD

June 8 2012 Patient was admitted to the emergency room; ambulatory, conscious and coherent, with heplock and removed aseptically and replaced with IV fluid of D5 0.3 NaCL connected to microset. Seen by Dr. Mendoza. Chemo drugs started as ordered with precautions noted. All chemo drugs ended with no reactions noted. Health teachings done and instructed to mother/relatives. No complaints of any discomfort as claimed by the mother. Discharge instruction instructed to the patient relative well understood as claimed. Went home per wheelchair accompanied by the patients

COURSE in the WARD

June 15 2012 Received with dislodged IV fluid of D5 0.3 Nacl 500ml, currently saved set on sitting position; alert and afebrile, with no complaints of any discomfort as claimed. Health teachings done; Examined by Dr. Mendoza with orders made and carried. Above IV fluid shifted to L- asparagenase 3525 units 100ml 125 water and regulated at drip 100 gtts/min. Remove IV fluid aseptically; went home with relatives.

COURSE in the WARD

June 23 2012 2 year old boy admitted, cuddled by relative with admitting orders from Dr. Puno-Mendoza; awake D5 0.3 NaCL inserted aseptically connected to microset. In to ward per wheelchair, weak in appearance and afebrile. Present IV fluid removed and shifted with D5 0.3 NaCL 500ml incorporated with 5ml potassium chloride regulated for 58-59 mgtts/min with health teachings done to relatives. Rest and comfort promoted; reversed isolation precaution observe Take home instructions instructed to mother/relatives. Went home per wheelchair.

COURSE in the WARD

July 5 2012 In from ER per wheelchair; conscious, weak and pale in appearance. Transferred to room with on going IV fluid of D5 0.3 NaCL 500ml. Consent for blood transfusion signed and health teachings done. Present IV fluid changed to PNSS as ordered. BT of PRBC 170ml with serial number 062912-003 properly types and cross matched. Started BT mgtts/min, no signs of reactions; BT regulated at 10 mgtts/min. BT was consumed and removed aseptically, vital signs are stable with no complaints of discomfort. Examined by Dr. Puno-Mendoza. Health teachings done/ home instructions instructed to relatives; went home.

COURSE in the WARD

July 8 2012 Admitted a 2 year male cuddled by mother with complaint of hematoma 1 day PTA. Attended by Dr. Uy with orders. Inserted PNSS 500ml and regulated to 10mgtts/min. laboratory result secured and relayed to Dra. Mendoza. Pre-BT meds given. 2 units of platelet concentrate with serial number of B-12-1303 and B-12-1304, typeB-RH positive; transferred with no transfusion reaction noted. Transfusion ended. For BT of 160cc PRBC BT with serial number 070312002 properly typed and cross matched and regulated 10gtts/min; with no reactions. BT meds given. BT was consumed and ended, removed aseptically. Examined by Dr. Mendoza. Weak in appearance, discharge instructions instructed to the relatives; went home per wheelchair with relatives

COURSE in the WARD

July 18 2012 (Emergency Room) Received a 2 year old cuddled by mother with chief complaint of blooding gum for hours prior to admission attended by Physician on Duty Dr.Borja with orders made and carried out. With Attending Physician Dr. Puno-Mendoza. Intravenous Fluid of D5 0.3 NaCL 500ml connected to microset insolution using a gauge of 24 on left arm and regulated at 55mgtts/min. Thanexamic acid 110 mg given as stat dose; Metoclopramide 0.8 mg given as stat dose; Paracetamol 110mg given as stat dose; fast drop of d5 0.3 Nacl 100ml dose Blood extraction done by NOD Brought to 4th floor General ward by wheelchair accompanied by NOD with aid.

COURSE in the WARD

(General Ward) In from ER per wheelchair accompanied by NOD; awake and alert; weak in appearance with swelling at left cheek transfer to bed and room safety oriented to room and hospital policies well understood as claimed by the mother. With on-going IV fluid of D5 NaCL 500ml on around 400ml level and regulated at 5mgtts/min. Received SMS order from Dr. Mendoza and carried out. Skin sensitivity testing of Ceftrizidine on right forearm done; Check after 30 minutes and revealed as negative. Skin sensitivity testing of Amikacin on Left forearm done; check after 30 minutes and revealed negative. Consent for blood transfusion signed Pre- BT meds given; present IV fluid change to Plain NSS 500ml and regulated as same rate. Blood transfusion of IV platelet; concentrate started with blood bag serial number 071812-001; type B Rh positive properly typed and crossmatched with initial vital signs of temperature 38.4C RR-28, PR-130 and relayed to Dr. Mendoza. Blood Transfusion ended and removed aseptically; hematocrit done Latest temperature 38.9C

COURSE in the WARD

July 19 2012 Received with on-going IV fluid of Plain NSS 500ml on around 350ml level and regulated at 10mgtts/min; alert and awake; watch out hematoma on Left cheek noted with bleeding on mouth noted. Received SMS order from Dr. Puno-Mendoza and carried out. Examined by Dr. Puno-Mendoza and carried out.

GORDONS

ORGANIZING DATA ACCORDING TO GORDONS 11 FUNCTIONAL HEALTH PROBLEMS

Functional Health Pattern Health Perception/ Health Management Prior The patient has a normal lifestyle. During Hospitalization The patients relative becomes more careful about their patients needs. Rationalization The child undergoes chemotherapy; the child can be immune compromised, that causes the patients relatives to be more careful on the patients health and needs.

GORDONS
NutritionalMetabolic The patient has a very consumption of food especially on vegetables and fluids. During the course of chemotherapy the patients appetite decreases and as verbalized by the mother the weight of the patient also decreased. Irregularity of the patients elimination occurs; sometimes the patients suffers diarrhea. One of the common side effects of chemo-drugs is loss of appetite and weight loss; also accompanied by nausea and vomiting; poornutrition. Diarrhea is one of the side effects of chemo-drugs, it is one to the response or induced response to the condition or treatment of the patient.

Elimination

Patients frequency of bowel movement and urine elimination is within normal.

GORDONS
ActivityExercise The patient is active on many activities. Upon hospitalization, the patient has decreased activity pattern and play. Fatigue and exhaustion; prior to medication, the patient is received chemotherapy, chemotherapy destroys the good cells and it decreases the patients energy and mobility range. Being a child he is not aware of its disease; lowcoping mechanism.

CognitivePerceptual

The patients physical and mental development is normal.

Becomes irritable and restless during the course of the treatment.

GORDONS
Sleep-Rest Prior to hospitalization, the patient has a normal sleep pattern. Upon hospitalization, the patient now has late sleep and wakes up early. It is due to the hormonal imbalance of the patient; uncomfortable of having side effects such as pain, fatigue, nausea and vomiting, etc. The mentality of a child cannot conceive his present condition of having a disease.

Self Perception/ Self Concept

Before hospitalization, the patient has no clue or perception about the disease.

The child still doesnt know his disease and still has a childish perception.

Rolerelationship

The patient is the only son of his family.

There has been a prioritization of care by the family members.

Being the only son of his family and his present condition; he becomes the concern and priority of his family.

GORDONS
The patient has a strong belief that his disease will be cured. Daily prayers are done by the family members for their belief that the patients disease will be cured. Because of their strong belief that God can answer their prayers and makes miracle about it and boost their self esteem through faith.

Values and Beliefs Spiritual

Hygiene

The patient has a normal pattern of hygiene.

There are no changes on the patients hygiene pattern/ the patient is now completely assisted in doing his routine hygiene.

Having some alternations on physical and hormonal state, the patient cannot do his normal routine; he is completely assisted.