CLIENTS INITIALS: H.J.

M ADDRESS: AGE: 5 months BIRTH DATE: September 6 2012 BIRTH PLACE: GENDER: Male CIVIL STATUS: RELIGION: Roman Catholic HIGHEST EDUCATIONAL ATTAINMENT: OCCUPATION: BUDGET: II. REASON FOR SEEKING HEALTH CARE

DATE ADMISSION: Feb. 9 2013 TIME OF ADMISSION: DATE OF INTERVIEW: Feb. 11 2013 PRIMARY INFORMANT: SECONDARY INFRMANT:

Acute Gastroenteritis with severe dehydration

III. HISTORY OF PRESENT ILLNESS According to the mother, baby HJM started vomiting and diarrhea when they switch his milk bona to promil kid, then after a few days baby HJM showed symptoms like pallor and being lethargic. They sent baby HJM in hospital to assure his health after checking up, he is diagnosed with Acute Gastroenteritis with severe dehydration.

IV. PAST MEDICAL HISTORY The patient doesnt experienced any illness, only fever but his mother immediately give him medicine so that it will not take so long. Baby HJM doesnt have any allergies and injuries.

VI. HEREDO-FAMIALIAL HISTORY

E.Y

A.Y

A&W

A&W A&W

A&W

M.E

A.Y

A.Y

E.G

A.M

E.Y

A&W

A&W A&W A&W

A&W A&W

A&W

A&W

A&W

A&W

A&W

LEGEND: -Boy -Girl A&W alive and well -Patient

H.J.M

GORDONS 11 FUNCTIONAL HEALTH PATTERNS

A.

HEALTH PERCEPTION HEALTH MANAGEMENT Baby HJM was diagnosed with Acute Gastroenteritis with severe dehydration characterized by vomiting and diarrhea. But before he got ill, he is healthy, he also taking vitamins every morning. The patient received vaccine in BCG, OPV and last dose for DPT and Hepa B. His heart rate, respiratory rate, blood pressure and temperature was all normal.

IMMUNIZATIONS ME BCG Baby HJM 1

DPT 2

OPV 3 1 2 3

MEASLES

HEPA B 1 2 3

B.

NUTRITIONAL METABOLIC

The patient drinks atleast __ bottles of milk every day or __ cc a day his milk was bona. They usually cooked mashed vegetables like carrot, potato and squashed for him.

C. ELIMINATION Baby HJM usually consumed 3-4 diapers a day, its color is brownish and aromatic. When he started to have diarrhea his stool become color green and wet. There is too much water loss in his body because of the diarrhea that result into severe dehydration. While baby HJM confined at the hospital, his urine output was monitored every hour.

D. ACTIVITY- EXERCISE Before baby HJM confine at the hospital always playing with his cousin.

*KATZ INDEX OF INDEPENDENCE IN ACTIVITIES OF DAILY LIVING ACTIVITIES Bathing Dressing Toileting Transferring Continence Feeding TOTAL POINTS: INDEPENDENCE POINT DEPENDENCE

E. SLEEP- REST The patient sleep almost 16 hours a day, before he sent in the hospital. But when he confined, he is always sleeping to fasten the recovery but sometimes he usually attack by a seizure whenever he gets awake.