NURSING HEALTH HISTORY

Age:
Gender:
Marital status:
Religion:
Place of residence:
Date and time of history: 13 April 2015
Source of the history: Mother

Chief complaint: for workup (staging) and 1st course of chemotherapy

History of Present Illness:

Previously known to be a very active, sensitive, playful and happy child, he was noted to
have episodes of being suddenly quiet and he would made gesture of suddenly banging his fists
whenever his condition was being discussed and cover his ears. He was noted to cry at night
more often, refused to do self-care such as brushing of the teeth and taking a bath, changing the
patch of his eye and application of the eye ointment become daily struggle, She tries to separate
him from his sisters and she tends to give him everything he wants like toys as verbalized by
mother

6 weeks prior to admission, patients mother observed to have a lump on left upper eyelid
which rapidly progressed in size with deviation of left eyeball downward, symptoms rapidly
progressed which prompted consultation to optha on March 21, 2015 at Asian Hospital, biopsy
of the orbital mass was done which revealed Rhabdomyosarcoma, currently admitted for staging
and 1st course of chemotherapy.

Past health history

REVIEW OF SYSTEMS

General

Usual weight: 17-18 kg

Current weight: 16 kg
Weight loss: 1.5kg, afebrile

Skin
Denies rashes, lumps, sores, itching, dryness, changes in color, changes in hair or nails
and color/ sizes of moles

Head, Eyes, Ears, Nose, Throat (HEENT)

Denies headache, head injury, use of glasses , hearing aids
 No complaint of pain on both eyes,
Denies colds, nosebleeds, bleeding of gums, sore throat, hoarseness

Neck
Denies pain, stiffness in the neck

Breast
Denies pain, discomfort, nipple discharge,

Respiratory
Denies dyspnea, cough

Cardiovascular
Denies chest pain, palpitation, edema

Gastrointestinal
Denies difficulty swallowing, heart burn, abdominal pain
Last bowel movement- 8 April 2015
Picky eater, decreased appetite

Peripheral Vascular
Denies leg cramps, swelling with redness or tenderness

Urinary
Denies changes in pattern of urination, flank pain
(+) bedwetting

Male reproductive
Denies discharge from or sores on the penis, scrotal, swelling

Musculoskeletal
Denies muscle or joint pain, stiffness, backache

Psychobiologic
Become moody during dressing

Neurological
Denies fainting, blackouts, seizures, paralysis, numbness, tingling, tremors

Hematologic/ immunologic
Does not experience easy bruising or bleeding

Endocrine
Denies excessive sweating, excessive thirst or hunger
PHYSICAL ASSESSMENT

General survey
Sitting on bed with his mother, preferred to keep his eyes close, speech was non-
spontaneous,
Weight: 16kg
Vital signs: Temperature: 36.5C, Heart rate: 100bpm, Respiratory rate: 22cpm,
Pain: 0/10

Skin
Uniform in color, no presence of any foul odor

Hair
Evenly distributed, no signs of infestation observed

Nails
Smooth, intact with the epidermis, return to usual color in less than 3 sec

Head
Normocephalic, and symmetrical

Eyes
Right eye- no swelling, redness, discharge
Left eye- (+) eye patch, dry and intact

Ears
Auricles are symmetrical, aligned with the outer canthus of eye
Mobile, firm and not tender, was able to hear ticking sound in both ears

Nose
Appears symmetric, straight and uniform in color, no presence of discharge
No tenderness and lesions

Mouth
Lips are dry, symmetric, was able to purse his lips when asked
Pinkish in color of gums, buccal mucosa
Tongue is centrally positioned

Neck
Head movement with no discomfort, no palpable lumps

Thorax and Lungs

Full and symmetric expansion, quiet, rhythmic and effortless respirations
Heart
No visible pulsations, no presence of heaves or lifts

Abdomen
Uniform in color, symmetric contour,

Extremities
Symmetrical in size and length, no tenderness, swelling, coordinated movements.