Nursing Health History

Name: Huang Yi Fei

Sex::Female
Age: 2 years old
Address: sta. Cruz
Date of birth: October 23, 2006
Place of birth: Hongkong
Religion: Buddhist
Nationality: Chinese
Marital status: C
Chief Complaint: Fever
Room no: 510
AMD: Dra. Castro, Cereus
Diagnosis: Herpetic Gingivostomatitis

Present Health History

The patient started to have an intermittent fever since

Thursday and presently on her normal temperature. She
experiences a gradual loss of appetite because of mouth discomfort
and difficulty in eating and drinking. The patient was brought to the
Metropolitan Medical Center one day (June 27, 2009) prior to
admission. There are different laboratory test that was done such as
Culture and smear test to identify the cause of infection. When vital
sign’s taking the patient is still sleeping because of her complain on
her mouth. There is an IV fluid of D5IMB 500cc at 80cc level
regulated at 40 gtts/min and located at her lower left side of the
arm. She was instructed to have a soft diet. Vital signs were check
every 4 hours. When the patient was assessed the patient gets tired
and irritated easily than other normal child. There was a blister like
on the sides of the gums and some sores. The patient’s mother
refuses to continue the IV fluid replacement and requested for
discharge due to what the doctor said to her last night.

Past Health History

The patient was born via normal spontaneous vaginal delivery. The
patient is on its first time hospitalization. According to the client’s
mother she doesn’t still experience any chickenpox, mumps, &
German measles. Ms. Fei has completed the immunization vaccines
according to what the mother recalled—BCG, DPT, OPV, Hepa-B,
Measles, were noted. She did not have any minor and major
operations. When it comes to childhood eating habits, Ms. Fei
prefers to drink milk than to eat. She has no known allergies.
.

Family Health History

The Family has no known history of hypertension and diabetes.

Social History
The patient is always inside the house because her parents
are afraid for their child to acquire some disease. She was always
visited by her grandmother and play with her cousin. The members
of the family are open to share when there is a problem within the
family or personal problems. They are very close to each other.

Lifestyle
The patient loves to watch television and play inside their
house. She prefers to drink her milk than eating solid foods.

Psychological data

The patient is always crying when her mother is not near with
her. When she can’t get what she wants she cry and stamp her
feet. She shows a little scared when we try to talk to her and take
her vital sign’s but as the assessment took longer she feels alright.
Review of the Systems

Urinary System
“wala naman siyang masakit na sinasabi pag umihi”as verbalized by
the mother

Digestive system
“Tapos ayaw pa kumain....Parang singaw tapos mapula.” As verbalized by the mother

Musculoskeletal system
“wala naman siyang ginagawang iba kundi manuod ng t.v at
maglaro sa loob ng bahay.” as verbalized by the mother

Integumentary System
“Wala naman..kahit anong allergies wala.…” as verbalized by the
mother

Respiratory system
“Hindi naman siya hirap huminga..normal lang” as verbalized by the
mother