Pneumonia Case Study
Patient’s Profile
Name : D.E
Age : 67 years old
Address : Annafunan, Tuguegarao City
Sex : Male
Civil Status : Married
Occupation : None
Nationality : Filipino
Religion : Roman Catholic
Date of Admission : Nov. 01, 07
Time of Admission : 9:45 pm
Chief Complaint : Irritability and DOB
Final diagnosis : CVA infarct pneumonia
Attending Physician : Dr. Marlene Cinco
Patient’s History
Past Health History:
Patient D.E. had completed his immunization when he was a child. He experiences cough and cold in the past. According to the SO, the patient had a Hypertension.
History of Present Illness:
Five days prior to admission, the patient had a stroke and was confined at CVMC and few hours prior to admission the patient was irritable and had a difficulty of breathing.
Family Health History:
Patient D.E. has family history of hypertension and heart disease but not on respiratory problems such as bronchitis, asthma or pneumonia.
Gordon’s 11 Functional Pattern
1. Health Perception – Health Management Pattern
Before Hospitalization: According to the S.O, the patient views health as very important to human. One cannot function that well with the absence of it. Once health is absent, other aspects such as emotional, spiritual and social are affected. They always consult a doctor for any health problems. The S.O. also reports that he also takes over-the-counter drugs for simple illnesses such as fever
During hospitalization; The S.O. said that patient D.E perceived his self as weak and wasn’t able to do his daily activities. He manages his condition by complying with the entire doctor’s order and taking adequate rest. He reported no allergies to any foods and medications. At present, he manages his condition by complying with the entire doctor’s order and taking adequate rest.
2. Nutritional – Metabolic Pattern
Before hospitalization:
According
Name : D.E
Age : 67 years old
Address : Annafunan, Tuguegarao City
Sex : Male
Civil Status : Married
Occupation : None
Nationality : Filipino
Religion : Roman Catholic
Date of Admission : Nov. 01, 07
Time of Admission : 9:45 pm
Chief Complaint : Irritability and DOB
Final diagnosis : CVA infarct pneumonia
Attending Physician : Dr. Marlene Cinco
Patient’s History
Past Health History:
Patient D.E. had completed his immunization when he was a child. He experiences cough and cold in the past. According to the SO, the patient had a Hypertension.
History of Present Illness:
Five days prior to admission, the patient had a stroke and was confined at CVMC and few hours prior to admission the patient was irritable and had a difficulty of breathing.
Family Health History:
Patient D.E. has family history of hypertension and heart disease but not on respiratory problems such as bronchitis, asthma or pneumonia.
Gordon’s 11 Functional Pattern
1. Health Perception – Health Management Pattern
Before Hospitalization: According to the S.O, the patient views health as very important to human. One cannot function that well with the absence of it. Once health is absent, other aspects such as emotional, spiritual and social are affected. They always consult a doctor for any health problems. The S.O. also reports that he also takes over-the-counter drugs for simple illnesses such as fever
During hospitalization; The S.O. said that patient D.E perceived his self as weak and wasn’t able to do his daily activities. He manages his condition by complying with the entire doctor’s order and taking adequate rest. He reported no allergies to any foods and medications. At present, he manages his condition by complying with the entire doctor’s order and taking adequate rest.
2. Nutritional – Metabolic Pattern
Before hospitalization:
According