PALMA, Mara Angelie S.
BSN, NCM 103
July 11, 2013
CASE STUDY: TONSILLITIS
Name: Mr. Nathan S. Potter
Birthdate: December 10, 1985
Age: 24 y/o
Civil Status: Single
Religion: Roman Catholic
Address: Zone 7A, Sua, Camaligan
Chief Complaint: Fever, Sore throat
Present Treatment: Self-medication
Past Treatment: None
Past Hospitalization: None
Patient’s History of Present Illness
Mr. X is a resident of Zone 7A, Sua, Camaligan, Camarines Sur. He has no permanent job and he does sidelines to earn for a living and to earn for his family. He spends his time mainly at home, doing some household chores. He reported drinking coffee every morning. He denies smoking and drinking alcohol. On the night of June 24, 2005, he felt hot and experienced a sore throat. He thought of having tonsillitis. He immediately took ALVEDON 500 mg.
GORDON’S FUNCTIONAL HEALTH PATTERN
1. Health Perception – Health Management Pattern
The patient’s health rating is 1. Due to his present condition, he cannot perform ADLs by himself and he needs assistance by a caregiver or significant other. He hasn’t gone yet to a professional health care personnel. He doesn’t use tobacco, doesn’t drink alcoholic beverages, and doesn’t take any drugs for abuse. Objective The patient is alert even though having a bad feeling. He is lying on bed to promote rest. He communicates well and talks fine. He can move his different parts of the body and he shows emotions by different facial expressions. PR: 78 bpm, RR: 22 cpm, T (axillary): 38⁰ C, BP (sitting): 110/90 2. Nutritional – Metabolic Pattern Daily Food and Fluid Intake He usually drinks coffee in the morning. For lunch and dinner, he eats vegetables and rice. He often eats fish and seldom eats meat. He eats anything available for snacks. He doesn’t have...
Please join StudyMode to read the full document