II.

Personal Data Patient s name: MS. X Address: Gonzales st. Prinza Teresa Rizal Age: 15 yrs old Sex: Female Occupation: None Height: 4 8 Weight: 90.2 lbs. Religion: Roman Catholic Status: Single Attending Physician: Dra. Vista Date of Admission: September 11, 2010

III.

Chief Complaint/s and Medical Diagnosis: CC: Fever for 4 days with headache Dx: Dengue Fever Syndrome

IV. History of Present Illness Four days prior to admission the patient is complaining of fever with headache, and went Queen Mary Help of Christian Hospital to have a check up. On the day prior to admission, she was still complaining of fever with head ache and mild abdominal pain..

She also said that she is only the one in the family have been hospitalized.. and cotrimoxazole for her UTI. VII. She takes naps in the afternoon. V. DIET She eats 3 full meals and 2 snacks a day. she can t recognized health status among her mother and father side. Past Health History When she was 9 y/o she was hospitalized at Queen Mary Help of Christian Hospital because of her inflamed chick manifested by her toothache. She was already take paracetamol for her fever. rice and vegetables and fruits. head ache and mild abdominal pain. Family History She said that there is no any known illness or disease among her family. She was diagnose with UTI last Wednesday on her urine analysis. chief complaint of fever. . cousins and family is her form of relaxation. She drink occassionally as she said. VI. She doesn t have any childhood illness and no known allergies to any food and medication. She prefers to drink water.She was admitted to Queen Mary Help of Christian Hospital. She also consider dancing as her form of exercise. Watching TV and talking with her friends. Her usual diet includes mostly meats. Social History She likes going outside with her friends. She eat 1 cup of rice per meal time.

Fruits Lunch (10:00pm): Rice. 2010 Breakfast (7:00am): Rice. Longganisa. . There have been no major health injuries in her life. Environmental History Ms. Water Dinner(6:00pm): Rice. Water AM snack (9:00am): Sandwich. X describes her current health condition as a simple fever that can treat by antipyretic drugs. Water PM snack : Fruits. Saging.Her 24 hour diet recall includes the following: September 12. Siningang na Baboy. Health Perception and Health Management Ms. Water Septermber 13. finances is not a problem because her mother have a stable work in abroad. X family consists of 4 members. Water. Their windows have no screen. She said that she is active at home and is very energetic. She also mentioned that their home is at least a 10 minutes trycicle ride to the nearest health center. They live in a 2 bedroom house. 2010 Breakfast (7:00am):Lugaw. REVIEW OF SYSTEM (GORDON S) A. According to her. IX. Pandesal VIII. but they also utilized the living room as sleeping area. Pininyahang Manok.

She has no known food allergies. 2010 Breakfast (7:00am):Lugaw. Her father manages the daily budget and they allots Php 200-300 for their daily food allowance. Nutritional Metabolic Pattern She eats 3 full meals and 2 snacks a day. She is not taking any vitamins. She eat 1 cup of rice per meal time. Water Septermber 13. X likes eating home cooked meals specially her father s recipe. Water PM snack : Fruits. Pininyahang Manok. She prefers to drink water. Siningang na Baboy. Water Dinner(6:00pm): Rice. Water. Her usual diet includes mostly meats. Longganisa. rice and vegetables and fruits. Fruits Lunch (10:00pm): Rice.B. She prefers to drink water. . She has no known food or medicine allergies. Pandesal Ms. Her father cooks the food at home. Saging. 2010 Breakfast (7:00am): Rice. Water AM snack (9:00am): Sandwich. Her 24 hour diet recall includes the following: September 12.

X goes to bed around 9:00 pm and usually wakes up around 3:00am sleep again and wakes up 7:00am. She has no difficulty in perfroming physical activities of daily living nor does she require any assistance with it. . Dancing is her form of exercise. Elimination Mrs. X stated that she has a regular bowel movement. She doesn t use eye glassess for reading. if weekdays she sleep around 10:30pm and wakes up around 5:00am She gets up 1-2 times during the night to urinate. She stated that she sleeps peacefully and don t have any nightmares. X doesn t have any difficulty hearing. She is able to respond or answer simple instructions. E. skin and face. She watches TV and takes nap in the afternoon every weekends. her stools are mostly soft in texture.C. According to her. Cognitive And Perceptual Based on my physical assessment using the watch tick method . D. She urinates at least 7 times per day mostly at morning. Activity And Exercise She is still studying. She is not taking any medication in her elimination. Sleep And Rest Mrs. she also does not feel any discomfort in term of elimination. As I observed she have no difficulty on breathing. Ms. She also takes an afternoon nap for at least 1 hour. No cyanosis present on her lips. F.she mostly stays at home specially every sunday.

. her relatives and family are there to support her. I. Sexuality And Reproductive Her first menstual period was started when she was 11 y/o. X sees her family as her greatest achievement in life and regards them as her treasure in life. They lives in their own house. H. She goes to church every Sunday with her father an 2 siblings. X her mother as their support systems. X stated that she seldom gets stress except in times of doing her homeworks from school.Ok lang. Values And Beliefs Ms. Perception And Self Concept She describes herself as Mabuti naman ako. They a nuclear family. She said that he feels comfortable with her life although she said she was in the hostpital. J. Role And Relationship Pattern Ms.G. They have good relationship with each other. Her Father recieves monthly budget from her mother. Coping And Stress Tolerance Ms. K.

. FUNCTIONAL ASSESSMENT A.X. X is able to perform all the physical activities or tasks and also all the instrumental activities mentioned by herself. PHYSICAL ACTIVITIES OF DAILY LIVING PHYSICAL ACTIVITIES Bathing Dressing and Undressing Grooming Oral Care Eating Transferring from bed to chair and back Walking Climbing stairs Voluntary control of elimination Use of toilet Patient is able to do 3 3 3 3 3 3 3 3 3 3 Patient is not able to do INSTRUMENTAL ACTIVITIES Housekeeping Preparing meals Taking medications Shopping Managing Money Travel Laundry Patient is able to do assisted assisted 3 3 3 3 3 Patient is not able to do INTERPRETATION Mrs.