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Published by: jordan11111111 on Sep 14, 2010
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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


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..

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

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

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

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

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

.X. X is able to perform all the physical activities or tasks and also all the instrumental activities mentioned by herself. FUNCTIONAL ASSESSMENT A. 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.

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