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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

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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..

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

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

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

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

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

.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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