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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..
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 also consider dancing as her form of exercise. She drink occassionally as she said.She was admitted to Queen Mary Help of Christian Hospital. She also said that she is only the one in the family have been hospitalized. Family History She said that there is no any known illness or disease among her family. She takes naps in the afternoon. She eat 1 cup of rice per meal time. She was already take paracetamol for her fever. rice and vegetables and fruits. . head ache and mild abdominal pain. she can t recognized health status among her mother and father side. She was diagnose with UTI last Wednesday on her urine analysis. chief complaint of fever. She prefers to drink water. Watching TV and talking with her friends. V. Her usual diet includes mostly meats. and cotrimoxazole for her UTI. VI. 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. VII. cousins and family is her form of relaxation.
According to her. 2010 Breakfast (7:00am): Rice. Water. They live in a 2 bedroom house. 2010 Breakfast (7:00am):Lugaw. . Longganisa. IX. She said that she is active at home and is very energetic. Water Septermber 13. Environmental History Ms. X describes her current health condition as a simple fever that can treat by antipyretic drugs. There have been no major health injuries in her life. Health Perception and Health Management Ms. finances is not a problem because her mother have a stable work in abroad. Water Dinner(6:00pm): Rice. Their windows have no screen. Water AM snack (9:00am): Sandwich. Pininyahang Manok. Pandesal VIII. but they also utilized the living room as sleeping area. REVIEW OF SYSTEM (GORDON S) A. Fruits Lunch (10:00pm): Rice. Saging. Siningang na Baboy. Water PM snack : Fruits.Her 24 hour diet recall includes the following: September 12. X family consists of 4 members. She also mentioned that their home is at least a 10 minutes trycicle ride to the nearest health center.
Nutritional Metabolic Pattern She eats 3 full meals and 2 snacks a day. She eat 1 cup of rice per meal time. She prefers to drink water. Longganisa. Saging. X likes eating home cooked meals specially her father s recipe. Her father manages the daily budget and they allots Php 200-300 for their daily food allowance. She has no known food allergies. 2010 Breakfast (7:00am):Lugaw. Water AM snack (9:00am): Sandwich. Water Septermber 13. She is not taking any vitamins. . Water Dinner(6:00pm): Rice. She has no known food or medicine allergies. Water PM snack : Fruits. Fruits Lunch (10:00pm): Rice. Siningang na Baboy.B. Water. 2010 Breakfast (7:00am): Rice. Her 24 hour diet recall includes the following: September 12. Her usual diet includes mostly meats. Her father cooks the food at home. Pandesal Ms. She prefers to drink water. Pininyahang Manok. rice and vegetables and fruits.
She stated that she sleeps peacefully and don t have any nightmares. her stools are mostly soft in texture. Dancing is her form of exercise. No cyanosis present on her lips. X goes to bed around 9:00 pm and usually wakes up around 3:00am sleep again and wakes up 7:00am. Activity And Exercise She is still studying. She also takes an afternoon nap for at least 1 hour. Cognitive And Perceptual Based on my physical assessment using the watch tick method . According to her. She doesn t use eye glassess for reading. she also does not feel any discomfort in term of elimination. . if weekdays she sleep around 10:30pm and wakes up around 5:00am She gets up 1-2 times during the night to urinate.C. X doesn t have any difficulty hearing. Ms. She has no difficulty in perfroming physical activities of daily living nor does she require any assistance with it. She is able to respond or answer simple instructions. She urinates at least 7 times per day mostly at morning. Sleep And Rest Mrs. skin and face. E. She watches TV and takes nap in the afternoon every weekends.she mostly stays at home specially every sunday. She is not taking any medication in her elimination. As I observed she have no difficulty on breathing. Elimination Mrs. D. F. X stated that she has a regular bowel movement.
They have good relationship with each other. X sees her family as her greatest achievement in life and regards them as her treasure in life. X stated that she seldom gets stress except in times of doing her homeworks from school. Coping And Stress Tolerance Ms. Sexuality And Reproductive Her first menstual period was started when she was 11 y/o. I. J.G. H. She goes to church every Sunday with her father an 2 siblings.Ok lang. X her mother as their support systems. K. . They a nuclear family. Perception And Self Concept She describes herself as Mabuti naman ako. Role And Relationship Pattern Ms. She said that he feels comfortable with her life although she said she was in the hostpital. her relatives and family are there to support her. Her Father recieves monthly budget from her mother. Values And Beliefs Ms. They lives in their own house.
.X. 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. FUNCTIONAL ASSESSMENT A. X is able to perform all the physical activities or tasks and also all the instrumental activities mentioned by herself.