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

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

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

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

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

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

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