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

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

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

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

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

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

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