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

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

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

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

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

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

Sign up to vote on this title
UsefulNot useful