II | Lunch | Clinical Medicine


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

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

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

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

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

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