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Client Pres on URTI

Client Pres on URTI

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Published by: Danna Christine Gumboc Paguntalan on Jun 30, 2012
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12/24/2012

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CLIENT PRESENTATIONThis is the case of Y.P. a 17-year old female; born on July 4 1991. Client currentlyresides at 385 Mangga st. Cembo, Makati City. According to the patient, “may ubo’t siponako for three days at nahihirapan akong huminga.” Patient consulted a physician last May13, 2009 in Corporate Health and Wellness Center – Makati Medical Center. Y.P. wasdiagnosed to have Upper Respiratory Tract Infection. Y.P. has been experiencing mildheadache at the frontal head with a localized description and a throbbing quality. Theseverity of symptom is mild and the onset of pain was sudden that lasts for about fiveminutes. She verbalized, “bigla na lang siyang sumakit habang nanonood ng T.V..” The pain is aggravated by cold weather and is relieved by resting and medication such as:Cefalexin 500mg, Levopront syrup, Nafarin, Paracetamol 500mg. Patient don’t have anyknown allergies. Primary symptom is associated with other symptom such as: fever anddifficulty in breathing.Y.P.’s past health history were rubella, mumps and chicken pox; all with unrecalledtreatment. She has been completely immunized with BCG, DPT, OPV and MMR. She alsohas been completely immunized with anti-rabies and an on-going immunization on anti-hepatitis. Laboratory examinations were CBC and urinalysis with no significant findings;stool exam revealed the presence of Blastocystis Hominis. Y.P. had her first menstruationwhen she was 14 years old. She had a regular menstruation within 28-30 days cycle amonth with moderate amount that lasts for 3-4 days. She uses 6 pads of napkins per day.She had her last menstrual period last April 27, 2009.
 
“I have a middle self esteem,” as perceived by the patient. Patient has a closefamily relationship that serves as her support system, together with her friends. She canfeed her own self. Her hygienic practices are bathing once a day, brushing her teeth twice aday, combs hair 5-7 times in a day. Her usual activities would be brisk walking every 30minutes a day and she jogs once a week for one hour. Y.P.’s normal hours of sleep is about8-10 hours. According to her “simula ng nagka ubo’t sipon ako, paputol putol na rin ungtulog ko at feeling ko pagod ako pagkagising. She defecates every other day with tenesmus.She urinates approximately 8 times a day. “Does not use laxatives or other aides” asverbalized by the patient. She urinates approximately 8 times a day. Her food preferencesare fruits, ice cream, chocolates and meat. She drinks occasionally such as beer for about 5-6 bottles twice a month. According to the patient, she eats five times a day including snacksin between meals. “Ok naman, healthy naman ako,” as verbalized by the patient.Her physical assessment revealed with vital signs of temperature 36.8C taken ataxilla; pulse rate 60bpm taken at radial area; blood pressure 90/60mmHg; pain assessment3/10 recurrent, frontal head with sudden onset, localized description and a throbbingquality. Y.P.’s weight is 59kg (123.2 lbs) and her height is 5’4”. Client’s gait is normal andhas a wide range of motion. She looks appropriate to stated age. Her clothing wasappropriate with the weather and temperature; unkempt, properly buttoned, and zippedclothes. No obvious physical deformity was observed. She has no aids or supportivedevices. No odor of breath was noted.On systems assessment it reveals that patient has smooth skin, warm to touch andhas a good skin turgor. She has fine, black and evenly distributed hair. Lice, nits anddandruff were not noted on hair. Her head is normocephalic. She has 20/20 visual acuity

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