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..

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

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

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

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

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

FUNCTIONAL ASSESSMENT A. . 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.

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