DEMOGRAPHIC DATA

A. Initials of Clients Name: Via Lao Date of Admission: January 17, 2013
B. Address: General Trias Cavite Time of Admission: 7: 35 p.m.
C. Age: 18 yrs old Mode of Admission: Transfer
D. Birth Date: March 12,1999 Date of Interview: April 26,02017
E. Birth Place: Manila
F. Gender: Female
G. Civil Status: Single Other Data Sources: Patients Chart
H. Religion: Roman Catholic
J. Occupation: N/A
K. Monthly Income / Budget: N/A

REASON FOR SEEKING HEALTH CARE

Patient was brought awake and coherint, experiencing vomiting.

HISTORY OF PRESENT ILLNESS

Patient condition started one week prior to consultation, she experienced (+) body

pain, no consultation or medication made. Three days prior to admission, patient's

experienced (+) vomiting, (+) abdominal pain and fever. And one day prior, patient still

has abdominal pain. Patient was then brought to the institution.

PAST MEDICAL HISTORY

Patient has no history of gastric ulcers. Duodenal ulcers, diabetes mellitus, hypertension,
pulmonary tuberculosis, cancer and bronchial asthma and has no know food and drug
allergies. According to her mother patient Lao has a hepatitis b and when she gave birth 7
months ago she had given a hepatitis B IgG and hepatitis B vaccination.

GENERAL HEALTH STATUS

Patient body build is mesomorph, he stands 5 feet 9 inches and weighs 76
 kilograms. The patient looks weak and has signs of distress can be seen. He also
has limited movements because he cant stand either sit alone because his lower
extremities are already loss of function. He was mostly lying on the bed in
different position such as supine position or in Fowler or semi-fowlers position.
The patient has been staying at the hospital without any proper bathing. He also
looks untidy. Since the patient was paraplegia, he cannot perform proper hygiene
independently. He has no unusual body and breath odor.

COMPREHENSIVE PHYSICAL EXAMINATION

DIAGNOSTIC TEST
PHARMACOLOGICAL MANAGEMENT