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Clinical Abstract Sample - Prac 2

This clinical abstract summarizes a patient's admission to Adventist Medical Center Manila on April 23, 2019. The 27-year-old male patient, Michael Kean Cai, was admitted with a chief complaint of high fever, migraines, and vomiting and an admitting diagnosis of dengue fever. Upon examination, the patient was conscious but febrile, weak, and moderately dehydrated with flushed skin and rashes over his body. Based on his symptoms of high grade fever for 3 days, weakness, headache, loss of appetite, and dehydration, he was admitted for observation for the possibility of dengue fever.

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Andrea Diwa
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49K views1 page

Clinical Abstract Sample - Prac 2

This clinical abstract summarizes a patient's admission to Adventist Medical Center Manila on April 23, 2019. The 27-year-old male patient, Michael Kean Cai, was admitted with a chief complaint of high fever, migraines, and vomiting and an admitting diagnosis of dengue fever. Upon examination, the patient was conscious but febrile, weak, and moderately dehydrated with flushed skin and rashes over his body. Based on his symptoms of high grade fever for 3 days, weakness, headache, loss of appetite, and dehydration, he was admitted for observation for the possibility of dengue fever.

Uploaded by

Andrea Diwa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Clinical Abstract

DATE RECEIVED

ADVENTIST MEDICAL CENTER MANILA


Donada St. cor. San Juan St., Pasay

CLINICAL ABSTRACT
NAME OF HOSPITAL/AMBULATORY CLINIC: CASE NO.
01238395
ADMISSION:
DATE: APRIL 23, 2019
ADVENTIST MEDICAL HOSPITAL
TIME 9:45 AM/PM

ACCREDIATION NO.: PH-123312

ADDRESS OF HOSPITAL/AMBULATORY CLINIC BARANGAY


Donada St. cor. San Juan St., San Isidro
MUNICIPALITY CITY PROVINCE ZIP CODE
Pasay City NCR 1306

PATIENT’S CLINICAL RECORD

1. PATIENT’S NAME 2. AGE 3. SEX


LAST NAME Male
CAI 27
FIRST NAME 4.

MICHAEL KEAN
MIDDLENAME
_______________________________________
L PRINTED NAME AND SIGNATURE OF ADMITTING OFFICER

5. ADMITTING DIAGNOSIS

Dengue fever
6. CHIEF COMPLAINT
High fever, migraines, vomiting
7. REASON FOR ADMISSION
Possibility of dengue fever; for observation
8. BRIEF HISTORY OF PRESENT ILLNESS/OB HISTORY

High grade fever, 3rd day; weakness of body malaise; moderate to severe headache; and loss of
appetite 4th day.
On and off epigastric discomfort on 3rd day
Dehydration
Skin Rashes with fever
9. PHYSCIAL EXAMINATION (PERTINENT FINDINGS PER SYSTEM)

General Survey: Patient is conscious, coherent and febrile, weak, moderately dehydrated with flushed
skin with rashes over body
Vital Signs BP GP 88/60 HR 96/min RR 116/min TEMP: 40.7 C
HEIGHT 164 cm WEIGHT 85 kg

HEENT: congested conjunctiva, pupils equal and reactive (-) jaundice sclerea

CHEST/LUNGS: clear breath sounds but tachypneic

Heart: tachycardic, distinct Heart Soungs; no murmur

ABDOMEN: slight tenderness epigastric area

SKIN/EXTERMITIES: moderately poor skin turgor, flushed skin; generalized petechial rashes

NEUROLOGIC: conscious, coherent, no difficulty in movements but with generalized weakness

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