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..

 She was admitted to Queen Mary Help of Christian Hospital, chief complaint of fever,

head ache and mild abdominal pain.

V. 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 doesn’t have any childhood

illness and no known allergies to any food and medication.

She was diagnose with UTI last Wednesday on her urine analysis.

She was already take paracetamol for her fever, and cotrimoxazole for her UTI.

VI. Family History

She said that there is no any known illness or disease among her family, she can’t

recognized health status among her mother and father side.

She also said that she is only the one in the family have been hospitalized.

VII. Social History

She likes going outside with her friends. She also consider dancing as her form of

exercise.

She takes naps in the afternoon. Watching TV and talking with her friends, cousins and

family is her form of relaxation.

She drink occassionally as she said..

DIET

She eats 3 full meals and 2 snacks a day. Her usual diet includes mostly meats, rice and

vegetables and fruits. She eat 1 cup of rice per meal time. She prefers to drink water.
 Her 24 hour diet recall includes the following:

September 12, 2010

Breakfast (7:00am): Rice, Longganisa, Water

AM snack (9:00am): Sandwich, Water, Fruits

Lunch (10:00pm): Rice, Siningang na Baboy, Saging, Water

PM snack : Fruits, Water

Dinner(6:00pm): Rice, Pininyahang Manok, Water

Septermber 13, 2010

Breakfast (7:00am):Lugaw, Pandesal

VIII. Environmental History

Ms. X family consists of 4 members. They live in a 2 bedroom house, but they also

utilized the living room as sleeping area. Their windows have no screen.

She also mentioned that their home is at least a 10 minutes trycicle ride to the nearest

health center.

IX. REVIEW OF SYSTEM (GORDON’S)

A. Health Perception and Health Management

Ms. X describes her current health condition as a simple fever that can treat by

antipyretic drugs. She said that she is active at home and is very energetic.

According to her, finances is not a problem because her mother have a stable work in

abroad. There have been no major health injuries in her life.

 B. Nutritional Metabolic Pattern

She eats 3 full meals and 2 snacks a day. Her usual diet includes mostly

meats, rice and vegetables and fruits. She eat 1 cup of rice per meal time. She prefers to drink

water.

Her 24 hour diet recall includes the following:

September 12, 2010

Breakfast (7:00am): Rice, Longganisa, Water

AM snack (9:00am): Sandwich, Water, Fruits

Lunch (10:00pm): Rice, Siningang na Baboy, Saging, Water

PM snack : Fruits, Water

Dinner(6:00pm): Rice, Pininyahang Manok, Water

Septermber 13, 2010

Breakfast (7:00am):Lugaw, Pandesal

Ms. X likes eating home cooked meals specially her father’s recipe. She prefers to drink

water. She is not taking any vitamins. She has no known food allergies.

Her father manages the daily budget and they allots Php 200-300 for their daily food

allowance. Her father cooks the food at home. She has no known food or medicine allergies.
 C. Elimination

Mrs. X stated that she has a regular bowel movement. According to her, her stools are

mostly soft in texture. She urinates at least 7 times per day mostly at morning. She is not taking

any medication in her elimination, she also does not feel any discomfort in term of elimination.

D. Activity And Exercise

She is still studying,she mostly stays at home specially every sunday. Dancing is her form

of exercise.

She watches TV and takes nap in the afternoon every weekends. She has no difficulty in

perfroming physical activities of daily living nor does she require any assistance with it.

As I observed she have no difficulty on breathing. No cyanosis present on her lips, skin

and face.

E. Cognitive And Perceptual

Based on my physical assessment using the “watch tick method”, Ms. X doesn’t have

any difficulty hearing. She doesn’t use eye glassess for reading. She is able to respond or answer

simple instructions.

F. Sleep And Rest

Mrs. X goes to bed around 9:00 pm and usually wakes up around 3:00am sleep again

and wakes up 7:00am, 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 stated that she sleeps peacefully and don’t have any nightmares. She also takes an

afternoon nap for at least 1 hour.

 G. Perception And Self Concept

She describes herself as “Mabuti naman ako.Ok lang.” She said that he feels

comfortable with her life although she said she was in the hostpital, her relatives and family are

there to support her.

H. Role And Relationship Pattern

Ms. X her mother as their support systems. They lives in their own house. They have

good relationship with each other. They a nuclear family. Her Father recieves monthly budget

from her mother.

I. Sexuality And Reproductive

Her first menstual period was started when she was 11 y/o.

J. Coping And Stress Tolerance

Ms. X stated that she seldom gets stress except in times of doing her homeworks from

school.

K. Values And Beliefs

Ms. X sees her family as her greatest achievement in life and regards them as her

treasure in life. She goes to church every Sunday with her father an 2 siblings.
X. FUNCTIONAL ASSESSMENT

A. PHYSICAL ACTIVITIES OF DAILY LIVING

PHYSICAL ACTIVITIES Patient is able to do Patient is not able to do

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 

INSTRUMENTAL ACTIVITIES Patient is able to do Patient is not able to do

Housekeeping assisted
Preparing meals assisted
Taking medications 
Shopping 
Managing Money 
Travel 
Laundry 

INTERPRETATION

Mrs. X is able to perform all the physical activities or tasks and also all the

instrumental activities mentioned by herself.