Demographic Data Case

Date: July/17/2009 Time: 9:05am DEMOGRAPHIC DATA Name: Hartmanella Age: 15 y/o Address: San Miguel Ramon Isabela Gender: Female Date of Birth: October/31/1992 Place of Birth: San Miguel Ramon Isabela Civil Status: Single Religion: Pentecostal Nationality: Filipino Date of Admission: July/16/2009 Time of Admission: 2:25pm Chief complaint: fever for 7 days, dizziness, abdominal pain, headache, chilling, body malaise and vomited 4 times prior to admission. With initial vital signs BP: 90/70; PR: 82 Temp: 37.9 Attending Physician: Dra. Cristobal Admitting Diagnosis: Dengue Hemorrhagic Fever Mode of Admission: Wheelchair History of Present Illness According to Hartmanella’s SO it was then on the 16th day on the month of July of the present year she was been admitted to Callang General Hospital at 2:25 in the afternoon via wheel chair, having a chief complaint of : fever for 7 days, dizziness, abdominal pain, headache, chilling, body malaise and vomited 4 times prior to admission. Her initial vital signs then are as follows BP: 90/70; PR: 82. her mother becomes so nervous that time with the condition of her daughter since it is true that their area has a dengue outbreak and 3 cases of death was been reported. At first her mother know that it’s just only a minor illness but as it progresses resulting for her to consult her daughter to the hospital under the service of Dra. Cristobal with an admitting diagnosis of DHF, moreover diagnostic procedure drawn such as CBC considering her platelet count and blood typing and inserted an IVF of D5LRS 1L x 6hrs @ 40gtts/min, DAT diet except dark colored foods and ordered for I&O monitoring q hs and further treatment medications were given and started. Past Medical History of Ilnesses Pt Hartmanella, told that she was not hospitalized before nor the past years but experiencing some minor illness such as fever, colds and cough and are usually treated by OTC drugs such as paracetamol, biogesic and neasep. She had already received also her complete immunization during her childhood. Family History of Illnesses According to her mother, as to her mother side her 2nd younger brother is experiencing hypertension and older sister has a history of PTB but it was cured for her continuous medication. Aside from that no other illness or diseases were present neither her father side nor her nearest relatives had been reported.

Health Perception and Management Pattern Whenever she experiences some minor illness such as colds, cough and fever her4 mother bought some OTC drugs on the nearest pharmacy, sometimes they also consult on their RHU for further treatment and at the same time as a health advice and education as well. They also have herbal medications along their home they used them as a secondary treatment medications. Nutrition and Metabolic Pattern PTA, Hartmanella eat twice a day and consumes 1 cup of rice per meal and fond in eating junk foods and barbeque and drinks at least 4-5 glasses of H2O/day since she cannot tolerate higher amounts of fluid per day. DAP, Hartmanella cannot eat well d/t lack of appetite and at the same time tasteless sensation to foods. She consumes at least 4-5 spoonfuls of rice/meal/day and drinks at least 3-4 galsses of water/day. Elimination Pattern PTA, Hartmanella defecates once in a day since she’s experiencing constipation each day due to low H2O intake and voids 1-2 times a day. And she also noted that her stool is somewhere blackish in color as her illness progresses. DAP, Hartmanella defecates nothing for the last day and urinates 1-2 or sometimes once in a day. Activity and Exercise Pattern PTA, Hartmanella is fond in cooking as her daily routine she also used to clean her room regularly since she’s living on a boarding house and leaves her room early for her class. After her class, she washes her used uniforms and clothes simultaneously cooking her supper. After her supper she used to open her notes to make her assignments and reviewing for the following days. DAP, Hartmanella is experiencing muscle weakness but she can perform light activities but sometimes needs for assistance by the help of her mother. Sleep Pattern PTA, Hartmanella wokes up early as early as 5 since she needs to go to school early and sleeps at 10 in the evening. DAP, Hartmanella wokes up at 6 and sleeps at 9 in the evening. Cognitive Pattern Hartmanella is a fourth year high school, intelligent, and honored student. She also told that whenever she has free time she usually read her books alone or sometimes in a group. Role Relationship Pattern Hartmanella is only one daughter of Mrs. Eikenella, her father died early and has a step father with only one daughter whose wife already pass as well. As of now they were living in barangar San Miguel Ramon. She is a helpful, kind and loving daughter. She has a lot of friends in their school. When she’s at home she used to help her mother in delivering breads to sari-sari stores taken from a bakery as their source of income.

DAP, Hartmanella is somehow cannot converse well with the others except her mother due to her conditions. Personal Hygiene Pattern PTA, Hartmanella takes a bath twice a day including nights and brushes her teeth twice a day morning and before she sleep. DAP, Hartmanella doesn’t take her bath for the day and brushes her teeth twice a day late in the morning and before sleep. Environmental Pattern Hartmanelle’s home is living near the rice field were houses are far apart and plenty of trees grown where plenty of mosquitoes living along the edges of the leaves. Their house is made up of concrete and bricks having an adequate living space that may somehow accommodate them as family. They were also reached by current, they also have a little poultry and swine raising as well as their source of income. They their own water pump. Their garbage were thrown along a pit and burn when it as it withered. Values and Beliefs Pattern Pt Hartmanella, is a Pentecostal as to religion and goes to mass regularly. Their family doesn’t in quack doctors. Course in the Ward DATE/TIME 7/16/09 2:33pm BP: 80/60 Temp: 38.1

DOCTOR’S ORDER > Admit to ROC > Secure consent > TPR q shift > DAT except dark colored foods >Diagnostic Test CBC, platelet in AM > IVF D5LRS 1L X 6 hrs @ 40 gtts/min > Ranitidine 1 amp IV q 8hrs >Paracetamol 1 amp IV q 6hrs > Monitor Temp and BP q1hr

SIGNIFICANCE > > For legal form of document > For baseline data > To monitor for occult blood > For exploring the cause of the illness exploratory basis > For fluids and electrolytes replacement. Vomitted 4 times > H2 blocker/Antacids > Antipyretic-Analgesic > For baseline date and progress notes

> I&O hs and record

>refer 7/17/09 8:15 BP: 100/80 Temp: 37.3

> Continue meds > TF: D5LRS 1L X 6hrs @ 40gtts/min > BP and Temp q 2hrs > Isoprinosine 1tab TID OD

> to monitor for kidney tissue perfusion especially when it is hemoconcentrated resulting to inadequate fluid volume circulation > Continuity of care > Continuity of care > For fluid and electrolyte maintenance > For baseline date and progress note > Immunobooster and Inosine Prabonex, Antiviral

> HCT am

> To monitor for fluid loss d/t plasma cell leakage resulting to hemoconcentration.

Clinical Laboratory Results Date: 7/17/09 Time: 9:15 PAREMETERS Hemoglobin Hematocrit White Blood Corpuscles Neutrophils Eosinophils Lymphocytes Basophils Platelet

NORMAL VALUE 11-16 g/dl

RESULT 10.1

27-47% 5-10X10/L 50-56%

35.7 8.39 35.6

3-5%

1.8

25-35% 0.1-1% 150-4-x10/L

56.6 0.1 96

SIGNIFICANCE Impaired supply and demand of oxygen d/t plasma disruption Normal Normal d/t bone marrow depression associated with viral infection d/t GI irritation causing release of inflammatory mediators such as histamine Immuno-response to viral infection Normal d/t plasma leakage (further explanation and support in Pathophysiology)