Patient Profile

Patient Profile

Patient X is female, 15 years old, Filipino citizen, single and currently residing @ J.C Aquino Ave. Butuan City. She was a second year high school student of Agusan National High School and a Born Again by faith. She is the eldest of 4 siblings. Upon assessment, Pt. X has a long curly hair, black in color. Eyes were symmetrical as well as her ears. She stands 5’3 in height and weight’s 45 kg. She has brown skin and fair complexion, good skin turgor without lesions. She is well groomed. Pt. X has a general overview of her condition and understands the reason for her admission. She and her mother directly seek for medical management and didn’t rely on quack doctors. 3 days PTA, pt. X had a fever with 3 to 4 episodes of vomiting and claimed for headache. Her mother directly brought her to Butuan Doctor’s Hospital around 2 pm on Dec. 3,2007 with a chief complain of headache and vomiting. Admitting diagnosis is Acute Gastritis under the service of Dr. Aala. Upon interaction, pt. X was having a #6 D5.3 NaCl 1L @ 10gtts/min @ Left metacarpal vein @ the level of 950cc; infusing well. She didn’t claim for vomiting but claimed for moderate headache during my shift. She was febrile, T:39C P: 85 bpm R: 22 cpm BP: 100/70 mmHg and was having a PRN meds of Paracetamol 500 mg 1tab q 4h. She also have an IV meds of Pen G 4m ”u” q 6 ANST and Ranitidine 50mg IVTT q 12h.