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 DOCTOR’S ORDER SIGNIFICANCE

7/16/09 > Admit to ROC >
2:33pm > Secure consent > For legal form of document
BP: 80/60 > TPR q shift > For baseline data
Temp: 38.1 > DAT except dark colored foods > To monitor for occult blood
>Diagnostic Test
CBC, platelet in AM > For exploring the cause of the illness
> IVF D5LRS 1L X 6 hrs @ 40 exploratory basis
gtts/min > For fluids and electrolytes replacement.
Vomitted 4 times
> Ranitidine 1 amp IV q 8hrs
>Paracetamol 1 amp IV q 6hrs > H2 blocker/Antacids
> Monitor Temp and BP q1hr > Antipyretic-Analgesic
> For baseline date and progress notes
> I&O hs and record
> to monitor for kidney tissue perfusion
especially when it is hemoconcentrated
resulting to inadequate fluid volume
>refer circulation
> Continuity of care
7/17/09 > Continue meds > Continuity of care
8:15 > TF: D5LRS 1L X 6hrs @ > For fluid and electrolyte maintenance
BP: 100/80 40gtts/min
Temp: 37.3 > BP and Temp q 2hrs > For baseline date and progress note
> Isoprinosine 1tab TID OD > 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 NORMAL VALUE RESULT SIGNIFICANCE

Hemoglobin 11-16 g/dl 10.1 Impaired supply and demand of
oxygen d/t plasma disruption
Hematocrit 27-47% 35.7 Normal
White Blood Corpuscles 5-10X10/L 8.39 Normal
Neutrophils 50-56% 35.6 d/t bone marrow depression
associated with viral infection
Eosinophils 3-5% 1.8 d/t GI irritation causing release of
inflammatory mediators such as
histamine
Lymphocytes 25-35% 56.6 Immuno-response to viral infection
Basophils 0.1-1% 0.1 Normal
Platelet 150-4-x10/L 96 d/t plasma leakage (further
explanation and support in
Pathophysiology)