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    Rochelle Policarpio Dela Torre, a 30-year old married woman, presented to the emergency room at San Lazaro Hospital with a 4-day history of fever, body weakness, back and joint pain, headache, and abdominal pain. Her symptoms worsened in the past 2 days with the addition of chills, sweats, and vomiting. On admission, she had a high fever and rash on her lower extremities. Based on her symptoms and lab tests, she received a final diagnosis of Dengue Hemorrhagic Fever II. Her past medical history included previous dengue infections and she had an unclear vaccination history. Her family history was notable for hypertension, dengue,

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    Rochelle Policarpio Dela Torre, a 30-year old married woman, presented to the emergency room at San Lazaro Hospital with a 4-day history of fever, body weakness, back and joint pain, headache, and abdominal pain. Her symptoms worsened in the past 2 days with the addition of chills, sweats, and vomiting. On admission, she had a high fever and rash on her lower extremities. Based on her symptoms and lab tests, she received a final diagnosis of Dengue Hemorrhagic Fever II. Her past medical history included previous dengue infections and she had an unclear vaccination history. Her family history was notable for hypertension, dengue,

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    22 views2 pages

    Case Analysis

    Uploaded by

    chesterlozano
    Rochelle Policarpio Dela Torre, a 30-year old married woman, presented to the emergency room at San Lazaro Hospital with a 4-day history of fever, body weakness, back and joint pain, headache, and abdominal pain. Her symptoms worsened in the past 2 days with the addition of chills, sweats, and vomiting. On admission, she had a high fever and rash on her lower extremities. Based on her symptoms and lab tests, she received a final diagnosis of Dengue Hemorrhagic Fever II. Her past medical history included previous dengue infections and she had an unclear vaccination history. Her family history was notable for hypertension, dengue,

    Copyright:

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    CLINICAL CASE ANALYSIS San Lazaro Hospital

    PATIENTS PROFILE
    Name Gender Date of Birth Status Address Nationality Religion Date of Admission Time of Admission Final Diagnosis : : : : : : : : : : Rochelle Policarpio Dela Torre Female February 12, 1990 Married Tatalon, Araneta Ave. Quezon City Filipino Roman Catholic September 13, 2011 4:58 pm Dengue Hemorrhagic Fever II

    NURSING HISTORY

    Chief Complaint
    Fever

    History of Present Illness


    Four days PTA, the patient suffered from moderate fever accompanied with body weakness, back pain, arm and leg pain, headache and abdominal pain. The fever was relieved by doing Tipid Sponge Bath. She took Bioflu for fever and Biogesic for headache. Two days PTA, the patient still on febrile condition accompanied with chills and colds sweat. She experienced also vomiting of ingested food but no presence of bleeding. And an hour PTA, the patient experienced high grade fever with body weakness, and persistence of rashes at the lower extremities. She was rushed at San Lazaro Hospital Emergency Room by her husband. She was seen and examined by the Physician and Lab exam (Urinalysis, CBC,) were requested.

    Past Medical Health History


    A. Past Hospitalization She had her previous hospitalization during her childhood age because of Dengue Fever. Last year, she was confined due to Dengue Fever again. B. Surgery or any Invasive procedure She did not undergone any surgical procedure. C. Immunization Mrs. R.D.T is not sure if she received complete immunization during her childhood days. D. Intake of Maintenance Drugs She is also taking some vitamin supplements and paracetamol when she experiencing headache. Theres no known allergy on drugs and medications. E. Accident No previous accident was reported F. Common Illness Mrs. R.D.T experienced German measles when she was a child. G. History of Travel No history of travel

    FAMILY HEALTH HISTORY The family has no family history of heart disease and asthma. But on Mrs. RDTs mother side, they have a history of hypertension and dengue fever. Her father has Diabetes Mellitus.

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