UNIVERSITY OF SANTO TOMAS

COLLEGE OF NURSING
España Boulevard, Sampaloc, Manila, Philippines 1015
Tel. No. 406-1611 loc. 8241 Telefax: 731-5738 Website:
www.ust.edu.ph

PATIENT CARE RECORD

Patient’s Name: S.B.A Room No: 211- A Ward: Medicine Forbes Ward Date: 11/06/2017
Chief Complaint: high fever Diagnosis: dengue with danger signs

A. Health History
I. Biographical Data:
Age: 50 Sex: Female Citizenship: Filipino Religion: Roman Catholic
Birthdate: January 8, 1968 Civil Status: Single
Educ. Attainment: High School Graduate
Address: 3 Johnson St., North Green hills, San Juan, Metro Manila

II. History of Present Illness

Five days prior to admission, patient started having intermittent high fever with headache,
nausea and generalized body weakness. The patient started taking paracetamol 500mg/tab which
provide temporary relief of the fever. The patient started to seek consult to a private physician
that advised her to do labprtpry work up such as CBC and Urinalysis. CBC showed a leucopenia
(2.86 10^9/L), low RBC (4.1), thrombocytopenia (0.118^12/L), high segmenters (0.80) and
lymphocytopenia (0.14) and in the urinalysis resulted a low specific gravity 1.020, positive
blood, and positive bacteria.

III. Past Health History

(+) Breast CA stage II (2015)

(-) HPN (-) DM (-) Kidney disease (-) Liver disease (-) GERD (-) PTB (-) Dengue

Medication:
Paracetamol 500mg/Tab q4
Tamoxifen 20mg/tab
Metoclopramide 10mg/IV

Allergies: None

IV. Family Health History

(+) Cancer of the Lungs – Paternal side

Summary of Diagnostic Procedures

DATE PROCEDURE SIGNIFICANT FINDINGS IMPLICATIONS
October 07, Urinalysis (+) erythrocytes - Erythrocytes in the
2018 (+)Squamous cell, bacteria urine indicates
infection or
inflammation of the
urinary tract itself.
-Squamous epithelial
cells in the urine
increases when
someone has an
infection or other
cause of
Specific Gravity = 1.020 inflammation.
(Normal:

October 07, Blood Chemistry Low Creatinine= 0.45 -Low in creatinine

2018 (Normal: 135-145) levels may indicate
that the patient have a
muscle disease, such
as muscular
dystrophy.
- Low levels of AST
High SGPT – ALT = 132 in the blood are
(Normal: 135-145) expected and are
normal.
-Low potassium levels
Low Potassium = 3.44 has many causes but
(Normal: 3.5-5.1) usually, it results from
vomiting or diarrhea
which can make
muscles feel weak,
cramp, twitch or even
become paralyzed and
abnormal heart
rhythms may develop.

-Low leukocytes
October 6, Complete Blood Count Leukocytes = 2.86 (Normal: caused by: Viral
2018 4.5to 11.0 × 109/L) infections that
temporarily disrupt
7:27 PM the work of bone
marrow. This finding
is significant for the
patient who is having
dengue.

-Low platelet is
Thrombocytes = 85 (Normal:
150 to 400 × 109/L) because of the Dengue
virus, the main cause
of dengue fever
induces bone marrow
suppression. Since
bone marrow is the
manufacturing center
of blood cells its
suppression causes
deficiency of blood
cells leading to low
platelet count.
Segmenters = 0.80
-Segmenters are one
of the types of
neutrophils found in
the blood. They would
be elevated if the
overall white count is
Lymphocytes = 0.14 up, usually due to
some kind of
infection.
-Lymphocytes are part
of our immune
defense and act to
 recognize antigens,
produce antibodies
and destroy cells that
could cause damage.
Some causes of
having a low
lymphocyte count
include treatments for
cancer such as
chemotherapy and
October 06, Negative Dengue IgM radiation.
2018 Positive Dengue IgG
Immunochromatographic
rapid test - Positive IgM and
IgG tests for dengue
antibodies detected in
an initial blood sample
mean that it is likely
that the person
became infected with
dengue virus within
recent weeks. IgM
antibody tests can be
positive if a person
has been infected with
a similar virus, such as
chikungunya (called
cross-reaction).

- Negative tests for

IgM antibody may
mean that the
individual tested does
not have a dengue
infection and
symptoms are due to
another cause, or that
the level of antibody
may be too low to
measure. The person
may still have a
dengue infection – it
may just be that it is
too soon after initial
exposure to the virus
to produce a
detectable level of
antibody.