Patients Profile

Patient X is a female, 15 years of age, single and is the second child among the four children. She is a natural born Filipino citizen. Patient X has a height of 49 and is weighing 43.5 kilograms. She lives with her parents in 278 Purok Yakal Pangabugan, Butuan City. She is a 3rd year high school student at Agusan National High School. Patient X eats at least three times a day and most of her meal pattern during breakfast, lunch and dinner are mix vegetables, fried chicken and fried fish with water. She also drinks not less than 8 glasses of water a day. She likes to eat ice cream and spaghetti but dislikes amplaya. She eats lumpia in between meals at school that serves as her snack. She eats most of the time with her family. In terms of her elimination, she urinates not less than four times a day and defecates once a day. Her sleeping hours were altered for only 5 hours because she indulged herself more on studying at nighttime and midnight. Patient X had no any allergies when it comes to food and medicine. She is taking multivitamins daily such as neutroplex. She had a history of hospitalization before with a chief complaint of typhoid fever in her elementary years and again typhoid fever and dengue fever when she reached 1st year high school. According to her, she had undergone a surgery before in her right ear when she was just 5 years old after she had been hit by a car at the street. The family of Orientation of Patient X in her fathers side is known to be diabetic and the mothers side is hypertensive. In terms of their home environment, it is clean and is surrounded by many trees that make their place breezy. The community of patient x where she lives and her school is clean. Prior to admission, the patient was experiencing epigastric pain, loose stools and vomits at close intervals. According to the patient, last November 20, 2011 during their dinner, she had eaten fish with soup. At 1 am early in the morning of November 21, 2011, patient x vomited watery rice a couple of times and had watery stools of not less than two times. As the condition worsened at 11am, she was immediately rushed to the emergency room of Butuan Doctors Hospital where she was given Plasil 0.5 ml IVTT and Omeprazole 20 mg IVTT. She was then confined at Floor 3 for proper management of her current condition. On the same day, she underwent a series of laboratory examinations such as Complete Blood Count, Urinalysis and Fecalysis. The chief complaint was vomiting and she was under the care of Dr. Nebrada. She was having IVF # 1 D5NSS 1 liter at 20 gtts/min. She had experienced fever also on the same day and was ordered by the doctor Paracetamol 500mg. 1 tab every 4 hours if having fever. On the next day November 22, 2011, the doctor ordered medications such

as Omeprazole 20mg IV once at 6am and Ampicillin 500 mg. IV every 6 hours and After Negative Skin Test (ANST) where it revealed negative. During the rounds in the afternoon of the same day, the patient was lying on bed with ongoing IVF # 2 D5LR 1 liter regulated at 20 gtts/min inserted at the left cephalic vein at the level of 600 cc. initial vital signs were Blood Pressure 80/60 mmHg, Temperature is 35.88 degrees Celsius, Pulse Rate 78 beats per minute and Respiration rate is 19 breaths per minute. According to the patient, the doctor said that maybe the reason why she vomits is that their water contains amoeba. She was on her full diet where she had eaten well. Patient X said that she was not anymore vomiting. She was already improving as to her condition and was responsive. The complete/ final diagnosis of the doctor is Acute Gastroenteritis with mild dehydration.