Patient’s Profile

• Name : Patient Y
• Address: Tagaloan, Lanao del Norte
• Age : 16 years old
• Sex : Female
• Birth date : January 7, 1993
• Occupation : Student
• Religion : Islam

Nursing Health History

I. Chief Complaint: fever, painful urination

II. History of Present Illness

2 days prior to admission, patient has onset

fever undocumented and intermittent, temporarily
received with Paracetamol 500 mg/tablet every 4
hours associated with frontal throbbing headache
and periumbilical pain, cramping radiating all over
abdomen, vomiting 4x of 30 cc/episode, post prandial
a day PTA, site was noted to have dysuria.

Patient Y stated that the signs started last

October 10, 2009, Saturday and she described it as
a gradual onset of sign. The patient heightened the
pain with the rating scale of 7/10 with 2 hours
interval, and pain tolerance that lasts within 4 to 5
 minutes, located at the right lumbar region. She was
at school during the first occurrence of pain.

III. Past History

The patient’s SO (mother) stated that the

patient had not experienced any serious childhood
illnesses except for common illnesses like fever,
cough and colds. Patient’s immunization is only BCG.

The patient had also experienced a minor

accident at the age of 7 years old during her school
days in Madrasa. She had fallen from a chair and she
had experienced a sprain from her left elbow. They
did not go to the hospital. Instead, they sought
treatment from a versionist (a traditional therapist).

She was hospitalized before for the same

case (acute pyelonephritis). The case was diagnosed
last June 2008 and she has stayed for 2 days in the
hospital. By then, she was discharged for the relief
of symptoms.

For medications she had taken

Cefuroxime(cefuci) as Doctor prescribed a dosage of
750 mg via IVTT Q8H ANST(-) the side effects of
these drugs include: CNS: headache, dizziness,
lethargy, GI: nausea, vomiting, diarrhea, anorexia,
abdominal pain, flatulence, HEMATOLOGIC:
bonemarrow suppression (decreased WBC, decreased
platelets, decreased hematocrit),
HYPERSENSITIVITY: ranging from rash to fever to
anaphylaxis, serum sickness reaction, LOCAL: pain,
abscess at injection site, OTHER: super infection. The
other drug is Paracetamol (zestagesic), 500mg/tab
Q4H PRN for fever. The side effects of these drugs
are the following; CNS: headache, CV: chest pain,
dyspnea, myocardial damage when doses of 4 g/day are
ingested for 1 year, GI: hepatic toxicity and failure,
jaundice, GU: acute renal failure, renal tubular
necrosis, HEMATOLOGIC: methemoglobinemia,
cyanosis, haemolytic anemia-hematuria, anuria
neutropenia, leukopenia, pancytopenia,
thrombocytopenia, hypoglycaemia,
HYPERSENSITIVITY: rash, fever. The third one is
Mefenamic acid (zestan), 500 mg cap.1cap Q6H PRN
for flank pain. The side effect includes;CNS: headache,
dizziness somnolence, insomia, fatigue, tiredness,
dizziness, tinnitus ophthalmic effects,
DERMATOLOGIC: rash, pruritus, sweating day, mucous
membranes, stomatitis, GI: nausea, dyspepsia, GI pain,
diarrhea, vomiting, constipation, flatulence, GU:
dysuria, renal impairment, HEMATOLOGIC: bleeding,
platelet inhibition with higher doses, neutropenia,
eosinophilia, leukopenia, RESPIRATORY: dyspnea,
hemoptysis, pharyngitis, bronchospasm, rhinitis. Last
drug is: Mebendazole ( Mebendazole), Oral, 500mg
1tab. As a single dose. The side effects are
abdominal pain, diarrhea, convulsions in infant,
exanthema, urticaria, rash, nausea and vomiting.

The patient also took herbal medicines

such as tawa-tawa for fever and ulasimang-bato as an
alternative for diuretic.

Family History of Illness

Patient and her family did not have any

history of heart disease and cancer. A few of her
relatives, mostly elderly, are noted to have
hypertension. Allergies and obesity are not
identified within her family. No family member is
diagnosed with tuberculosis same with mental
health disorders. However, her mother had noted
of diabetes mellitus and a certain kidney illness
during her 20’s.

Social Data

Patient loves to eat cheesy and salty foods.

She likes to eat junk foods and she also drinks
soft drinks. Since she is young, she doesn’t have
any job and she is also concentrating with her
studies. Her medical care is handled by her
parents. Patient stated that their home and
neighbourhood are in good condition. They have a
happy and peaceful environment that is conducive
for living.