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    Clinical Abstract Sample Prac 2

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    John Paul Alfafara
    The document is a clinical abstract from Adventist Medical Center Manila documenting the admission of 27-year old male patient Michael Kean Cai on April 23, 2019 with a chief complaint of high fever, migraines, and vomiting. He was admitted with a possibility of dengue fever for observation. His physical exam showed he was conscious but febrile, weak, and moderately dehydrated with flushed skin and rashes over his body.

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    Clinical Abstract Sample Prac 2

    Uploaded by

    John Paul Alfafara
    206 views2 pages
    The document is a clinical abstract from Adventist Medical Center Manila documenting the admission of 27-year old male patient Michael Kean Cai on April 23, 2019 with a chief complaint of high fever, migraines, and vomiting. He was admitted with a possibility of dengue fever for observation. His physical exam showed he was conscious but febrile, weak, and moderately dehydrated with flushed skin and rashes over his body.

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    436108296 Clinical Abstract Sample Prac 2

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    The document is a clinical abstract from Adventist Medical Center Manila documenting the admission of 27-year old male patient Michael Kean Cai on April 23, 2019 with a chief complaint of high fever, migraines, and vomiting. He was admitted with a possibility of dengue fever for observation. His physical exam showed he was conscious but febrile, weak, and moderately dehydrated with flushed skin and rashes over his body.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    206 views2 pages

    Clinical Abstract Sample Prac 2

    Uploaded by

    John Paul Alfafara
    The document is a clinical abstract from Adventist Medical Center Manila documenting the admission of 27-year old male patient Michael Kean Cai on April 23, 2019 with a chief complaint of high fever, migraines, and vomiting. He was admitted with a possibility of dengue fever for observation. His physical exam showed he was conscious but febrile, weak, and moderately dehydrated with flushed skin and rashes over his body.

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    © All Rights Reserved
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    of 2

    DATE RECEIVED

    ADVENTIST MEDICAL CENTER MANILA


    Donada St. cor. San Juan St., Pasay

    CLINICAL ABSTRACT
    NAME OF HOSPITAL/AMBULATORY CLINIC: CASE NO.
    01238395
    ADMISSION:
    DATE: APRIL 23, 2019
    ADVENTIST MEDICAL HOSPITAL TIME 9:45 AM/PM

    ACCREDIATION NO.: PH-123312


    ADDRESS OF HOSPITAL/AMBULATORY CLINIC BARANGAY
    Donada St. cor. San Juan St., San Isidro
    MUNICIPALITY CITY PROVINCE ZIP CODE
    Pasay City NCR 1306

    PATIENT’S CLINICAL RECORD

    1. PATIENT’S NAME 2. AGE 3. SEX


    LAST NAME Male
    CAI 27
    FIRST NAME 4.

    MICHAEL KEAN
    MIDDLENAME
    L _______________________________________
    PRINTED NAME AND SIGNATURE OF ADMITTING OFFICER
    5. ADMITTING DIAGNOSIS

    Dengue fever
    6. CHIEF COMPLAINT
    High fever, migraines, vomiting
    7. REASON FOR ADMISSION
    Possibility of dengue fever; for observation
    8. BRIEF HISTORY OF PRESENT ILLNESS/OB HISTORY

    High grade fever, 3rd day; weakness of body malaise; moderate to severe headache; and loss of
    appetite 4th day.
    On and off epigastric discomfort on 3rd day
    Dehydration
    Skin Rashes with fever
    9. PHYSCIAL EXAMINATION (PERTINENT FINDINGS PER SYSTEM)

    General Survey: Patient is conscious, coherent and febrile, weak, moderately dehydrated with flushed
    skin with rashes over body
    Vital Signs BP GP 88/60 HR 96/min RR 116/min TEMP: 40.7 C
    HEIGHT 164 cm WEIGHT 85 kg

    HEENT: congested conjunctiva, pupils equal and reactive (-) jaundice sclerea

    CHEST/LUNGS: clear breath sounds but tachypneic

    Heart: tachycardic, distinct Heart Soungs; no murmur

    ABDOMEN: slight tenderness epigastric area

    SKIN/EXTERMITIES: moderately poor skin turgor, flushed skin; generalized petechial rashes

    NEUROLOGIC: conscious, coherent, no difficulty in movements but with generalized weakness

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