History

In Partial Fulfillment of the Requirements In NCM 101 SUBMITTED BY: LEE-ANN CARLA L. SALAZAR BSN (2A)MT SUBMITTED TO: MRS. LALAINE CHRISTALES VITAL instruction unwrap: MR. G.D. AGE: 30 Years oldSEX: antheralCIVIL posture: s Single RELIGION: Roman Catholic NATIONALITY: Filipino BIRTHDATE: terrible 15, 1982 BIRTHPLACE: Banbanan,San Remigio, Antique CURRENT ADDRESS: Bugo, San Remigio, Antique EDUCATION: 3rd year High School OCCUPATION: Bagger ( Iloilo plastic center) CHIEF COMPLAINTS: consistency Malaise DATE & TIME OF ADMISSION TO ER: 3:00PM, Jan. 6, 2012 modality OF ADMISSION: Stretcher ACCOMPANIED BY: MR. J.T. (Employer) MENTAL/EMOTIONAL STATUS UPON ADMISSION: unconscious ADMISSION VITAL SIGNS: T: 37.3 PR: 108 bpm RR: 23 bpm BP: 60/40 mmHg MEDICAL DIAGNOSIS: Weils Syndrome (leptospirosis) attend PHYSICIAN: Dr. Gonzales; Dr. Divinagracia; Dr. Retiro NUMBER & DATES OF PREVIOUS HOSPITAL ADMISSIONS: NONE WARD/UNIT,BED & inhabit #: SJM 1 FOOD OR DRUG ALLERGY: NONE SOURCE OF INFORMATION: Client; Mother (MRS. C.D); chart HISTORY OF PRESENT ILLNESS Client has a wound on the left foot. But wasnt frightful and thought it was nearly.

He went to super in Iloilo city to buy vegetables for lunch when it rained and he got his foot wet and got no selection but to go oer the dirty water w/o boots. On January 1,2012, patient had a sudden blast of fever. He took biogesic and Bioflu 3 times a day. Intervention was effective. January 2,2012, lymph gland returned to work at Iloilo plastic center. But immediately returned to his boarding house at Molo because he was not feeling well; he felt dizzy. January 3,2012, lymph node wasnt able to report to work because of high fever, jaundice skin all over the body, and dizziness. January 4, 2012, client stayed at the boarding house. alike(p) feeling was felt. Same medications. Only biogesic and bioflu taken 3 times a day. January 5, 2012, client went to St. Pauls Hospital for check-up with his... If you want to get a full essay, order it on our website: Orderessay

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