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    Fariñas, Rhizel Marie C. - Section C

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    Rhizel Marie Cauilan Fariñas
    Mary Anne Cosmo Andrade, a 27-year-old female, was admitted to the hospital with chief complaints of dizziness, headache, nausea, and lethargy. She was diagnosed with systemic viral infection with mild dehydration. Her vital signs were a temperature of 38.8 degrees Celsius, respiratory rate of 22, pulse rate of 95, and blood pressure of 130/80 mm hg. Her treatment plan included IV fluids, medications, and laboratory tests.

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    Fariñas, Rhizel Marie C. - Section C

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    Rhizel Marie Cauilan Fariñas
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    Mary Anne Cosmo Andrade, a 27-year-old female, was admitted to the hospital with chief complaints of dizziness, headache, nausea, and lethargy. She was diagnosed with systemic viral infection with mild dehydration. Her vital signs were a temperature of 38.8 degrees Celsius, respiratory rate of 22, pulse rate of 95, and blood pressure of 130/80 mm hg. Her treatment plan included IV fluids, medications, and laboratory tests.

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    Fariñas, Rhizel Marie C._Section C.xlsx

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    Mary Anne Cosmo Andrade, a 27-year-old female, was admitted to the hospital with chief complaints of dizziness, headache, nausea, and lethargy. She was diagnosed with systemic viral infection with mild dehydration. Her vital signs were a temperature of 38.8 degrees Celsius, respiratory rate of 22, pulse rate of 95, and blood pressure of 130/80 mm hg. Her treatment plan included IV fluids, medications, and laboratory tests.

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    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    33 views8 pages

    Fariñas, Rhizel Marie C. - Section C

    Uploaded by

    Rhizel Marie Cauilan Fariñas
    Mary Anne Cosmo Andrade, a 27-year-old female, was admitted to the hospital with chief complaints of dizziness, headache, nausea, and lethargy. She was diagnosed with systemic viral infection with mild dehydration. Her vital signs were a temperature of 38.8 degrees Celsius, respiratory rate of 22, pulse rate of 95, and blood pressure of 130/80 mm hg. Her treatment plan included IV fluids, medications, and laboratory tests.

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    © All Rights Reserved
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    of 8

    ADMISSION AND DISCHARGE RECORD

    Room and Bed No: large private 102 PHIC No: 234567
    Patient's Name:
    Andrade Mary Anne Cosmo
    Surname First Name Middle Name
    Permanent Address:
    # 45 Mamatid Cabuyao Laguna 4025
    House Number Barangay Municipality/City Province Zip Code
    Provincial Address:
    # 45 Mamatid Cabuyao Laguna 4025
    House Number Barangay Municipality/City Province Zip Code
    Age Sex Civil Status Nationality Religion
    27 Female Married Filipino Catholic
    Date of Birth Place of Birth
    April 22, 1994 Camarines Norte
    Occupation Present Employer
    Junior Consultant Kojic International Laboratory
    Employer's Address Landline/Mobile Number:
    Kojic International Laboratory
    Name of Nearest Relative Relationship
    Ms. Kristina Magcamit Cousin

    Address: # 45 Brgy. Mamatid, Cabuyao Laguna Landline/Mobile Number: 91723452531

    Name of Spouse Landline/Mobile Number Occupation


    Mr. Andrade N/A OFW
    Total Number of
    Admission: Discharge Attending Physician/s:
    days
    Date Date 0
    Time Time
    Type of Admission:

    Informant:

    First Name Middle Name Surname

    Admitting Diagnosis:

    T/C Systemic Viral Infection with signs and symptoms of mild dehydration
    Final Diagnosis:

    Admitting Physician/ROD: Admitting Nurse:

    Dr. Sanchez Nurse Kathie

    Dr. Clarissa M. Yee


    LABORATORY REQUEST RECORD
    Last Name : Andrade First Name: Mary Anne Middle Name:
    Address: Street # # 45 Barangay: Mamatid City/Municipality:

    Laboratory Tests:

    Date: Kind of Tests: Requesting Physician:


    3/4/2023 CBC with PlHBAIC RBS Pregnancy Test Requesting Physician: Dr. Arianne C
    Requesting Physician:
    4/4/2023 LIPID PROFILE Requesting Physician: Dr. Arianne C
    Requesting Physician:
    5/4/2023 NA Requesting Physician: Dr. Arianne C
    5/4/2023 K Requesting Physician: Dr. Arianne C
    Requesting Physician:
    Requesting Physician:
    Requesting Physician:
    Requesting Physician:
    Requesting Physician:
    Requesting Physician:
    Requesting Physician:
    Requesting Physician:
    Requesting Physician:
    Requesting Physician:
    Requesting Physician:
    Requesting Physician:
    Cosmo
    Municipality: Cabuyao Laguna

    Dr. Arianne Castillo

    Dr. Arianne Castillo

    Dr. Arianne Castillo


    Dr. Arianne Castillo
    Patient's Name: Mary Anne Cosmo Andrade Age: 27 Sex: Female
    Admission Number: Room: 102 Attending Physician: Dr. Sanchez
    CLINICAL HISTORY
    BP: 130/80 mm hg HR:95 RR:22 TEMP.:38.8 WT.:
    PAST MEDICAL HISTORY Chief Complaints: dizziness, headache, nauseated and feeling lethargic
    Hypertension History:
    Diabetes Mother is diabetic
    Bronchial Asthma: YES Father is hypertensive and with history of kidney problem
    Liver Disease History of allergic reaction to seafoods especially crabs
    Hapatitis History of asthma since elementary
    Thyroid Disorder
    Kidney Disease
    Hospitalization
    Surgery
    Allergies: seafoods ESP. crabs
    Cardiovascular Disease
    Pulmonary Tuberculosis Review of Systems: Mental Status/ LOC
    Meds Zyrtec, Montelukast Neromuscular/Skeletal Status
    Others Sensory Status ( Vision, Hearing, Speech)
    Cardiovascular Status (Chest Pain)
    FAMILY HISTORY Respiratory Status ( DOB)
    Hypertension: YES GIT (Abdominal Pain)
    Diabetes: YES Others
    Bronchial Asthma Physical Examination:
    Liver Disease General Survey
    Hapatitis HEENT
    Thyroid Disorder Chest
    Kidney Disease: YES Lungs
    Hospitalization Heart
    Surgery Abdomen
    Allergies Extremities
    Cardiovascular Disease Genetalia
    Pulmonary Tuberculosis Internal Examination
    Meds Rectum
    Others
    PERSONAL HISTORY
    Smoking : NO ADMITTING EMPRESSION:
    Alcohol Intake: OCCASIONAL/C Systemic Viral Infection with signs and symptoms of mild dehydration
    Illicit Drugs
    Sexual
    Others
    OB HISTORY G: P: Plan:
    LMP: January 10, 2023
    AOG:
    EDC:

    OB Score:
    Dr. Arianne Castillo ,MD

    License No.:
    PHILHEALTH ACCREDITED

    NAME: Mary Anne Cosmo Andrade AGE: 27 years old


    ADDRESS: # 45 Brgy. Mamatid, Cabuyao Laguna BIRTHDATE: April 22, 1994
    GENDER: Female
    DATE/TIME OF ADMISSION: HOSPITAL No.:
    CHIEF COMPLAINT: dizziness, headache, nauseated, lethargic PHILHEALTH No. 234567
    DIAGNOSIS: T/C Systemic Viral Infection with signs and symptoms of mild dehydration
    ATTENDING PHYSICIAN: Dr. Arianne Castillo

    VITAL SIGNS: IVF: Laboratory:


    temp - 38.8 degrees Celsius D5 LRS 1 liter to run for 6 hrs CBC with/platelet
    RR - 22 RBS
    PR - 95 Na
    BP of 130/80 mm hg Lipid profile
    HBA1C
    pregnancy test
    SIDE DRIP:

    DIAGNOSTIC PROCEDURE:
    Chest x-ray APL view
    MEDICATION: ECG
    Paracetamol 500 mg 1 tab e
    Cephalexin 750 mg TIV everyIVF TO FOLLOW:
    Plasil 1 amp D5 LRS 1 liter to run for 8 hours

    CONTRAPTION: DIET:
    NPO

    SPECIAL NOTES/ENDORSEMENT

    WARD: large private


    ROOM: 102 NURSE ON DUTY: Nurse Kathie

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