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Date and Time of Assessment

The document summarizes a medical assessment for a 25-year-old married Filipino woman named A.T. who was admitted to the hospital on November 7, 2017 complaining that her systemic lupus erythematosus (SLE) had flared up. It notes her personal details, medical history including symptoms over the past 3 weeks of rash, fever, breathing issues, cough and dizziness, and her current medications of prednisone 3 times per day with no known allergies.

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Stephanie Louisse Gallega Hisole
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56 views2 pages

Date and Time of Assessment

The document summarizes a medical assessment for a 25-year-old married Filipino woman named A.T. who was admitted to the hospital on November 7, 2017 complaining that her systemic lupus erythematosus (SLE) had flared up. It notes her personal details, medical history including symptoms over the past 3 weeks of rash, fever, breathing issues, cough and dizziness, and her current medications of prednisone 3 times per day with no known allergies.

Uploaded by

Stephanie Louisse Gallega Hisole
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Date and Time of Assessment

November 11, 2017, 3: 30 PM

GENERAL DATA

 Name: A. T.
 Sex: Female
 Age: 25 years old
 Date of Birth: December 23, 1991
 Civil status: Married
 Educational Attainment: High school Graduate
 Place of Residence: Igbaras, Iloilo
 Occupation: Saleslady
 Nationality: Filipino
 Religion: Roman Catholic
 Blood type:
 Source of Data: Patient herself
 Reliability: 98%
 Date and Time of Admission: November 7, 2017 at 12: 00- 1: 00 PM
 Room: F10

CHIEF COMPLAINT:

“nag flare up akon SLE” as patient A.T. verbalized

HISTORY OF PRESENT ILLNESS:

A. CHRONOLOGICAL STORY
 3 weeks ago
o Rash on face
o Fever for 1 week (temp not recorded), was relieved by Paracetamol
o Difficulty in breathing
o Difficulty in walking
o Dry cough
 4days ago
o Difficulty in breathing
o Dizziness at around 10am
o Scheduled for check- up and was recommended to be admitted
o Since patient had financial constraints, admission was delayed

B. CURRENT MEDICATIONS:

1. Prednisone (20mg) 3x a day

C. ALLERGIES
No known Drug and Food Allergies

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