Date and Time of Interview: August 22, 2014, 2:00 P.M.
Informant or Source of Interview: Patient and Her Husband
Referral: None Reliability: 90 % Identifying Data: Rosemarie Guiwana 18 year old Female, a Roman Catholic, unemployed and is currently living with her husband in Brgy. Malibago, Babatngon, Leyte and was first admitted here in EVRMC last August 18, 2014. Chief Complaint: Seizure History of Present Illness: Seven days prior to admission, August 11, 2014, the patient given birth in Babatngon Leyte in their Rural Health Center to a healthy baby girl. She had a normal spontaneous vaginal delivery with no known complications and was sent home after. Two day after giving birth, five days prior to admission, August 13, 2014,the patients child got hospitalized due to a complication from an infection from the infants umbilical cord and was referred the same day from their Health Center to Eastern Visayas Regional Medical Center. After a few days of staying in the hospital, August 18, 2014, on the day prior to admission, the infant was already about to be discharged. The patient and her husband before leaving the hospital ate breakfast. The patient ate a cup noodles but claimed to have only consumed most of the soup and not the noodles. After a few minutes the patient felt a headache which she described to be a non-radiating, pricking pain and the patient pointed out it to be in located in the entire head and in a scale of one to ten, the patient described it to be 8 out of 10. Afterwards the patient vomited with no accompanying stomach pain, mostly of what she eaten which is the soup of the cup noodles, amounting to be a glass full about 250 ml of pure liquid with no blood. After the episode of head ache and vomiting, the patient had a seizure to what her husband described to be at most twenty minutes in duration. It was about 9 A.M. when the patient was rushed in the Emergency Room and thence was admitted. The patient woke up a few hours later and was already in the ward with no memory of her episode of headache, vomiting and seizure. She was given Phenytoin per orem, dosage unrecalled and name and dosage of other drugs unrecalled. The patient also claimed that she was febrile after waking up and was given Paracetamol 500mg 1 tab per orem and nothing more followed. Three days after admission, she manifested productive cough with yellowish sputum. No intervention was done for her cough.
Past Medical History: Childhood Illness: Had measles but date unrecalled. No chickenpox. No polio. No mumps. No rheumatic fever. Adult Illness MEDICAL: No previous hospitalization. No hepatitis. No asthma. No hypertension. SURGICAL: No history of surgical operations. OB-GYNE: Menarche age 14. G1P1 (1001) with NSVD at RHU Babatngon with no known complications. PSYCHIATRIC: No history of psychiatric problems. Health Maintenance Immunizations: Unrecalled. Screening Tests: Unrecalled. Allergies: No known allergies.
Family History: The patient is the third among seven siblings which all are girls. Her other siblings and her parents are all living and all seems to be well with no complaint of any illness or sickness. Her husbands family, all members including her husbands two other siblings and parents are also well. No history of hypertension, diabetes mellitus. No heredofamilial diseases noted. Personal Social History: The patient is an 18 year old who was previously living with her family in Abucay, Tacloban City and is now residing in Malibago, Babatngon, Leyte with her husband and her husbands family. She only finished third year High School in Leyte National High School here in Tacloban and was not able to continue due to her pregnancy just last November last year. She is not legally married to her husband, a 21 year old high school graduate and is currently working in a junkshop back home. They are living with her in-laws in Babatngon in a one story house made up of light materials composed of one room and one window. Their source of water for their everyday use is from a deep well. Their drinking water is taken primarily from a Poso and is usually bolied. The patients daily routine back home was waking up at about seven in the morning. She does not do much, but claimed that she done walking when she was still pregnant. Most of the chores at home is done by her husband. She sleeps at about ten at night with one pillow on her head and a second pillow as her tangdayan. She eats a lot of fish with rice and vegetables and claims only not to eat ampalya because of its bitterness. She drinks at most eight glasses of water each day. She micturitates at most five times a day before when she was home and claims that she only urinates at about 2 - 3 times when she got hospitalized with only a few urine to be urinated. She moves her bowel daily with no effort with yellow soft bulky stools but also claimed that it is still hard for her to move her bowel after her delivery because of the pain of her puerperium. The patient does not smoke but does drink and consumes at about a bottle of gin occasionally. She started drinking when she was still 14 years old. The patient claims that she had prenatal check-up before and at most had three check prenatal check-up. The patient is not a member of any organization in their barangay and in the church. Review of Systems:
General Survey:No significant change in weight except during pregnancy. Weight during pregnancy was 63 kilograms and weight after pregnancy and delivery is 59 kilograms. Skin: No changes in skin and nail color. No rashes, itching. No dryness. No sores. HEENT: Head: With headache. No lightheadedness. Eyes: With blurry of vision but no eyeglasses used. No redness. No teary eyes. No pain.
Ears: Hearing is good. No pain, ringing. No discharges. Nose: No pain. No epistaxis and discharges. No stuffiness and no itching. Throat: No dysphagia. No dentures. No hoarseness. No dry mouth. Neck: No pain. No stiffness. Breasts: No pain or discomfort. No breast self-examination practices. Respiratory:With cough. No hemoptysis. No dyspnea. Cardiovascular: No chest pain, no orthopnea. No paroxysmal orthopnea. Gastrointestinal: With vomiting. No pain. No belching and flatulence. No watery stools. Bowel movement every day but is having difficulty now after her delivery, stools are yellow, soft and bulky. Peripheral Vascular: No pain. No leg cramps. Urinary:No oliguria. No pain, no nocturia. No hematuria. Musculoskeletal: No joint pains. No muscle pains. Psychiatric: No mood swings. No nervousness. Neurologic: With fainting or black outs. No involuntary movements. Endocrine: No heat and cold intolerance. No polyuria. No polyphagia. No polydypsia. Physical Examination: The patient is small with extremities in proportion to the size of the trunk or is mesomorphic. She is awake but reponds or answers questions after a pause. She is well oriented with place and time. Her physical appearance was quite inappropriate for she has not taken a bath since she delivered; this is because of the superstitious beliefs of her husband. Her hair was dry and was not well kept or was not neatly combed. She was wearing a white shirt with a yellow with strips of green jogging pants. Her color is good and was able to sit appropriately with ease. Vital signs: Heart rate (HR) was 100 beats per minute. Respiratory Rate (RR) was 16 cycles per minute. Blood pressure (BP) was 140/110 mmHg. Axillary temperature was 37.2 C. Skin: Skin color is good. Skin turgor is also good. HEENT: Head: Normocephalic or head is of appropriate size to the body, hair is evenly distributed, a bit dry. No lice. No scalp lesions or any kind of swelling and no tenderness. Eyes: Pupils are round and are briskly reactive to light but right eye (OD) is 3mm in diameter compared to the left eye (OS) which is 2mm in diameter (Anisocoria). Conjunctiva is pink, sclera is white. Extraocular movements intact. Ears: With no discharges. Nose: With red round adenoid in her nose located at the left side of the septum. She has pink and moist mucosa. No tenderness upon palpation of the nose and the frontal and maxillary sinuses. Mouth: Oral mucosa is moist and pink. Presence of dental caries. Tongue is in the midline and is colored white with a fissure in the midline or in the middle of the tongue. Neck: Swallowing is good. Thyroid is not palpable and trachea is in the midline. Lymph nodes: Non-tender and are also not palpable. Thorax and Lungs: Symmetrical lung expansion with no use of accessory muscles for breathing. No nodules or lumps palpated. Hyperresonant in the left side or the posterior thorax.Decreased tactile fremitus on the left side of the posterior thorax. Crackles are noted upon auscultation of the posterior thorax. Breasts: Nipples are everted and are located at the center of the breasts. Breasts are pendulous with no discharges. No retractions or change in color.