Date and Time of Interview: August 14, 2017;10:35 A.M.

Source of History:Husband and Mother in law Reliability: 80%

Referral: None

General Data:

E.G.,18 years old, female, married, a Roman Catholic, residing at Tilaon, Pinabacdaw, Eastern
Samar, was admitted for the 2nd time at EVRMC on August 12, 2017 at around 12:00 noon.

CHIEF COMPLAINT: Fever and Headache

HISTORY OF PRESENT ILLNESS:

The patient was apparently well until 1 week prior to admission, she experienced a sudden
onset of high grade remittent fever noted upon touch and petechial rashes on the upper extremities.
This was not associated byheadache, abdominal pain, musculoskeletal pain, nausea and vomiting,
diarrhea, urinary frequency and dysuria. The patient claimed to have relief after sleeping. No
medications were taken and no consult was done.

Three days prior to admission, the patient still has a high grade fever but is now continuous in
character and there was headache localized on the frontal area throbbing in character which occurred
all throughout the morning with a pain scale of 5/10. This was accompanied by body weakness, loss of
appetite and a nonproductive cough. Thiswas not associated with joint pain, vomiting, dysuria, anorexia,
abdominal pain, bowel changes and rashes. The patient was brought to tambalan. They gave her herbal
decoctions such as: malunggay and cacao. This offered relief to the patient as she was still capable of
doing her daily chores. Still no medications were taken and no consultation was done.

A day prior to admission,the patient still has a high grade continuous feverand a frontal
throbbing headache at a pain rating scale of 7/10. This was associated still with body weakness, loss of
appetite and now with a productive cough having a yellowish phlegm of approximately 1tbsp. There was
no abdominal pain, arthralgia, nausea and vomiting, dyspnea, rashes, bowel changes and mucosal
bleeding. The patient was still taking 250ml of the decoctions advised by the tambalan three times a
day. This somehow offered relief. But she was no longer capable of doing her daily chores. No
medications were taken and no consultation was done.

5 hours prior to admission, there was still a high grade fever upon touch and the frontal
headache was intolerable already by the patient with a pain rating scale of 10/10. This was accompanied
by dizziness upon movement, body malaise and productive cough. There was no nausea and vomiting,
abdominal pain, arthralgia, mucosal bleeding and dyspnea. But the patient could no longer stand on her
own and was irritable. She was immediately brought to this institution through an ambulance hence
admitted.
 24 HOUR DIET RECALL:

Before the onset of Illness

Breakfast:
Rice: 3 cups: (100kcal x 3 = 300kcal) 300
Chicken (thigh; fried):1pc (6 matchbox): (211 kcal x 1 = 211) 211
Water 0

Lunch
Rice: 3 cups: (100kcal x 3 = 300kcal) 300
Lumpia: 2pcs (4 matchbox): (196.5 x 2 = 393) 393
Vegetables: 2 (65 x 2 =130) 130
Water (0kcal) 0

Dinner:
Rice: 2 cups: (100kcal x 2 = 200kcal) 200
Fried Fish: 1pc(3 matchbox): (251kcal x 1 = 251) 251
Vegetables: 2 cups (65 x 2 = 130) 130
Water (0kcal) 0
-------------------------------------------------------------------------------------TOTAL: 1, 915

During the course of illness

Breakfast:
Porridge: 1 cup 100
Herbal decoction 0

Lunch:
Rice: 1cup 100
Fish tinola: pc 125.5
Herbal decoction 0

Dinner:
Porridge: 1cup 100
Fried fish: pc 125.5
Herbal decoction 0
-------------------------------------------------------------------------------------TOTAL: 551

GROWTH AND DEVELOPMENT

Physical Cognitive Social Emotional
56 in height Formal operations: Young (12 14): identify with Middle adolescents (15-17):
Sexual Maturity Rating not peer group; social status largely examination of others
obtained Thinks hypothetically: calculate related to group membership; values and beliefs of others
consequences of thoughts and actions slowly learning to be organizes perceptions of
without experiencing them. independent from adults; ones attitudes, behaviors,
ambivalent about sexual values into coherent
Thinks logically. Able to identify and relationships whole;
reject hypotheses or possible outcomes
based on logic Middle (15 17): friendships

understands and consider others
perspectives.
Able to solve problems and consider
multiple solutions.
based on loyalty,
understanding, trust; conscious
choices about trusting adults
not sexually active

Behavior:

The patient is shy and friendly. She wakes up at 5 A.M. and sleeps at 9 P.M.

VII. IMMUNIZATION
ADVERSE EFFECTS
BCG 1 hr after birth none
DPT 1 2 mos none
DPT 2 4 mos none
DPT 3 6 mos none
OPV 1 2 mos none
OPV 2 4 mos none
OPV 3 6 mos none
HBV 1 1 mos none
HBV 2 4 mos none
HBV 3 6 mos none
Measles 9mos none

PAST MEDICAL HISTORY:

The patient has no history of measles, chicken pox, rubella and mumps. She has no allergy to
food and drugs. She was admitted at this institution last February 2017 because of vomiting and loose
bowel movement. The medications given were unrecalled. There were no surgical operations done and
dhe did not receive any blood transfusions.

FAMILY HISTORY:
The patients father died because of ulcer. Her mother is already 60 years old, apparently well
and works in the rice fields. She has 8 siblings. Two of them died from an unknown cause while the
others are known to have a good health condition. There are no heredofamilial diseases such as
Diabetes, Hypertension, Asthma, Cancer, Renal diseases and mental illness.

X. Psychosocial History:
HOME: The patient already has her own family. Her husband is a farmer and they have a 1 yr old child.
They live together in a house made up of a concrete floor and used combined materials located a few
meters away from the main road. Their toilet is a bored-hole latrine located outside their home at about
5 meters away from home. Water used for drinking and cooking is taken from their neighbors faucet
(NAWASA) and are stored in covered plastic containers.Water used for washing and bathing is taken
from an uncovered deep well. Garbage is disposed in a fire pit for burning.
EDUCATION: The patient is an Elementary graduate
ACTIVITY:Thepatienttakes care of her son and does the daily household chores, she is a moderate
drinker, able to consume one to two bottles in a session. The patient does not smoke and does not
gamble
DRUGS: denies any form of drug use, no vitamins, no maintenance medication
SEXUAL ACTIVITY: The patient already has a family of her own. She doesnt use any form of
contraception.
SUICIDE: the patient is shy, but interacts well with his friends and family
SOCIAL ACTIVITY: The patient is not a member of any organizations in their community.

REVIEW OF SYSYTEMS
General: had weight loss, febrile, with body malaise

SKIN: warm skin; No lumps, sores, or puritus.

HEENT
HEAD: hadheadache; had dizziness, no lightheadedness.
EYES: No blurring of vision. No pain, redness, spots, specks, or flashing of lights. Does
not use eyeglasses
EARS: With hearing loss, No tinnitus, vertigo, earache, infection, or discharge.
NOSE: no discharge, no pain, no stuffiness
MOUTH/THROAT: No dentures. No sore throat or swallowing difficulty. No dry mouth
or hoarseness of voice.
NECK: No lumps, pain, or stiffness.

BREASTS: No lumps, no pain

RESPIRATORY: With productive cough, no hemoptysis, no difficulty of breathing

CARDIOVASCULAR:
No hypertension, palpitations, or edema.

GASTROINTESTINAL: no abdominal pain, no vomiting, nodysphagia, heartburn, jaundice, no

hemorrhoids, no diarrhea or constipation, no excessive belching or passing of gas. Bowel movement of
once a day with formed, brown stools

URINARY: No polyuria, no nocturia, urgency, burning or pain in urination, no hematuria, flank pain
or incontinence. urinary output of 200 ml per voiding at least 3-4 times a day and
yellowish color

GENITALS: No pain, swelling, and abnormal discharge.

PERIPHERAL VASCULAR: No leg cramps and edema. No intermittent claudication, no varicosities

MUSCULOSKELETAL: no arthralgia, no myalgia but wth body malaise, No neck or low back pain. No
history of trauma

NEUROLOGIC: Unable to speak. No fainting, blackouts, seizures, paralysis, loss of sensation, no tremors
or other involuntary movements.
PSYCHIATRIC: No nervousness, no tension, no depression, memory change or suicide attempts.
HEMATOLOGIC: No anemia, easy bruising. No blood transfusion done.
ENDOCRINE: No heat or cold intolerance, no excessive thirst, hunger or polyuria

XI. PHYSICAL EXAMINATION

GENERAL SURVEY:

Patient was examined sitting on bed, conscious, febrile, poorly nourished, poorly-groomed,
ectomorph and not in a respiratory distress.

TEMPERATURE: 38.8C (Right Axilla) (Range= 36.5C 37.4C)

PR: 90 bpm
RR: 18cpm
BP: 100/70 mmHg (Right Arm)

INTEGUMENT:
SKIN: warm to touch, moist, brownish complexion, with good perfusion, no rashes, no
petechiae, no lesions, no scars, no hypo- or hyperpigmentation, no jaundice, no edema

HEAD:
Hair: slightly long, straight, fine, black with light brown tint, intact with no patches of alopecia,
no infestation of nits and lice
Scalp: no lumps, no tenderness, no scars, no engorged veins, no dandruff
Skull: normocephalic, temples not depressed.

EYES:
Eyebrows: symmetrical, fine, black, intact, no scars or active lesions
Eyelashes: fine, black, oriented outwards
Eyelids: no edema, no ptosis, no lidlag, no sty
Conjunctiva: pinkish palpebral and bulbar conjunctiva, no hemorrhage
Sclera: clear, anicteric, no hemorrhage
Cornea: no ulcerations, no scars, no opacities
Pupils: symmetrical, approximately 2mm in diameter, reactive to direct and consensual light
stimulation
EOM: intact/full

EARS: symmetrical, no discharge, no active lesions, no impacted cerumen

NOSE: no nasal discharge, no abnormal configuration, no septal deviations, no epistaxis, no flaring

MOUTH & THROAT:

Lips:pinkish, no angular drooping, no sores, no cuts
Mucous Membrane: moist, no bleeding, no sores
Gums: pinkish, no bleeding
Teeth: no dentures
Tongue: pinkish, no ulcerations, deviations
 Throat: uvula at midline, tonsils not inflamed

NECK: trachea at midline, thyroid gland not enlarged, moves with deglutition, no engorged veins, no
visible pulsations

BREAST: no discharges, no lumps

CHEST & LUNGS:

Inspection: Symmetrical chest expansion, no bulging, no retractions
Palpation: Symmetrical chest expansion, impaired tactile fremitus on right lower lung field, no masses
Percussion: Dullness in the right lower lung field, resonant on the other lung fields
Auscultation: With crackleson both inspiration and expiration, no wheezing

CARDIOVASCULAR
Inspection : no precordal bulging, no visible pulsations, no lumps
Palpation : apex beat palpable at 5th (L) MCL, no thrills, no heaves
Auscultation: no murmurs, no bruits, no precardial friction rub

ABDOMEN:
Inspection: globular, no visible peristalsis, no engorged veins, no hyper and hypopigmentation, no
bulging,inverted umbilicus.
Palpation: soft, non-tender, liver, spleen and kidneys not palpable.
Percussion: tympanic on all quadrants
Auscultation: normoactive bowel sounds 10 clicks/min, no arterial bruit, no venous hums

EXTREMITIES:
Inspection: symmetrical, no deformities, no lesions, no edema, no cyanosis, no atrophy
Palpation: tenderness at the left calf with palpable mass approx. 2cm in diameter with smooth
borders, immobile

BACK AND SPINE:

Inspection: no abnormal deviation, no retraction, no bulging
Palpation: no paravertebral tenderness or mass

GENITOURUNARY: Not done

RECTAL EXAM: Not done

Neurologic exam:
Mental status exam: patient is awake, irritable, poorly groomed, unattentive and is unable to speak.
Cerebellum: not tested

CRANIAL NERVES:
Olfactory nerve not tested
Optic and oculomotor nerve Pupils are 2 mm in diameter, equally round and reactive to light and
accommodation.
Oculomotor,trochlear, and abducent nerve The patient was able to move eyes upward, downward,
medially, laterally.
Trigeminal nerve Not tested
Facial nerve- The patient was able to smile and frown.
Vestibulocochlear nerve- The patient was unresponsive to verbal stimuli.
Glossopharyngeal and vagus nerve The patient was able to swallow, there is intact gag reflex.
Accessory nerve able to shrug shoulders.
Hypoglossal nerve- The tongue was at midline, able to move up, down, left and right
Motor : The patient can flex and extend both extremities without limitations.
Sensory : Not tested.
Reflexes :

2+ 2+

2+ 2+

2+ 2+

2+ 2+

Meninges : There is no nuchal rigidity, no Kernigs sign, no Brudzinskis sign.

ANS : There is no excessive sweating, no urinary incontinencece.