PATIENTS DATA BIOGRAPHICAL: Patients Name: Patient D Address: NHA Matina, Davao City Date of birth: January 15,

1996 Parents Religion: Roman Catholic Mother: Mama D Occupation: Housewife Father: Papa D Occupation: Bachelor bus driver Health Insurance: PhilHealth (under fathers name) Source and Reliability of Information: Mother and Father Profile: Age: 16 years old Gender: Female Weight: 58 kgs. Height: 149 cm Parents Race/Ethnic Background: Bisaya Chief Complaint: seizure Date of Admission: August 15, 2012 Healthcare institution: Southern Philippines Medical Center Admitting Diagnosis: Hydrocephalus secondary to bilateral porencephalic cyst Admitting Physician: Dr. del Rosario Vital Signs upon admission: Pulse Rate: 137 bpm Respiratory Rate: 22 bpm Temperature: 38 C Blood pressure: 90/60 mmHg

HEALTH HISTORY

Present Health History: According to her mother, the patient suddenly experienced seizure at 7 in the morning when she was still lying on bed just after waking up. As the seizure episode happened from 7 am to 11am, the mother said that her husband helped her turn the patient in side lying position to drain the saliva and put a spoon on her mouth to promote breathing.

Date symptom appeared/ felt

P,Q,R,S,T,U

Date sought consulation admission

Hospital

No. of days confined

treatment

August 15, 20 12 seizure

Palliative On August 15, 2012 @ 7 A.M., Dayon pagmata niya nagkalit lang

July 13, 2012

Southern Philippines Medical center

6 days

July 11 2012 LBM with Vomitting

man siyag kurug- kurog tapos dugay man kayo nahuman mga upat ka oras gyud to as verbalized by the mother. On August 15, 2012 @ 7 in the morning, while lying in bed, the patient suddenly had a seizure episode that lasted until 11 A.M. The first thing they did was let her lie on the floor in a sidelying position. To drain the saliva, to promote breathing and to prevent the tongue from getting injured, the father put spoon on her mouth. After that, they were very worried so without any further ado, her parents rushed her to SPMC.

Quality or Quantity Mao na gyud to ang pinakagrabe ug dugay niya na seizure sukad , as verbalized by the mother verbalized. The episode started from 7 A. M. to 11 A. M. which took 4 hours. It was her first seizure episode ever since she turned 16 years of age. Region Naa man daw problema sa isa ka parte sa iyahang utok ana iyahang doctor. Naa lagi daw cyst mao na nagadako iyahang ulo, as verbalized by the mother. Central Nervous system was affected. Seizures are disturbances in normal brain function resulting from abnormal electrical discharges in the brain, which can cause loss of consciousness, uncontrolled body movements, changes in behaviours and sensation, and changes in the autonomic system.

Severity Sukad, mao na gyud to ang pinakagrabe niya na seizure. Naluya siyag taman at okay upat gyud to ka oras siya nagkurug-kurog, as verbalized by the mother. The seizure episode lasted for 4 hours which left the patient very weak. At the hospital

another seizure episode happened on the day of the admission at 12:30 pm that lasted for about 30 minutes.

Timing: Patient had seizure at around 7 A. M. until 11 A.M. for about 4 hours. Just after admission, around 12:30 P.M., patient experienced another episode but this time, it just took a couple of minutes; around 30 minutes. Understanding of the Patient: Mao to siya naingon- at okay tungod sa iyahang sakit na hydrocephalus. Dugay naman na siya nagaseizure gyud, bata pa lang na siya pirme naman na siya magseizure. Nakuratan lang mi kay nagbalik nalang mana atong nagedad siyag 16, as verbalized by the mother

Past Health History: According to the mother, the child didnt have any communicable disease. Her first hospitalization was at Misamis Oriental Emergency Hospital just after 4 days from birth due to meningitis. She also stated that the child didnt have any history of accident. As the interview continued, she said that as far as she can remember, the child had only received DPT, BCG, and Hepa B vaccines. The patient was vaccinated when they were still living in Misamis Oriental and it was given at Misamis Oriental Emergency Hospital. The patient was delivered in the said hospital with the aid of the attending physician. Regarding the allergies, the mother said that the patient is allergic to dye and sea foods and that the patient did undergo surgeries from 2006 to

2012. In the year 2006, she had an appendectomy and VP shunting at Davao Regional Hospital in Tagum City. Just after 2 years from those surgeries, she undergone revised shunting at the same hospital in Tagum City. And recently, she had undergone removal of VP shunt last August 28, 2012 at SPMC.

Medication

Indications as known by the parents

Dosage

Prescribing Health Care

Celecoxib Acetazolamide Keppra

Pain reliever Treatment epileptic seizure Treatment epileptic seizure for for

200mg 250mg 500 mg

Dr. del Rosario Dr. del Rosario Dr. del Rosario

GENOGRAM MATERNAL SIDE A, 66 B, 64 C,79 PATERNAL SIDE E, 75

F, 46

J, 41
G, 39

H, 44

I, 43

K, 33

LEGEND:

Patient D, 16

L, 12

- Hydrocephalus -Myocardial Infarction

-Marriage
-Patient D -Hypertension

Social History The mother verbalized that upon their stay in the hospital; mother-child bonding was established. The mother usually feeds the patient, changes her clothes, and provides her with comfort. The mother usually watches over the patient since her husband is working as a bus driver. She never left the hospital since their child was admitted. Her mother is a housewife while the father is a Bachelor bus driver and earns 7,500 pesos per month. He works daily except for Sundays from 4 in the morning to 9 pm in the evening. The mother takes over the role of taking care of her daughter every day. When asked if a certain medications had affected her child while she was still in her womb she replied and said that she was not taking any form of medicines and also not drinking any alcoholic beverages when she was still pregnant. Since the father was still alive, he is the one who is in charge of making decisions for the family.

Health maintenance According to the mother, the patient usually wakes up at around 8 or 9 in the morning and sleeps at around 8 pm in the evening. The patient and her mother said that they are fond of walking every morning after waking up. The mother verbalized that they do not go to the health center regularly for check-ups and follow up check-ups because they usually travel from one place to another with no permanent residence. The patient tells her mother whenever she is hungry and she wants her mothers assistance. Nutritional Assessment: Height: 149cm Weight: 58kg BMI: 27.7 Head circumference: 58cm Chest circumference:114 cm Abdominal circumference: 104cm

Diet History The mother said that the patient has her usual diet every day. At breakfast, she usually eats biscuit or bread and drinks a glass of milk. At lunch, she eats with her mom and they usually

have rice, fish, meat and vegetables. They eat rice, fish and vegetables in the evening and the mother said that whenever there are leftovers of their food at lunch they would still eat them at dinner.