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DATA BASE

a) Biographical Data

Name: N.M.A
Address: 19 Bliss Site Poblacion Polomolok, South Cotabato
Age: 27 years old
Birthdate: May 13, 1989
Birthplace: General Santos City
Ordinal Rank:
Sex: Female
Nationality: Filipino
Religion: Catholic
Civil Status: Single
Educational Attainment:
Occupation: Office Staff
Monthly income:

Mother: E.V.A
Occupation:
Father: E.A
Occupation:

b) Clinical Data

Date and Time of Admission: February 20, 2017 @ 1pm


How Admitted: Ambulatory
Chief Complaint: neck mass
Impression: Papillary Thyroid Carcinoma, Right; Bronchial Asthma not in Acute
Exacerbation

Ward/Room#: Room 464, Sta. Rita Ward


Attending Physician: Dr. Magnaye

c) Past Health History

Our client Mrs. E.S.D was delivered full term via normal spontaneous
vaginal delivery at South Cotabato; she was breastfed by her mother until she
was 9 months old. She verbalized that she didnt have any childhood diseases,
didnt had complete immunization since there were no immunizations during their
time and stated that she is not allergic to any medications, food, cosmetics, etc.
She sleeps for about 7-8 hours a day at about 8-9pm to 5am. As verbalized she
hadnt encountered any serious accidents or injuries prior to her present
condition. However, last October 2016, she was hospitalized due to perineal
sepsis and was treated accordingly.

Mrs. E.S.D, also experienced coughs and colds but they do not have
checkups instead she will just opt to increase her fluid intake, take a bath and
rest. Sometimes, they will just get over the counter medicines at the health center
like paracetamol for headache and fever, neozep for colds and lagundi capsule
for coughs when it gets a little worse. She also takes iron supplement (Fortefare)
twice daily since last year as ordered by her doctor and also takes moringa
supplement once daily. Her only form of exercise is when she is doing house
chores for about 1-2 hours daily. Mrs. E.S.Ds favorite leisure time is when she
and her husband watch tv shows every night. She eats 5 times a day including
an AM and PM snack; usual food intake is vegetable, fish and lean meats and a
cup of rice. Her husband also verbalized that she usually only drinks about 1 liter
of water daily. Frequency of bowel movement is once a day every morning;
voiding pattern frequency is about 2-3 times a day as verbalized. She is not
sexually active for approximately 5 years and had her menopause when she was
53 years old. Mrs. E.S.D doesnt smoke and drink alcohol containing beverages.

d) Present Health History


2 months PTA, patient noted neck mass. There was no associated signs
and symptoms such as heat or cold intolerance or palpitations. No consultation
was done, tolerated condition.
1 month PTA, persistence of neck mass, hence consult with an
endocrinologist. Normal TSH, FTLP and TT3. Neck ultrasound was done and
revealed multinodular goiter, right. FNAB was suggested.
2 weeks PTA, FNB was done and showed papillary thyroid carcinoma,
right, and was advised for thyroidectomy, did not undergo with the procedure. No
medications given and opted for a second opinion with AP.
5 days PTA, went consult with AP and advised for thyroidectomy, hence
this admission.

e) Family Health History

The common genetic disease they have in their family is hypertension.


The patient never met both of her grandparents on the paternal side and was told
that they already died. She has two uncles and three aunts and all of them
except her first aunt, who died from an accident, had hypertension. Her two
uncles and her third aunt all died of a complication from hypertension. Her father
also has hypertension and is taking maintenance medications until now. On her
maternal side, both of her grandparents died due to old age. She has three
uncles and an aunt and all of them, including her mother, had hypertension. Her
mother and three uncles all died from a complication from hypertension. They are
nine in the family; she is the 4th child, her two oldest brothers had hypertension
and both died of stroke. Her third brother was diagnosed with asthma since he
was a child while the fourth brother died of brain tumor almost 5 years ago. Her
only sister was diagnosed with hypertension and is taking maintenance
medication while her sixth brother died of a car accident.