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Virgen Milagrosa University Foundation

Martin P. Posadas St., San Carlos City, Pangasinan


College of Medicine
Department of Pediatrics
A.Y. 2018– 2019

HISTORY TAKING

Date and Time of History Taken: January 28, 2019, 8:45 AM


Date and Time of Admission: January 27, 2019, 9:32 PM
Informant: Patient and Siblings
Reliability: Reliable, 100%

Identifying Data: Patient YY is a 16 year old female, single, Filipino. She was born in Pagadian,
Zamboanga del Sur and currently residing in 9, Laoas, Labrador, Pangasinan.

Chief Complaint: Stiffening of the upper and lower extremities.

History of Present Illness:


On October 2018, YY experienced her first seizure episode lasting for 10 minutes that happened
in the afternoon while she was resting. There were no other presenting signs or symptoms. She was
given Bioflu (500mg), was taken every 4 hours. YY claims that she could not remember that she had had
seizures. After this episode, the patient seemed to be healthy.

On December 2018, while asleep, the patient experienced her second seizure episode lasting for
2 minutes which happened around 9AM. She was given paracetamol and was brought to a nearby
hospital, but was sent home because the seizure was brought about by hypoglycemia as stated by a
nurse so she was advised to eat food and rest.

12 hours prior to admission, patient experienced throbbing headache, dizziness and hunger
before having an episode of seizure with associated rigidity of muscles, muscle contractions and loss of
consciousness. The episode happened for 10 minutes. There is no pallor nor bluish discoloration of lips
and fever. She stated that she cannot remember she had a seizure episode. She was brought to Lingayen
Hospital. Another 2 episodes of seizures around 1pm and 7pm both lasting for 7 minutes happened
hence patient was referred to Region 1 Medical Center.

Past Medical History:


Childhood Illnesses: Chicken Pox
Injury: Vehicular Accident (2012): She had a knee injury and referred to a hospital in Margosatubig,
Zamboanga del Sur.
Immunization: Claims to have complete childhood vaccines
Hospitalization: No prior hospitalizations
Allergy: None
Alcohol: Not a drinker
Tobacco/Cigarette: Not a user
Illegal Drugs: Not a user
Family History:
Paternal Grandfather: None
Paternal Grandmother: Diabetes
Maternal Grandfather: None
Maternal Grandmother: None
Father: Hypertension (2009)
Mother: Lung Cancer (2016)

HEADSSS:
HOME: YY is the youngest of 8 children. She lives with her siblings and stated that she feels safe at
home.
EDUCATION: She is a Grade 7 student who attends school at Sual National High School. She belongs to a
group of 10 people and stated that she’s doing good in academics.
ACTIVITIES: She is not fond of playing any kind of sports. She stated that she’s always on her cellphone
browsing to social medias.
DRUGS: She’s neither a non-smoker nor an alcoholic drinker.
SUICIDALITY: No signs.
SEX: She never had a boyfriend.
SPIRITUALITY: She’s a Roman Catholic and believes in God. They attend mass regularly.

Review of Systems:
Constitutional: (-) significant change in weight, (-) generalized body weakness, (+) fatigue, (-) fever, (-)
chills, with good appetite
Skin: (-) itchiness, (-) excessive dryness or sweating, (-) cyanosis, (-) pallor, (-) jaundice, (-) erythema
Head: (-) headache, (-) dizziness, (-) vertigo
Eyes: (-) pain, (-) blurring of vision, (-) double vision, (-) lacrimation), (-) photophobia, (-) use of
eyeglasses
Ears: (-) earache, (-) deafness, (-) tinnitus, (-) ear discharge
Nose and sinuses: (-) changes in smell, (-) nose bleeding, (-) nasal obstruction, (-) nasal discharge, (-)
pain over paranasal sinuses
Mouth and throat: (-) toothache, (-) gum bleeding, (-) disturbance in taste, (-) sore throat, (-) hoarseness
Neck: (-) pain, (-) limitation of movement, (-) mass
Breast: (-) pain, (-) lumps, (-) nipple discharge
Respiratory: (-) pleuritic chest pain, (-) cough, (-) sputum production, (-) hemoptysis, (-) audible
wheezing
Cardiovascular: (-) easy fatigability, (-) palpitations, (-) substernal pain, (-) syncope, (-) orthopnea, (-)
ankle edema
GIT: (-) abdominal pain, (-) nausea, (-) vomiting, (-) dysphagia, (-) diarrhea, (-) constipation, (-)
hematemesis, (-) melena, (-) hematochezia, (-) regurgitation, (-) stool for 24 hours
GUT: (-) dysuria, (-) urinary frequency, (-) urgency, (-) hematuria, (-) polyuria, (-) incontinence, (-)
urethral discharge, (-) genital pruritus
Extremities: (-) edema, (-) swelling of joints, (-) stiffness, (-) numbness, (-) intermittent claudication, (-)
limitation of movement
Nervous: (-) loss of consciousness, (-) focal weakness, (-) paresthesia, (-) speech disorder, (-) loss of
memory, (-) confusion
Hematologic: (-) bleeding tendency (-) easy bruising
Endocrine: (-) intolerance to heat/cold (-) excessive weight change (-) polyuria (-) polydipsia
PHYSICAL EXAMINATION

GENERAL SURVEY: Patient YY is conscious, awake and responds to verbal stimulus. She’s oriented to
time, place and person. She’s calm and attentive. During the interview, she was lying on bed.

GROWTH PARAMETERS:
Weight: 42.5 kg
Height: 152.2 cm
BMI: 18.3 (Underweight)

VITAL SIGNS:
BP: 100/60mmHg
Systolic BP: <90th Percentile
Diastolic BP: <90th Percentile
Normal Blood Pressure
PR:90 beats/min
RR: 18 breaths/min
T: 36.7 oC
O2 Sat: 97% (room air)

SKIN & LYMPHATICS: Skin is light brown. Hair is black, fine and evenly distributed. Nails are smooth with
normal folds. No clubbing and cyanosis.
HEAD: Normocephalic, without deformities and swelling, no tenderness, no masses. No lesions on the
scalp. Temporal arteries are not visible but palpable with strong equal pulsations.
EYES: Pupils are equal, round and reactive to light and accommodation, no discharges. Eyebrows are
black, thick, normally distributed and smooth in texture. No lid edema and tremors. There is an
observable ptosis in her right eye. Eyelashes are thin, with normal outward growth, without matting.
Pinkish palpebral conjunctiva, anicteric sclera. Lens are transparent without lesions. Corneas are
transparent. Iris are black with normal contour.
EARS: External ears are symmetrical, without deformities, lesions and tenderness. No mastoid
tenderness. External canal is patent, without discharge and lesions.
NOSE: Normal midline septum, symmetrical and no tenderness.
MOUTH & PHARYNX: Lips are pink brown, moist without lesions. Moist mucosal membrane and no
inflammation. Tongue is symmetric and pinkish in color.
NECK: No cervical lymphadenopathy, no lumps, no tenderness.
LUNGS & THORAX: Normal respiratory rate, clear lung sounds, no wheezing, no nasal flaring and
grunting
CHEST: Normal heart sound, no murmur and regular rate and rhythm.
BREAST & ABDOMEN: No lumps or tenderness of the breast. Abdomen is soft, non-tender and non-
distended. Normal bowel sounds. No masses.
GENITALIA: Sexual Maturity Rating (Tanner Staging)
Pubic Hair Stage 3: The pubic hair is more widespread. The hair is darker and curls may have appeared.
Breast Stage 4: Nipples and areolas are elevated and form an edge towards the breast. The breast has
also grown a little larger.
MUSCULOSKELETAL: No myalgia, no arthralgia
NERVOUS SYSTEM:
 Sensory: face is not sensitive to light touch
 Strength: Normal Strength
 Coordination: Rapid alternating movements on finger to nose test
 Cerebellar Exam: able to distinguish right from left

Cranial Nerves:
CN I: Intact
CN II: Intact, visual fields and acuity are normal
CN III: Intact, no eye deviation
CN II, IV, VI: Intact EOM
CN V: facial sensation is not sensitive to touch
CN VII: able to make different facial expressions
CN VIII: intact
CN IX and X: Intact, phonation is normal
CN XI: Intact, able to go against force from hand using the head
CN XII: there is a difficulty in moving the tongue in different directions

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