II.

Clinical Summary
A. General Data
Name: Patient M
Address: 143 C. Balagtas St., Malate, Manila
Age: 19 yrs. old
Religion: Roman Catholic
Civil Status: Single
Nationality: Filipino
Date of birth: May 8, 1996
Date and Time of Admission: May 21, 2015

1:30pm

Ward/room: Pavilion 2 Room 231 Bed 2

Attending Physician: Dr. Nor-Aine P. Kansi, MD
Tentative/Revised/Final Diagnosis: Viral Encephalitis, Rubella
Date of discharge/transfer: May 23, 2015
Source of Information: Mother
B. Chief Complaint: seizures and loss of consciousness
C. History of Present Illness:
The condition started 6 days prior to admission, when the patient complained
of headache and rashes on the face with associated fever. Consultation was done
and was given medications (unrecalled). Medications were taken but patient still
complained of persistent headache. 3 days prior to admission, there was still rashes
on her face and now noted on the trunk, abdomen and upper extremities. No
bleeding and vomiting noted and no consultation was done. Few hours prior to
admission, patient was noted lying on the floor with seizure episodes and claimed to
be unconscious. Patient was rushed to Adventist Medical Center and eventually
transferred to our institution and thus admitted.
D. Past Medical History:
The patient is completely immunized. There were no allergies to foods and
drugs. There were no previous hospitalizations
E. Familial History:
There were no hereditary disease in her mothers side but to her fathers side
there were history of hypertension, heart disease, and arthritis.
F. Social History:
The patient is non alcoholic and non smoker.