I.

Biogrrahic Data

Patient’s Name : Mrs. Seizure

Age : 44

Sex : Female

Address :

Civil Status : Married

Occupation : Vendor

Religion : Catholic

Admission Data

Date and Time of Admission : June 6, 2010 ; 5:45pm

Attending Physician : Dr. Ancheta

Diagnosis : Seizure

II. Chief Complaint

This is the case of Mrs. Seizure 44 years old that was admitted @ Gat
Andress Bonifacio Medical Memorial Center with chief complaint of dizziness
with blurred vision and numbness @left side of the body and was diagnosed
with CVA infarction secondary CAD and Seizure.
III. History Of Present Illness

June 6, 2010 five hours PTA, patient was doing her laundry and his
husband called her for lunch when patient experienced sudden onset of
slurring of speech accompanied by transient blindness @ left eye, right sided
headache and dizziness. After experiencing these symptoms, patient was
rushed to Gat Andress Medical Memorial Center Emergency Room, given
oxygen and had her blood pressure of 140/100. The patient was advised to
undergo some laboratory exam such as Urinalysis, Plain Cranial CT scan,
CXR, CBG, CBC with APC, BUN, Creatinine, Na, K, HBAIC and Lipid Profile.
Her condition was observed and monitor until the doctor ordered to admit her
to Medical Ward for further monitoring and observation.

IV. Past Medical History

Mrs. Seizure had her history of chicken when a child. She also
experiences common colds, fever and cough due to weather change. She self
medicates it Paracetamol. Mrs. Seizure was hospitalized 7 years ago at
Makati Medical Center with diagnosis of heart problem according to her
husband. She had her maintenance drug of Lanoxin given to her freely of
Alay Puso for her heart problem.

Father

V. Family Medical History

Mother

Heart Problem (+) (-)

 Kidney Failure (-) (-)

Hypertension (-) (-)

CVA (+) (-)

Diabetes Millitus (-) (-)

VI. Lifestyle of Client

Mrs. Seizure eats her meal on regular basis (breakfast, lunch, dinner).
They usually eat fish, rice and vegetables. She had poor appetite according to
her husband. She take her breakfast around 7am, usually coffee and
pandesal. No meryenda on her part for she is busy selling her things in
divisoria. She doesn’t have any form of exercise. Her sleep cycle goes around
10pm-6am.

VII. Social Data

Family Members

Rudy Malobaggo 83 Fisherman

Rommel Malobago 10 Grade 4

Lorna Malobago 8 Out of School

 Lerma Malobago 3

They are responsible for the welfare of their children. They belong to
Roman Catholic family.She is a vendor in Divisoria and her husband is
fisherman. Their everyday income is insufficient for the needs of their family.
They can afford to send their other children in school for the lack of money.

VIII. Pattern of Health Care

They don’t necessarily believe in so called manghihilot. They rely much on

doctors when it comes with their health status.

IX. Specific Needs and Problems

(Hospital Setting)

Mrs. Seizure usually awakes. She takes nap at times but she will be awake
because of the noise and when there is someone who will come at their room
like the nurses. Her husband is her companion while at hospital and taking
care of her needs. Her husband is the one who feed her via NGT with
osteorized feeding of 1800 Kcal/day.her elimination pattern had beeb altered
because of her condtion . the ventilation of the room makes the patient
uncomfortable according to the husband. They prefer to be at their house
rather than be in hospital. Mrs. Seizure has her oxygen via face mask with
2Lpm.