PATIENT HISTORY

GENERAL DATA: Patient A.B., a 11-year-old, male, right-handed dominant, Filipino,

Roman Catholic, born on December 17, 2011, a resident of Vista Allegre Relocation
Site, Zone 2, Bacolod City, was admitted at Corazon Locsin Memorial Regional Hospital
on April 11, 2023, at around 5 p.m.

Date & Time of Hx & PE: April 17, 2023 10am-12nn

Source/s: Patient, cousin, mother
Reliability: 95%
CHIEF COMPLAINT: Headache ( Ga sige sakit ang akon ulo, kag ga suka ko)

P Provoking/Relieving Provoked by sudden rising from bed/sleep and

relieved by resting the head and sleeping

Q Quality Throbbing

R Region & radiation bifrontal area radiating to occipital area

S Severity 6/10 on PE but 10/10 from the start of symptom

T Time Upon waking up, for 30 mins to an hour, occurs

maximum 3 times a day

HISTORY OF PRESENT ILLNESS

One month prior to admission, it was noted that the patient started having daily
postprandial vomiting. It is often accompanied by epigastric pain. The patient was given
Nifuroxazide (Ercefuryl) suspension and Simeticone (Restime) suspension by the
mother for two days, unrecalled dosage, but no relief was noted.

3 weeks PTA, the symptoms persisted, now with accompanying headache, in the
bifrontal region (10/10) that radiates into the occipital area, throbbing in character upon
waking up and would last from 30 minutes to an hour, with associated dizziness and
appetite loss.

2 weeks PTA, persistence of symptoms was noted. Additionally, the patient also
complained that he could not see what was written on the blackboard in his school
anymore. They consulted a primary care physician and were prescribed Paracetamol
for 7 days taken as needed but discontinued on the fifth day due to no relief. The
mother also gave antacids (Kremil-S) to the patient, 1 tablet divided into 8 parts, taken
twice daily for 4 days, but there was no resolution of abdominal pain.
 ODA, persistence in the intense severity of the headache prompted the patient to
seek further management at CLMMRH. (4/11/23)

REVIEW OF SYSTEMS:

General
(-) body weakness
(+) weight loss
(-) fever, chills
(-) trouble sleeping

Skin
(-) rashes, lumps, & sores
(-) cyanosis
(-) pallor
(-) itchiness
(-) dryness
(-) nail changes
(-) hair loss

Head and neck

(+) headache
(+) dizziness, lightheadedness
(-) head injury/ trauma
(-) Jugular vein distention
(+) neck discomfort

Eyes
(-) sunken eyeballs
(-) lacrimation
(+) blurring of vision
(+) Retro-orbital pain

Ears
(-) discharge
(-) hearing problem
(-) earache
(+) history of right ear infection no significant sequelae
Nose
(-) discharge
(-) swelling
(-) flaring
Throat
(-) pain in tonsils
(-) sores
(-) bleeding gums
(-) toothache
(-) hoarseness

Respiratory
(-) cough
(-) hemoptysis
(-) difficulty in breathing

Cardiovascular
(-) chest pain
(-) cyanosis
(-) palpitation
(-) edema
(-) murmur

Gastrointestinal
(+) loss of appetite
(+) vomiting
(+) abdominal pain
(+) hematochezia
(-) change in bowel movement

Genitourinary
(-) dysuria
(-) incontinence
(-) polyuria
(-) hematuria
(-) swelling
(-) pain

Musculoskeletal
(-) mass or lumps
(-) muscle pain
(-) hypotonia

Neurologic
(-) tremors
(-) numbness
(-) seizure
(-) memory loss
Hematologic
(-) easy bruisability
(-) pallor
(-) bleeding

PAST MEDICAL HISTORY:

Past Medical History

At 2 years old, the patient developed an ear infection, site unrecalled, which
prompted consultation to a primary physician due to temporary hearing loss. It was
noted to be earwax impaction and the patient was prescribed with unrecalled ear drops,
infection was cured after a week.
At age 3, the mother noted that the patient developed tender lumps on his forehead
and behind his ears, alternating on each side. The mother and the grandmother only put
ice on these lumps and noted the resolution after 2 to 3 weeks. No other medication
was done. These lumps went on for two years without consultation with a physician.
Last December 17, 2022 the patient was bitten by a dog and received his full rabies
vaccination on January 9, 2023 and blood test indicated normal antibody titer.
He has no prior hospitalizations or surgeries and has never had any history of
allergic reactions to food or medicine before. According to both the mother and the
patient he has never had a history of head trauma in the past.

Family History
The Family history is depicted below.

Father’s side:
Separated from the mother and no contact since mother went back to Bacolod
while one month pregnant with the patient. Mother does not have information about the
father’s family.

Mother’s side:
Mother is a nonsmoker and a non-alcoholic beverage drinker. She has a history
of miscarriage, pregnancy after the patient, due to being 1 week postterm.

Father, 91-years-old, is alive, history of hemorrhoids, and no medication currently

taken. Mother, 71-years-old, is alive and well, no maintenance. She has 9 siblings, 1
brother who died at 21 yo, had a bifof hyperglycemia but cause of death was unknown.
Another brother died due to an ambushed military encounter. One sister has a history of
migraine, duration unknown and taking unrecalled maintenance medication with poor
compliance.
 No known hypertensive in the family.

Patient’s sibling is alive, healthy, and with no known comorbidities.

Genogram

Personal and Social History

The patient was born in Bacolod City and lives with his aunt, mother, and
younger brother. A.B. is the eldest of 2 children. A.B.’s biological father was out of the
picture before the patient was born. A.B.'s mother is a housewife. The mother is
currently 6 months pregnant. She doesn't drink alcoholic beverages and is a
nonsmoker. A.B. was an active student, talkative, and loved to play sports before he
was sick. When he started to feel ill, his mother noticed changes in his behavior, such
as irritability and being unmotivated.
Birth and Maternal History:
The patient was delivered full term via spontaneous vaginal delivery in Well-
Family Center, Barangay Villamonte, Bacolod City. The mother was 25 years old at that
time. There were no prenatal complications or neonatal problems after delivery. The
mother conceived the patient with a 1-0-0-1 GP score.

Developmental history:
Developmental milestones correspond to patient age. Patient played sports and
attended school regularly before getting sick, knows how to follow complex instructions,
effortlessly constructs answers, and is able to build and maintain friendships.

Nutritional History:
The patient was calorie sufficient and had a solid appetite before becoming ill. He
eats home-cooked meals three times daily and widely consumes fruits and vegetables.

Immunization History
The patient had complete immunization according to health center booklet
requirements according to age.
Environmental History
The patient and his family reside in a home made of concrete. They lived in
Victorias City before transferring to his aunt’s house, which is located in Vista Allegre,
Bacolod City. There are no smokers or alcoholic beverage drinkers among the family
members they currently live with.The neighborhood where the patient resides is
regarded as relatively crowded. Utility water is supplied by BACIWA-Prime Water, and
the drinking water is purified water. The household has two pet dogs.

HEADSS (Home, Education, Activities, Drugs/Depression, Sex&Suicide)

H- Patient did not have any contact with his biological father, as the mother had cut off
any communication even before he was born. Growing up, he lived with his stepfather
and his siblings in Victorias City. After his mother and stepfather got separated, they
moved houses in December 2022 to Vista Allegre, Bacolod City, in her aunt’s house. He
still provides financial support for his unborn child. In his new home, he generally has a
supportive system and no known conflicts, as claimed.
E: Patient was an attentive student and attended school regularly. When he started to
manifest his symptoms, he stopped attending school.
A: He played recreational sports like basketball, and he also enjoys playing chess with
his cousins. He befriends everyone, even the mothers of his classmates at school.
D: No drugs or depression as claimed.
S: Male, no sexual experience
S: No suicidal tendencies
PHYSICAL EXAMINATION
General Survey
The patient was awake but preferred lying down on the bed and resting his head
on the pillow to alleviate his headache. He looks well-groomed though his shirt was
inside out by choice. He was able to joke around with his cousin who was looking after
him ever since he was admitted.

Anthropometric Measurements

Patient Interpretation

Weight (kg) 26.5 -2

Length (cm) 138 -2

Body Mass Index 13.9 Underweight

Body Mass Index: Based on the patient's height and weight,the BMI is 13.9, the BMI
for age should fall in the 5th - 95th percentile but the patient is below the 5th percentile
so he is considered underweight.

Z-Score Indicators: Interpretations for Z score for weight & height is based on CDC
guidelines.

Vital Signs
 Patient Normal Values Correlation

Blood pressure
100/80 100-120/60-75 Normal
(mmHg, sitting)

Pulse rate (bpm) 93 60-95 Normal

Respiratory rate
21 14-22 Normal
(cpm)

Temperature (℃) 36.8 36.6-37.9 Normal

O2 saturation (%) 98 >95% Normal

HEENT
Head: normocephalic, face is symmetrical with no mass, scars, deformities, and
no signs of trauma was noted, no palpable mass, not edematous, hair is normal
in texture and equally distributed, scalp is without lesion
Eyes: anicteric sclerae, pink palpebral conjunctivae, pupils are round, regular,
and equally reactive to light
Ears: without lesions and masses, and no discharge but has history of ear
infection
Nose: symmetrical, mucosa pink, septum midline, no nasal discharge, no nasal
flaring
Oral Cavity: oral mucosa pink and moist, tongue midline, no gum bleeding, no
lesion or masses, healthy, normal tonsils are pinkish in color, no high-arched
palate and tonsillo-pharyngeal congestion
Neck: trachea midline, no scars, lymphadenopathy, & palpable mass, no jugular
vein distention, any neck pulsation, no neck vein engorgement

Chest and Lungs

Inspection: no scars, masses, or lesions, no obvious deformities and defects on
chest wall, respiratory movement is not lagging, regular breathing, chest
expansion is symmetrical, no chest retractions
Palpation: no palpable masses, no tenderness, equal tactile fremitus
Percussion: noted resonant
Auscultation: bronchovesicular breath sounds all throughout the lung fields,
absent crackles or wheezing

Cardiovascular
 Inspection: adynamic precordium, no signs of precordial bulging nor lesions on
the chest
Palpation: apex beat was felt on the left midclavicular 4th intercostal space,
there were also no signs of heaves and thrills.
Auscultation: regular rate and rhythm, there were no murmurs or bruits heard

Abdomen
Inspection:flat, non-distended, no scars or lesions, discoloration, or visible veins
Auscultation:normoactive bowel sounds were noted
Palpation: soft, tenderness upon palpation on the left hypochondriac, lumbar
and iliac region, no palpable masses, no hepatomegaly and splenomegaly
Percussion: Tympanic all over

Skin and Extremities

no cyanosis and pallor, neither warm nor cold to touch, no hypo/hyperpigmentation,
lesions & masses was noted, full pulses, CRT = <2 secs

Genitalia and Rectal

normal external genitalia, no skin lesions, bilaterally descended testes and intact rectal
vault, no rectal bleeding, intact cremasteric reflex. Tanner stage 2. - describe tanner

NEUROLOGIC EXAM:
GCS: 15 E4V5M6

Eye Opening Spontaneous 4

Verbal Response Oriented to time, person, & place 5

Motor Response Obeys Command 6

15

Mental Status Exam: Patient was awake, able to focus and concentrate and able to
retain or remember information well. He was aware of the date, time, and place. Patient
can coherently converse with good insight and judgment. Mother noted a slight change
in behavior. The patient was easily annoyed and irritable due to the intensity of his
headache.

Cranial Nerves
Cranial Nerve/s Patient

I Olfactory nerve Patient was able to identify the smell on both

nostrils.

II Optic nerve Normal visual fields;

Patient was able to read through the Rosenbaum
pocket eye chart with both eyes. Patient was able
to see in 6 Visual fields.

III, IV, VI Oculomotor, PERRLA (pupils are equal, round and reactive to
Trochlear, Abducens light and accommodation)

Horizontal nystagmus and saccadic eye

movements were noted

V Trigeminal Patient was able to elicit corneal reflex, sensitive to

pain stimuli and distinguish hot from cold.

Motor
Patient showed appropriate symmetrical reactions
(laughing, opening of mouth)

VII Facial Patient

performed various facial expressions without any
difficulty and able to distinguish varied tastes

VIII Vestibulocochlear Patient can hear whispered words.

Patient has a swaying gait and cannot maintain

balance when eyes are closed.

Weber midline, AC>BC

IX, X Glossopharyngeal, Patient showed coordinated swallowing.

Vagus

XI Spinal Accessory The patient could hold his neck up and resist
external force.

XII Hypoglossal Patient was able to stick his tongue out; no

deviations, signs of atrophy, or lumps were noted.

Gait, Stance, & Coordination: Patient has wide stance and ataxic on tandem gait.
Positive on Romberg’s test swaying backward with both eyes closed and open.
Motor and Strength: No weakness, tremors, and involuntary movements noted.
Patient’s extremities were able to fight against resistance.

Sensory: Patient has an intact sensory, with ability to detect light touch, pain, and
pressure. Accurately discriminate changes in position & temperature. Was able to
identify two close points and written figures on palms.

Reflexes
(-)Deep Tendon Reflex
(+)Cremasteric Reflex
(-)Superficial Abdominal Reflex

Cerebellar
(-)Dysdiadochokinesia -
(+)Ataxia
(+)Nystagmus (R)
(+)Dysmetria
(+)Intention tremor
(-)Scanning dysarthria
(+)Heel to shin (right)

Meninges
(+) Kernig’s sign
(+) Brudzinski sign
(+) Nuchal Rigidity

MOTOR DEVELOPMENT:
The patient’s motor strength was 5/5 on all unaffected extremities. He had a wide
stance and ataxic gait. Ability to play games on his cellphone demonstrated well
coordinated fine motor skills.