HEALTH HISTORY

BIOGRAPHIC DATA

Name: Ms. Missy BonBon

Room Number: 244
Address: Lombayao Balindong, Lanao del Sur
Contact Number: 0918-563-0843
Age: 16
Birth Date: March 24, 1994
Birth Place: Lombayao Balindong, Lanao del Sur
Religion: Islam
Gender: Female
Ethnicity/Nationality: Filipino
Marital Status: Single
Educational Attainment: College Level
Occupation: Student
Usual Health Care Provider: Quack Doctor
Reason for Health Contact: For Further Evaluation and Management of difficulty of
breathing and edema on lower extremities
Date of Confinement: November 13, 2010
Source of History: 30% SO, 30% Chart, 40% Patient
Attending Physician: Dr. Timonera, Dr. Cabrera, Dr. Kamlian
Chief Complaints: Difficulty of breathing and edema on lower extremities
Final Diagnosis: Miliary PTB secondary to bacterial and fungal infection ; Chronic
Respiratory Failure secondary to Miliary PTB
Malnutrition secondary to chronic illness

DESCRIPTION OF PATIENT

DAY 1
Awake lying on bed in high back rest, conscious, coherent, and responsive,
oriented to time, place and person, and appears anxious, weak, drowsy, tachypneic and
not in respiratory distress. Has poor hygiene, with soiled t-shirt and on diapers, and
with uncombed hair. With patent IVF of D5NSS 1L plus meq KCL at 20 cc/hr with a side
drip of Aminoleban 500cc at 20 cc/hr hooked on right metacarpal vein. With O 2
inhalation at 9LPM via face mask, with dry and cracked lips, with occasional productive
cough with yellowish and slightly sticky sputum, with distended abdominal girth of 88 cm
and with Grade III bipedal pitting edema.
DAY 2
Awake lying on bed in high back rest, conscious, coherent, and responsive,
oriented to time, place and person, and appears anxious, weak, drowsy, tachypneic and
not in respiratory distress. Still has poor hygiene, with soiled t-shirt and on diapers, and
with uncombed hair. Still with patent IVF of D5NSS 1L plus meq KCL at 20 cc/hr with a
side drip of Aminoleban 500cc at 20 cc/hr hooked on right metacarpal vein. With O2
inhalation at 9LPM via face mask, still with dry and cracked lips, with occasional
productive cough with yellowish and slightly sticky sputum and with distended
abdominal girth of 88 cm, with Grade III bipedal pitting edema.

DAY 3
Asleep on high back rest, sttill has poor hygiene & uncombed hair, dressed
appropriate for age with diapers. Still with patent IVF of D5NSS 1L plus meq KCL at 20
cc/hr with a side drip of Aminoleban 500cc at 20 cc/hr hooked on right metacarpal vein.
With O2 inhalation at 8LPM via face mask, tachypneic, still with dry and cracked lips,
with occasional productive cough with yellowish and slightly sticky sputum and with
distended abdominal girth of 84 cm, with skin lesion approximately 2cm in diameter &
reddish in color on the sacral area and with Grade III bipedal pitting edema.

HISTORY OF PRESENT ILLNESS

Four months prior to admission, patient manifested fever and cough, she was at
Gensan City that time and decided to return home at Lombayao Balindong, Lanao del
Sur. She just took Paracetamol Biogesic for her fever, after a few days the fever
subsides and the family didn’t bother to ask for medical advice. After which the patient
returned to Gensan City to continue her schooling.
Three months prior to admission (August 9, 2010) the patient again manifested
fever and noticed abdominal distention then decided to return home at hometown, The
family decided for medical consultation on the Out Patient Department at AMAI Pakpak
Medical Center at Marawi City under Dr. Ipig. Ms. Missy Bonbon undergone to
laboratory tests such as ultrasound with a result of (1. Sonographically normal uterus, 2.
Massive Ascites, 3. Incidental note of contracted liver), total protein of 5.17 (normal: 6.4-
8.3g/dL), and albumin of 4.5 (normal: 35-54g/L). Dr. Ipig prescribed medications but the
father of Ms. Missy Bonbon can’t remember those medications.
After which, Dr. Ipig referred them at Northern Mindanao Medical Center at
Cagayan de Oro City under Dr. Magsayo and Dr. Yusof still as an Out patient. Series of
laboratory test was done such as ultrasound with a result of (1. Diffuse liver
parenchymal disease, cannot rule out early liver cirrhosis, 2. Massive ascites with thin
septations at the lower abdomen and pelvic cavity, 3. Thickened gallbladder wall likely
reactive cholecystitis, 4. Non-remarkable ultrasound findings in the pancreas, spleen,
abdominal aorta, kidneys, uterus and ovaries, 5. Empty urinary bladder, 6. Pleural
Effusion). Medications were given but the SO cannot recall its name. After that, they
were again referred by Dr. Magsayo to Cagayan de Oro Medical Center Hospital under
Dr. Tia. The family consulted with Dr. Tia and was advised to be confined at the hospital
for 2 weeks for further assessment but the family declined the advice due to financial
problem and “nawalan na kami ng gana pati siya dahil palagi nalang kaming ni rerefer
sa iba’t ibang doctor, sabi niya uwi nalang daw kami sa amin,” as verbalized by the SO.
Dr. Tia just prescribed Aminoleban powdered form.
After 1 week of stay in Cagayan de Oro City, they returned home at Lombayao
Balindong, Lanao del Sur and there they consulted to 8 quack doctors in 1 month
period. She was given leaves to be boiled and was instructed to drink it. According to
the quack doctors, Ms. Missy Bonbon was cursed by someone. The SO claimed that,
“Pagkatapos nung ngpa tingin kami sa manggagamot, lumiit yung tyan niya”.
Two weeks prior to admission, patient noticed edema on her right leg, they didn’t
do anything with regards to patient’s status. Condition persisted until the date of
admission associated with difficulty of breathing which prompted to admission.

PAST HEALTH HISTORY

During Ms. Missy Bonbon’s childhood times, she hadn’t experienced mumps,
rubella, chicken pox, pruritus nor strep throat. But two years ago, year 2008, the patient
experienced measles associated cough with fever. The family gave her Paracetamol to
cure her fever and was brought to a quack doctor. They just managed the patient’s
condition by applying some “dahon-dahon” as verbalized by the SO. Less than one
week, the condition subsides and they didn’t bother seeking medical advice.
The patient had not experienced any accidents or injuries, any serious or chronic
illnesses. This was Ms. Missy Bonbon’s first hospitalization, but was last examined
three months prior to admission at AMAI Pakpak Medical Center at Marawi City under
Dr. Ipig and undergo to some laboratory tests, also she had series of laboratory test at
Northern Mindanao Medical Center at Cagayan de Oro City under Dr. Magsayo and Dr.
Yusof and also consulted to Cagayan de Oro Medical Center Hospital under Dr. Tia
due to distended abdomen. She had not undergone any operation or surgeries. Ms.
Missy Bonbon started her menarche when she was 12 years old with 3 to 4 days
duration and 28 to 30 days interval and doesn’t experienced dysmenorrhea.
Ms. Missy Bonbon had her complete immunization at their hometown’s Barangay
clinic. Patient has no allergies to food, medications or any substances. She has no
maintenance drug, nor vitamins or supplements maintenance. She’ll just take over the
counter drugs such as Paracetamol Biogesic whenever she has fever.