PATIENT HISTORY Date of Interview: June 20, 2012 History taken by: Mauvecate Jade Piperno Source of Referral:

employer Informant: patient % Reliability: 95%

IDENTIFYING DATA: Rialyn Samar, 24 years old, female, single, Filipino, house helper, Catholic, born in Leyte, on August 9, 1987, presently residing at 23 Sampaguita St. Mapayapa Village Quezon City, admitted for the first time to FEU-NRMF Medical Center on June 19, 2012. CHIEF COMPLAINT: headache and stomach ache HISTORY OF PRESENT ILLNESS: The present illness started 6 days PTA. The patient experienced a sudden onset of severe, throbbing headache upon waking up in the morning which was felt especially on the frontal part of the head. It was accompanied by dry cough and colds and fever graded 38C to 40C which were relieved when she self medicated with Neozep and with Tempra (taken every 4 hours). Three days PTA, the patient experienced severe pain in the left lower quadrant of the abdomen of gradual onset which according to the patient was aggravated by movement and was relieved by drinking water and eating. The pain was described as a continuous, wringing pain. The patient also reported to have vomited twice. That same night, warm rashes began appearing all over the patient's body except in the hands and feet. On the day of the admission, there was persistence of severe headache and pain in the LLQ of the abdomen which prompted the patient to seek medical advice and she was subsequently admitted. PAST MEDICAL HISTORY: - Had chicken pox during childhood - Immunizations could not be recalled - No history if operations, blood transfusions, accidents, injuries, psychiatric or gynecologic diseases - No known allergies to food and drugs FAMILY HISTORY: - Mother: has hypertension - No history of cancer, asthma, psychiatric illnesses, diabetes mellitus, heart disease PERSONAL AND SOCIAL HISTORY: She was able to complete elementary education and is currently working as a house helper. She usually sleeps for 8 hours per day, an occasional alcohol drinker, and consumes a cup of coffee every morning. A non smoker, no regular exercise. Usually consumes fish and vegetables, occasionally chicken and pork, but not beef.

MENSTRUAL AND OBSTETRIC HISTORY: -Menarche at 14 years old - Subsequent menses were regular occurring at approximately once a month, moderate flow, lasting for 4 day, no associated symptoms -LMP: could not be recalled -Has never given birth before REVIEW OF SYSTEMS: Constitutional Symptoms: (+) weight loss (extent and period was not recalled), (-) generalized weakness, (+) fatigue, (+) fever, (-) chills, (-) loss of appetite Skin: (-) itchiness, (-) excessive dryness or swelling, (-) cyanosis, (-) pallor, (-) jaundice, (+) erythema (petechial rash) Head: (+) headache, (+) dizziness, (-) vertigo Eyes: (-) pain, (-) blurring of vision, (-) double vision, (+) excessive lacrimation, (-) photophobia, (-) use of reading glasses Ears: (-) earache, (-) deafness, (-)tinnitus, (-) ear discharge Nose and Sinus: (-) changes in smell, (-) nose bleeding, (-)nasal obstruction, (-)nasal discharge, (-) pain over paranasal sinuses Mouth and Throat: (-) toothache, (-) gum bleeding, (+) disturbance in taste (bitter 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: (-) palpitations, (-) syncope, (-) easy fatigability Gastrointestinal: (+) abdominal pain, (-) nausea, (+) vomiting, (-) dysphagia, (-) diarrhea, (-) constipation, (-) hematemesis, (-) melena, (-) hematochezia, (-) regurgitation Genitourinary: (-) dysuria, (-) urinary frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) hematuria, (-) incontinence, (-)genital pruritus, (-) urethral discharge Extremities: (-)edema, (-) swelling of joints, (-) stiffness, (-) numbness, (-) intermittent claudication, (-) limitation of movement Nervous: (+) headache, (-) vertigo, (-) syncope, (-) loss of consciousness, (-) focal weakness, (-) paralysis, (-) numbness, (-) paresthesia, (-) speech disorder, (-) loss of memory, (-) confusion Hematologic: (-) bleeding tendency, (-) pallor, (-) easy bruising Endocrine: (-) intolerance to heat and cold, (-) excessive weight gain/loss, (-) polyuria, (-) polydipsia