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CASE PRESENTATION Ramos, Dionne Joy

Taberna, Krishna Angela
Vasoya, Kishankumar
Date of Interview: September 20, 2018
Time: 10:15 in the morning
Informant: Patient and her daughter
Reliability: The patient was conscious and alert in answering questions.
Her daughter confirmed all the answers of his mother and she shared
some additional information.
GENERAL DATA
Patient RNV, a 52-year old Filipino female, widow, was born on
August 28, 1966 at Lallo, Cagayan. Her religion is Roman
Catholic. She was a farmer and now, a housemother in her house
in San Jose, Lallo, Cagayan. She was admitted at Cagayan
Valley Medical Center last September 3, 2018, around 2 in the
morning.
CHIEF COMPLAINT
The patient experienced nape pain and headache prior to
loss of consciousness.
 HISTORY OF PRESENT ILLNESS
Five weeks prior to admission, Patient RNV experienced headache and nape pain.
She self-medicated Catapres sublingually but after some time, she was still in pain.
Her daughter immediately brought her to Puyaoan Hospital. According to her
daughter that was assessed by the physician, patient’s BP was high and the
physician came to know that she wasn’t compliant with her maintenance which is
Losartan 50 mg once a day for about 2 months. The daughter added that the
physician took ECG and discovered that her mother has weak heartbeat. Her
physician prescribed her Carvedilol 50 mg and was instructed to take it once a
day after meal.
 HISTORY OF PRESENT ILLNESS
Few hours prior to admission, the patient experienced headache and
nape pain when she got home after travelling for 30 minutes. She called
her daughter to bring her to Puyaoan Hospital. Based on her daughter,
she became unconscious and was referred to CVMC. Mannitol was given
and tests were done such as blood tests and ECG as she added.

Few days after admission, Patient RNV became conscious and same tests
were done as shared by her daughter. She said that tests were normal
and her mother was scheduled for angiogram. But due to no available
medication or injection as what she described, the procedure was
rescheduled.
 PAST MEDICAL HISTORY
Patient RNV was prescribed for her hypertension and weak heartbeat
as she said. Her current medications are Losartan 50mg once a day
after breakfast and Carvedilol 50mg once a day at 6pm after meal.
According to her, she has no record of immunization but she contracted
Chicken pox and measles during her childhood. She remembered that
she was diagnosed with ulcer last 2008 and hypertension last 2013.
She has no known allergies to food, medications and animals. She
indicated that she did not undergo any surgical procedures.
 MENSTRUAL AND OBSTETRIC HISTORY
Patient RNV was 14 years old when she started her menstruation. Her
menstruation last for 3 to 5 days in regular or monthly menstrual cycle.
She used 2 cloths or “lampin” as her pad in a day. She has 5 living
children, 3 daughters and 2 sons. According to her, she had
miscarriage on her 1st baby and used to take pills. She was in
menopause when she was 45 years old.

G6P5 (5 0 1 5)
FAMILY HISTORY
Her father died when he can’t remember the exact age but
she said it was above 70 y/o due to old age.
Her mother died due to old age. She told us that she was not
certain about the age of her mother but it was above 80y/o.
No known history of hypertension, diabetes, asthma or any
diseases within her siblings and parents.
PERSONAL AND SOCIAL HISTORY
Patient RNV was 15 y/o when she married her husband who was 20 years old. They
have five healthy children, three daughters and two sons. Her husband died last 2010
due to hypertension. She was a farmer for so many years that she can’t remember the
exact year she started. She was advised by her physician to avoid getting tired
because of her heart condition and she stopped working.
She eats three times a day and takes snacks between meals. She eats vegetables, and
sometimes meat whenever they have extra money. She likes soy sauce or fish sauce
with calamansi as her sauce during meal. She drinks 2 litres of water per day. She
neither smokes nor drinks alcohol. Their source of drinking water is from commercialized
water refilling stations.
Her work was her exercise but now, she is doing some household chores and usually
takes some rest while watching TV.
She has no problem in defecating and micturition. She defecates once a day and
urinates almost every 2 hours or when she feels the urgency.
REVIEW OF SYSTEMS
Constitutional: Experienced easy fatigability. With slight weight
change. No fever and chills.
Skin: No rashes, lumps and dryness of skin. No changes in
color of skin and nails.
Hair: No loss of hairs.
Head: With history of headache. No tenderness,
lightheadedness and dizziness.
Eyes: Experiencing difficulty in raising her eyelids with slight
bulginess of left eye. Right eye is normal without blurry
vision.
Ears: No discharges, earache and hearing problem.
Nose and Sinuses: No history of epistaxis and other discharges. No
nasal itching and stuffiness.
Mouth and Throat: No history of difficulty of swallowing, toothache,
bleeding gums, mouth ulcers and sore throat. No
changes of voice.
Neck: With history of nape pain. No stiffness and
lumps on her neck.
Breast: No felt pain, lumps and discharges.
Respiratory: No history of difficulty in breathing and cough.
No history of bloody sputum.
Gastrointestinal: Has good appetite. No history of vomiting,
abdominal pain, nausea, fresh bloody stool or
black starry stool and diarrhea.
Genitalia: No pain, swelling, discharges, and itching.
Musculoskeletal: No difficulty in her movement. Shown both upper and
lower limbs can move without difficulty and assistance.
No muscle pain, stiffness, joint swelling and joint
pain, muscle weakness and backache.
Neurologic: No history of paralysis, tremors, numbness,
seizures and memory loss. Can remember her birthday
and date of birth of her children.
Hematologic: No history of pallor, bleeding and bruises.
Endocrine: Did not experience too much drinking and eating and
excessive sweating.
Psychiatric: No history of anxiety, depression and nervousness.
GENERAL SURVEY
Patient is conscious, coherent and cooperative while sitting on bed
comfortably. She is oriented to time, place and person. Her skin looks
normal. She can move in any position without any assistance. She has
symmetric facial features but her left eye is drooping with slight swelling
while her right eye is normal in appearance.

Height: 1.44 m
Weight: 43.6 kg
BMI: 21.03 kg/m2 (Normal)
VITAL SIGNS
Blood Pressure: 130/90 (taken while sitting on bed)
Temperature: 36.11 C (axillary)
Respiration Rate: 19 bpm (Normal)
Pulse Rate: 82 bpm (Normal PR but with weak
radial pulse)
Cardiac Rate: 85 bpm (Normal)
DIAGNOSIS/IMPRESSION
Hypertensive Cerebrovascular Disease secondary to
Hypertension Stage II