Tuesday, June 12, 2012

Health History Write-Up Sample


Reason for Seeking Care

            “Fever with rashes for 6 days PTA”

Present Health History

Last February 4, 2010 at 4:00 in the afternoon, Bebe Kho was requested by her teacher to sweep the scattered garbage and clean the comfort rooms located just behind their classroom. There, she claimed that she was bitten by a stripe-colored mosquito. She also verbalized that there are plenty of mosquitoes in their house that bite her from time to time.
On February 8, 2010, patient’s voice became hoarse. Two days after, February 10, 2010, Bebe Kho experienced fever associated with left temporal non-radiating continuous headache with a pain scale of 7/10. However, there was no sign of bleeding such as epistaxis and hematemesis. Her tonsils were already enlarged and have purulent exudates. She was then brought to the nearby clinic in Simbulan for check-up. Bebe Kho was diagnosed with Acute Tonsillitis and was given antibiotic, Cefalexin 50mg, orally for 5 days. The patient claimed that she had loss of appetite, body malaise, and pain during swallowing which she scaled 3/10. Home management included cold compress applied on the forehead and a mixture of one tablespoon of salt in a glass of water which the patient gargled every four hours. Despite the effort to manage the fever, it still persisted for three days.
On February 13, 2010, rashes were noted on Bebe Kho’s trunk. At home, she was asked to drink at least 2 glasses of tawa-tawa decoction a day because her father anticipated that she might have acquired dengue since it’s also rampant in their place. Moreover, one of their neighbors has had dengue fever a week prior to the onset of Bebe Kho’s fever. The next day, her headache subsided but she still had fever.
Bebe Kho continued to be febrile for 6 days and the rashes spread to her entire body despite the home management. On the morning (unrecalled time) of February 16, 2010, Mr. and Mrs. Kho decided to bring the patient at Simbulan General Hospital. CBC was done in the hospital with the following results: Hgb-14.0g/dL, Hct-42.1vol.%, WBC-2.4x103µL, RBC-3.49x103µL, MCV-86.2fL, MCH-26.9pg, MCHC-31.2g/dL, and platelet count-53(120x103)µL. Differential count of: Segmenters-48% and Lymphocytes-52%. These results prompted Bebe Kho’s parents to admit her to Valencia Sanitarium and Hospital. They left for VSH at 6PM riding on a motorcycle.
Bebe Kho together with her parents arrived at Valencia Sanitarium and Hospital Emergency Room at 8:38PM on February 16, 2010 with vital signs of: T-35.9oC, PR-80bpm, RR-28bpm, BP-100/70mmHg. Physical Examination findings: enlarged tonsils without exudates, dry parched lips, Petechial rashes multiple in abdomen and upper extremities. IV infusion of PLR ŤL @ 35 gtts/min on right arm was started.
The doctor ordered the following:
ü  DAT except dark colored foods
ü  Labs:
o   repeat CBC
o   platelet count serial
o   Hct and platelet every 4 hours
o   U/A
o   serum albumin
o   ABO blood typing
ü  3 units of fresh frozen plasma properly crossmatched with patients blood type
ü  monitor v/s q 30 min.
ü  record and monitor I & O q shift.
At 9:50 pm new doctor’s orders were made. This included fast drip 100 cc of Plain Lactated Ringer’s; refer for systolic BP ≤ 70 mmHg, diastolic BP ≤ 50 mmHg; narrow pulse pressure ≤ 20 mmHg or any unusualities; IV to follow PLR ŤŤL @ 31 gtts/min.
On Feb. 17 at 12:20 pm during doctor’s rounds, orders were made such as changing the IVF to D5LR ŤL. During the doctor’s rounds at 2:15PM, the patient still had fever and inflamed tonsils, thus, the doctor ordered to start Paracetamol 750 mg/3 mL q 4h for 37. 8OC or above.

Past Health History
  Bebe Kho’s family lives in Purok Daghang Lamok, Fantasea, Bukidnon. Their house is located approximately 10 meters away from a banana plantation and is surrounded by huge trees. Mrs. Kho mentioned that during rainy months, the incidence of dengue fever is increased. Some of her control measures included the use of mosquito nets, changing of water and scrubbing the sides of their flower vase once a week, and destroying breeding places of mosquito by cleaning their surroundings. However, she added that when it is raining, she hangs their washed clothes just below their roof’s eaves. She also said that she has a collection of potted bromeliads placed outside the house. Further, she mentioned about the tadjao (a rubber made jar) with cover they placed outside their house that serves as rain water reservoir. She’s aware that these are potential breeding sites for mosquitoes.
Bebe Kho was born, together with her twin sister Bubu Kho, on August 9, 2000, full term, at Maternity Hospital in Cagayan de Oro City via elective Caesarean Delivery. According to the mother, it took more or less 20 seconds before the baby was able to cry. She also observed that Bebe Kho’s upper and lower extremities were slightly cyanotic. Bebe Kho suffered from respiratory distress resulting to her prompt confinement in NICU; however, her mother cannot recall the medications and treatment that were given to the neonate. After one week, the patient was discharged with improved condition evidenced by pinkish body and extremities and good cry. Patient had her BCG vaccine right after birth. She received her first dose of DPT and OPV six weeks after birth. DPT2 and OPV2 were given four weeks thereafter. She completed the third dose of DPT and OPV before she reached 5 months old. When she was 9 months old, she was immunized with measles vaccine, thus completing her immunization before reaching one year old.
            Mrs. Kho claimed that she breastfed the patient for a week only following her discharge, because she thought that her twins were not satisfied of the breast milk and that they were not getting adequate nutrition from it. So she decided to give the twins formula milk, specifically Bonna, as a substitute.
At 6 months of age, mother recalled that Bebe Kho was dyspneic and had fever which prompted her to admit Bebe Kho to Laviña Hospital in Valencia City. Patient was diagnosed of Pneumonia. As far as Mrs. Kho remembered, Dr. Kisteria, patient’s pediatrician, ordered Salbutamol 1/2 nebule via face mask to be administered TID for 7 days.
At 1 year old, patient was admitted to Laviña Hospital after an episode of dyspnea for at most 3 hours. She was then given Salbutamol 1 nebule via face mask TID. The attending physician diagnosed the patient as asthmatic. Mother claimed that they use Baygon Katol, placed approximately 1 meter away from child’s bed, every night. The doctor instructed her parents to stop using Baygon to prevent the episode of dyspnea.
The patient was 4 years old when she had a fall. Bebe Kho’s mother was watching television in the living room while her twins were playing. The client accidentally fell from the bench which stood 14 inches from the floor. Mrs. Kho was fully unaware of what happened until their housemaid called her attention. Mrs. Kho managed it by applying cold compress over the patient’s left shoulder and she shifted to warm compress after four hours.
When the patient was already 6 years old, she had fever again which prompted immediate check up at Dr. Osorno’s clinic in Simbulan. Dr. Osorno advised the patient’s mother to admit the child in the hospital to confirm if she has UTI. The patient was prescribed of Cefalexin 50 mg TID. Since then, Mrs. Kho managed the patient’s fever with Paracetamol 250mg every 4 hours until it subsided. During this time, mother noticed that the patient is allergic to Cotrimoxazole, her medication for UTI, and in chicken’s egg and chicken meat.
The patient was transferred from a private Baptist school to Fairy Land Elementary School when she was in Grade 2 due to financial reasons. A man-made pond that contained tilapia and water lilies occupied the east side of the school. Located behind the classrooms were 4 public comfort rooms and nearby was an unused water-containing drum. The southern part of the school was all-laden with tall talahib grass.
Last August 2008, she had been hospitalized at Simbulan General Hospital due to Amoebiasis with Dr. Osorno as the attending physician. One day prior to that admission, she experienced abdominal pain and passed greenish watery stools. Bebe Kho’s parents were unable to remember the drugs prescribed by the doctor. She stayed in the hospital for 3 days. Mrs. Kho believed that it was due to the water that Bebe Kho drank two days before she manifested the symptoms. In addition, the family ceased drinking mineral water two days prior to the onset of the illness; instead, they got their water source from the faucet.
On the same year (exact date not remembered), the patient complained of dysphagia associated with fever for 3 consecutive days. Upon inspection, the mother noted red and swollen tonsils. Days prior to that, patient ate chocolates especially cloud 9. She could actually consume one big pack of chocolate a day. Again, she was brought for check up at Dr. Osorno’s clinic and was diagnosed of Acute Tonsillitis. The following medications were prescribed: Gargle of Bactidol TID, and erythromycin. Bebe Kho was also given maintenance multivitamins such as Ceelin syrup (alternate with Neotroplex syrup) and Growee syrup one tablespoon every after breakfast.

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