Fernandez_ Teresita CA

					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Fernandez, Tessie Age/Sex: 51/F Address: 397-B Hipodromo St. Sta. Manila Date of Admission: July 7, 2007, 11:00 am Admitting Diagnosis: Primary Seizure disorder Anemic probably result of pathology Final Diagnosis: --Residents-in-charge: Drs. Dalanon/Gutierrez/Gregorio Clerks-in-charge: Ocampo G/ Patayan/Roque

Hospital #: 1707178 Room #: 428 Date of Discharge:

Clinical Abstract This is a case of a 51 year old female of Sta. Ana, Manila, who was came in due to convulsions. History of Present Illness The patient is a diagnosed case of seizure disorder maintained on Phenytoin 100mg/day but stopped fully, months ago. Her last attack was more than 1 year ago. Three days prior to admission, patient had undocumented fever which occurred on and off with accompanying difficulty of breathing. She has no abdominal pain, no change in bowel movement, no hematuria and no oliguria. She then consulted to a private clinic where she was given unrecalled antibiotics. Eight hours prior to admission, while at rest, patient had generalized stiffening accompanied by upward rolling of eyeballs and drooling of saliva which lasted for less than a minute. There was no loss of consciousness and headache. Patient was brought to UERM but was not admitted there because there were no rooms available. Thus the relatives transferred to another hospital, hence the admission. Past Medical History No HPN, no DM, no previous hospitalizations Family History Known history of hypertension and liver CA on paternal side Personal/Social History: Non-smoker Non alcoholic beverage drinker Review of Systems: General: no weight loss, no loss of appetite HEENT: no tinnitus, no blurring of vision, no dysphagia Respiratory: with occasional cough, no cold, no difficulty breathing Cardiovascular: no chest pain, no PND, no palpitations, no orthopnea, with easy fatigability Endocrine: no polyuria, no polyphagia, no polydipsia Hematologic: no easy bruisability Physical Examination: Patient is conscious, coherent, not in cardiorespiratory distress o Vital Signs BP: 130/80 HR: 80 bpm RR: 20 cpm Temp: 36 C HEENT: anicteric sclerae, pale palpebral conjuctiva, no naso-aural discharge, no palpable cervical lymph nodes, no neck mass, no tonsillopharyngeal congestion, no neck vein distention Chest and Lungs: Symmetrical chest expansion, no retractions, clear breath sounds Heart: Adynamic precordium, normal rate, regular rhythm, no murmurs Abdomen: Flat, normoactive bowel sounds, soft, (+) direct tenderness on hypogastric area Extremities: grossly normal, no cyanosis, no edema, full equal pulses Neurologic: conscious, coherent, oriented to time, person and place. CN I – can smell CN II – intact visual fields CN III, V, VI - EOM, intact, pupils 2-3 mm CN V – with bilateral corneal reflex CN VII – no facial asymmetry CN IX, X – good gag reflex

CN XI – can shrug shoulders equally CN XII – tongue midline on protrusion
Sensory Motor Deep tendon reflexes

100%

100%

4/5

4/5

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++ 100% 100% 4/5 4/5

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No nuchal rigidity No BAbinski No Kernigs sign Assessment: Plan: Primary seizure disorder

for Admission


				
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