HEALTH HISTORY

A. Personal History

To preserve the anonymity of our patient’s name and information regarding our
patient, let us call our patient by the name, Patient X. Patient X is a 12 year old female.
She and her family came from Albay, with a Bicol or Filipino dialect.

B. Pertinent Family History

C. History of Past Illness

According to patient X’s mother, some of the common illnesses that patient X had
was fever, cough and colds. The family seeks medical advice straight from their family
doctor. The fever is usually treated with Paracetamol (Tempra), Carbocisteine for cough,
and for colds, the mother usually takes her children at the seashore to take in fresh air.

At 2 years of age, the mother noticed a lump at the right side of the neck, behind
the ear of patient X. There was also pain associated, which was distressing to the part of
the patient. This prompted the family to seek medical consultation. A diagnosis of
Mumps was given to the patient. No medical management was provided, except for
application of topical gentian violet on the area. The lump subsided and the pain was
resolved. At age 8, the Mumps reappeared, and the same management was performed.

D. History of Present Illness

At age 11, the Mumps was still present. In addition to that, periorbital edema was
observed around the eyes of the patient. This did not cause any alarm to the family.
During a shoe fitting at a mall, they noticed that her feet were swollen and pitting: “nung
tinanggal yung sapatos, parang may nakabakat, tapos matagal siyang bumalik sa normal.”
A few days later, they noticed that her abdomen was quite big, but the mother’s friend
said that it might be “baby fats” only. Patient X said that there was no pain felt on the
abdomen. They sought medical advice for this but the doctor said that it was not a serious
condition. In connection to this, patient X verbalized that she was fond of drinking
carbonated drinks but does not regularly drink water after consuming it. She consumes
about 2-3 glasses per meal and she ingests “chicharon” and “balot” almost every evening.

Due to this, the edema progressed from the abdomen to the lower extremities. The
skin was dry and flaking. Patient X thought it was dirt on her legs, so she tried to remove
it by scrubbing during bathing. This caused her legs to appear striated. The family sought
medical advice in Albay, Bicol on December 2009 and was diagnosed with Acute Kidney
 Injury secondary to Rapidly Progressing Glomerulonephritis. Patient was admitted for 1
week in Albay, and undergone Hemodialysis (HD) for a single session only. Because of
deteriorating condition, patient X’s physician referred the patient to National Kidney and
Transplant Institute (NKTI) for further medical advice. Admission date was on February
25, 2010. Peritoneal dialysis (PD) was advised instead of HD. The duration of
hospitalization lasted until March 26, 2010 when the family decided to take patient X
home and continue treatment through continuous ambulatory peritoneal dialysis (CAPD),
10 cycles per day, and after a few months, it was decreased to 5 cycles per day, with the
help of a private duty nurse (PDN).

Patient X continued her studies while on CAPD. During break time at school, she
undergoes CAPD with her PDN in their family car. At home, her CAPD was usually
done in her bedroom at the second floor, but because of the exhausting task of going up
the stairs, her mother decided to do CAPD at the master’s bedroom located at the ground
floor, where most of the family members stay together.

On January 2-5, 2011, patient X was confined again at NKTI due to distended and
painful abdomen. The pain was relieved with Dolcet. On the day of follow up check-up,
which was January 8, 2011, patient’s blood pressure fell below normal level. Likewise,
patient X experienced headache and dizziness, anasarca was observed from the patient.
This prompted the physician to admit the patient once again at NKTI. Peritonitis related
to Peritoneal Dialysis was diagnosed. PD catheter removal was performed on January 10,
2011.

ASSESSMENT