Patient Health HistoryHospital: Caraga Regional Hospital Room Number: Pediatric Ward, Miscellaneous Case number: 15-07-56 Name

of the Patient: Patient R Age : 16 years old Date of Birth : October 21, 1993 Civil Status : Single Religion: Iglesia Filipina Independiente Highest Educational Attainment : High School level Occupation : NONE Home Address : Esperanza, Loreto, Dinagat Island, Surigao del Norte Health Care Financing and Usual Source of medical Care : Family income Mode of Admission: carried by his father Date of Admission: September 25, 2009 Time of Admission: 10:25 am Vital Signs upon Admission: Temperature: 36.7'cPulse Rate: 86bpmRespiratory Rate: 18cpmBlood Pressure: 120/70 mmHg Chief Complain: Present condition noted as sudden onset of weakness of left lower extremities for almost 3 weeks, then after right lower extremities a week after Admitting Diagnosis:

Guillain Barre' Syndrome Final Diagnosis: Guillain Barre' Syndrome

Attending Physician: Dr. Asodisen (from September 25-30)Dr. Moleta ( from October 1-6) Name of Informant: Patient's mother Date of Discharge : October 6, 2009 Condition upon Discharge: Improved Source of Stability of Data gathered: Primary source (patient),Secondary Source (patient's SO and chart) IBW = 1 1 8 1 1 8 - 1 0 + 1 0 129 128 lbspatient is only 103.61 lbs, therefore patient is unde rweight BMI = weight (in kgs) / height (in m) 2 = 47 kg / (1.585 m) 2 = 47 / 2.51= 18.72 patient s BMI is normal

A. History of Present Illness

On the 2 nd week of August 2009, patient stated that he experienced abdominalcramps and diarrhea with watery stool characterized with yellow-green in color whichlasted for 2 days after he had eaten kinilaw.After two weeks, patient started to complain a tingling sensation or somethinglike an electric current on his feet and climbed up to the thighs and a little numb. Patientsuspected that the cause of this was the usual bathing of legs after having a walk for approximately 4kms everyday going to school and back home.On t he 2 nd week, patient experienced weakness, especially on his left leg thatmade him not able to walked and had limited range of motion. On the following days, hiscondition worsens. He felt weakness accompanied with tingling sensation which oftenattack early in the morning and late afternoon and a couple of time during hour sleep asclaimed by the patient. The day after, numbness on lower extremities with uncontrolledmovements/tremors occurs which last about ten minutes. At that time, he couldn t sit onhis own and when he did sit up with assistance as well as in his elimination purposes.He felt like an egg as stated by the patient.Patient s family sought advice from the local manghihilot who massaged theaffected area with his own-made mixture of herbs. The latter believed that patient condition is caused by buyag sa engkanto . They also a s k e d h e l p f r o m a mantayhopay who gave the same impression. His mother followed the instructions of the said persons such as soaking his feet with nilagang sambong every morning andat night before sleeping. Hospitalization was not possible during the said span of timebecause of financial constraints.One day prior to hospitalization, our patient was seen by his mother crying on thefloor of their sala. Patient stated that gusto na nako magpahospital, nahadlok na akobasin dili na ako makalakaw pagbalik. That incident prompted his mother to bring him toLoreto District Hospital that day but was referred directly to Caraga Regional Hospitalfor further assessment and management.Patient was admitted to Caraga Regional Hospital last September 25, 2009 atexactly 10:25 am for chief complaints: noted as sudden onset of weakness of left lower extremities for almost 3 weeks, then after right lower extremities a week after Upon confinement, the doctor prescribed the following: IVF D5IMB100 @ 25 gtts/min Vitamin B complex 1 cap OD Hydrocortisone 100mg IVTT q8 0

Laboratory tests were also ordered by the attending physician such as: Hematology Electrolytes Urinalysis

B. Past Health HistoryChildhood Illness Patient s mother claimed that his son don't have any childhood illnesseslike mumps, chickenpox, rubella and pertussis, etc. He experie nced diarrhea lastJanuary 2009 which lasted for almost 2 and a half days characterized with watery stoolyellowish-green in color. After that incidence he suffered diarrhea again last May 2009w i t h t h e s a m e d u r a t i o n a n d f e a t u r e b u t h e w a s n o t a b l e t o h o s p i t a l i z e d . P a t i e n t experienced 1 week fever accompanied with productive cough with thick yellow sputumon the last week of July 2009. Immunization Patient's mother claimed that only BCG had been immunized to her sonsince health center is far away from their house. History of Hospitalization Patient has no history of hospitalization; in fact this is his first time of being admitted in the hospital. Surgical History Patient claimed that he did not undergo any surgical procedure. Accidents and Injuries A week before he confined at Caraga Regional Hospital, he stated thatwhen he was having an exercise early in the morning nearby shore approximately 710m e t e r s a w a y f r o m t h e i r h o u s e s u d d e n l y h e f e l t w e a k n e s s o n h i s l e g s a n d t i n g l i n g sensation accompanied by tremors that made him fall down to the ground. He wastrying to drag himself going to their house that causes abrasion and wounds on his legs,left foot, right and left knees. Until now his wounds are in the healing process, hismother used herbal plants like malungay to treat his wounds. Allergic and Type of Reaction Patient claimed that he don't have any food allergy or drug allergy. Family Health History

Patient was the eldest of five. His mother is 43 years old and in goodcondition. His father is 56 years old currently suffering from cough for almost two weeksand has arthritis. The usual sickness of his siblings experienced, were colds and coughw h i c h c a n b e r e l i e v e d b y o v e r t h e c o u n t e r d r u g s s u c h a s b i o g e s i c , n e o z e p , carbocisteine and paracetamol. The grandmother/father in the mother side are alivewith no underlying illness. The grandfather/mother in the father side were alreadydeceased. His grandfather died last 1998 according to them it was just sudden onset ofswelling on his lower extremities and a week after the upper extremities and developedinto entire body. He was not hospitalized and was not diagnosed, in fact according totheir belief and rumors his grandfather was "na barang". After one month of sufferingfrom generalized swelling ha was died lying on the bed unnoticely. After 7 years, that is2005 his grandmother died as claimed by the patient's mother, she died with the samecase to her husband because of generalized swelling but patient's mother claimed thatshe can't recall if what happened to her mother-in-law since they were apart from herewhen that time happened, all she knows is that after one month also of suffering fromswelling she died. Personal Health HistoryLifestyle1. Personal HabitBefore Hospitalization Patient is a non-smoker and non-drinker and don't even used harmfuldrugs. Before he was confined at hospital, he already felt weakness on his legs thatmade him just stay on their house. He just watched wowowee and listening music andwhen he got bored he just sit nearby the window and just looked around to his friendsoutside since he can't walk and join with them. He just study his lesson by himself sincehe stop going to school for almost 3 weeks because of his condition. During Hospitalization Since patient was weak and can't moved his legs , he just lied on thebed and sometimes sit but still his legs were in straight and flat position. Patient haslimited movement that made him uncomfortable. He just sleep and sometimes awake if tingling sensation occur. He also used to have little conversation to his family. He justkeep on smiling whenever there were people looked at him. 2. DietBefore Hospitalization

Patient typical food is fish since they lived nearby the sea and his father o c c u p a t i o n i s f i s h i n g a n d a l s o v e g e t a b l e s . P a t i e n t e a t s h i s m e a l s 3 x a d a y b u t sometimes he doesn t want to eat in the breakfast. Patient drinks 8-10 glasses of water a day he don't have any special diet or any food restriction. Patient was fond of eating kinilaw with vinegar than cooked. He eats 3 large meals a day and drinks 5-6 glassesof water. Patient is fond of eating raw egg with salt. He eats junk foods as his snacks.He drinks coffee and Milo sometimes if it is available on their kitchen. During Hospitalization Patient eat the food that is being serve in the hospital but sometimes hismother buy food outside like tinolang baka and any food that has soup. He also eatsfruits like orange, banana and mango. And early in the morning his mother will makemilk/milo for him. Sometimes he refuses to eat because he felt fullness, he drink 3-4 glasses of water a day. He doesn t have any order of food restriction or any special dietfrom the dietician but the doctor ordered 1 banana last September 26, 2009. 3. Sleep and Rest PatternBefore Hospitalization Patient usually sleep at 8pm and wake up 6am, before the pr e s e n t illness he had no difficulties in sleeping, but when he started to felt weakness andtingling sensation he can't sleep appropriately cause he can't moved his legs side byside. During Hospitalization Patient has difficulty of sleeping and wakes up a number of times duringhour sleep. He claimed that his not comfortable to sleep in the hospital as well as hisposition in sleeping, he felt he's like a dead person lying in a straight and flat position.And sometimes he's mother awaken him when uncontrolled movements of muscleoccur since patient couldnt felt any sense. 4. Elimination PatternBefore Hospitalization Patient urinate 3x a day characterized by large amount with yellow incolor and defecate once a day characterized by scanty amount with yellowish/brownishin color with no history of difficulty or pain in urinating and defecating. Patient did notexperience constipation. Before the present illness , he eliminate with himself butbecause of his condition he really needs assistance for elimination purposes, usually hisfather carried him in going to comfort room. During Hospitalization

Patient urinate 4-5x a day, when he void he just sit on the bed and hismother will offer plastic container of the IVF since he can't go by himself to the comfortroom. Sometimes it takes 3-4 days before he can defecate and his father carried himgoing to the comfort room. His last void is scanty and yellow in color and his fecal ishard stool, yellowish in color. 5. Activities of Daily LivingBefore Hospitalization Even though before hospitalization patient has difficulty on his activitiesof daily living because of his condition he cant take a bath and dress alone, his mother has been always there for him in doing his grooming and hygiene as well as in hiselimination and locomotion, he had limited movements. The only thing he can do for himself is just that when he eat or holds any object. He couldn t help in householdchores unlike before. During Hospitalization Patient doesn t have any activities, he just lies on the bed. He claimedthat he was bored; he wants to have some exercise as what he usually did before his condition. He just has some conversation with his mother and after that he fined himself sleeping and awakens for a few hours. 6. Recreation and HobbiesBefore Hospitalization Patient usual recreation and hobbies were watching television and listend r a m a i n t h e radio. He used to read pocketbooks when he got bored. B e f o r e h i s condition he exercised everyday early in the morning and swimming in the sea. During Hospitalization Patient just lies in the bed. When the patient is in fine mood, he usuallychatty and lights up when he is talking to his visitors/parents. He always war beautifulsmiles on his face despite of his condition. 7. Social Data The patient usually turns to his parents for support during time of stressand school problem especially about what he felt on his first trimester of illness. Hereported to his parents for every detailed event that happened to his condition. Patientdoes not believe in superstitious belief or quack doctors even though his parent doso. Patient is currently studying first year high school but eventually stopped because of his condition. 8. Occupational Activity Not applicable. Patient is still studying. 9. Environmental Data Patient lived at Esperanza, Loreto, Dinagat Island, SDN. Their house islocated nearby the sea approximately 10-12 meters away from their house. Their houseis made of wood

and nipa hut. They have one sala, room, and kitchen and comfortroom. Their house is surrounded with plants and they have garden wherein they plantv e g e t a b l e s f o r t h e i r f o o d c o n s u m p t i o n . A n d a l s o a l i t t l e c h i c k e n p o u l t r y f o r t h e i r consumption of eggs. They have a clean environment where in he can breathe fresh air with no pollution. 10. Psychological Data Patient major stressor in life was his condition now, he was worriedabout his legs if it will be back in normal again but despite of his problem he was tryingto be strong and tend to be happy for he believed that he will be cured and nothing isimpossible with God. 11. Pattern of Health Care Patient is a non-member of Phil Health, GSIS and SSS. Patients mother used herbal plants and sought quack doctors and manghihilot whenever his son gotsick. They used their personal family fund to sustain his need for medical care.

REVIEW OF SYSTEMIntegumentary system Patient has no any allergic reaction to certain foods or medication, he don t haveany history of itchiness. He has lesions, abrasions and scars in his lower extremities. Nohair dyes, curling or strengthening preparation. Head, Eyes, Ears, Nose, Throat Patient doesnt felt any dizziness, lightheadedness and headache. Sometimeshe experienced seizures especially when it is cold and tingling sensation attack. Hedoesn t use any eyeglasses. No hearing problem patient experienced nasal stuffinesssometimes. Neck Patient claimed that he doesn t have any neck lumps and was not diagnosewith any thyroid problem. Breast and Axillae Patient did not experience any pain on his breast and axillae. Thorax and Lungs Patient experienced productive cough with thick yellow sputum. No history anddyspnea, asthma, pneumonia, and emphysema. He doesn t felt any chest pain. Cardiovascular System Patient doesnt have any history of cardiovascular disease. Gastrointestinal System

Patient experienced abdominal cramps and hyperactive bowel movement withwatery stool characterized with yellow-green in color which lasted for two days. Patientexperienced abdominal pain in the lower portion of the abdominal cavity; it just lastedfor few minutes and diminished. He used to drink hot water to relieve the pain, he alsoexperienced flatulence for 5x a day, for that day only. He don t any have difficulty inswallowing. Musculoskeletal System Patient claimed that he experienced like an electric current sensation on hisboth legs. It is gradual characterized first by the weakness of his legs followed by thetingling sensation and numbness on his legs especially in the left leg. Because of this,he had limited range of motion and he can t move his both legs. Tingling sensation oftenattack early in the morning and late afternoon and a couple of time during hour sleep asclaimed by the patient. He also had loss of function without pain in her legs. Neurologic System Patient experienced tingling sensation, numbness and uncontrolledmovements accompanied with tremors on his lower extremities. Patient can t feel lightpressure only deep pressure and pain through pointing point object. Urinary System Patient urinates 2-3x a day, he have difficulty in urination because he needassistance tot go to comfort room. But he doesnt have any painful urination. Hematologic Patient claims that he doesnt have any history of anemia. Endocrine System Patient verbalizes upon assessment that he cannot tolerate warme n v i r o n m e n t s i n c e i n t h e i r p l a c e t h e y h a v e f r e s h a i r . H e d o e s n t h a v e a n y t h y r o i d problems. Psychiatric Patient can manage the stress that his having now. In fact, he is a happyp e r s o n . He has a good memory and but he also tend to get nervous e a s i l y w h e n strange people like us talk to him and he tend to perspire more. PHYSICAL ASSESSMENT Date of Assessment: September 28-29, 2009Time of assessment: 05:45pmVital signs upon assessment:General Survey: Patient is awake appeared pale and his legs were numb and weak, patient lieson bed in a supine position. He appeared untidy with oily face, hair which is not properlycombed and tangled. Patient is coherent and responsive during our interview; he keepsin

smiling and felt shy to answer our questions. Ongoing IVF solution of D5IMB with thedrop rate of 15gtts/min, patently hooked at the right dorsal metacarpal vein. Integumentary System:Skin: Patient has a fair skin Good skin turgor noted Lesion noted in the lower extremities Scar noted at the left knee and left foot Dry skin notedHair: Hair is short, thick and reddish/brownish in color, brittle hair Doesnt use hair dyes No lice infestation noted Dandruff notedNails: Untrimmed, dirty nails on both fingers and toes Blanch capillary refill test <3 seconds Patients fingernails and toenails are thick Nails are convex with an angle at about 160 degrees Head, Eyes, Ears, Nose, Throat (HEENT)Skull and Face: Normocephalic and symmetrical with frontal, parietal, and occipital prominence Absence of nodules and masses upon palpation Can flex head without support

Facial features and movements are symmetricalEyes and Vision: Eyebrows are thin, but symmetrically aligned Frequent eye blinking No discharges, no discoloration and no masses noted Sunken eyes and eye bags noted Pupil Equally Round Reacted to Light and AccommodationEars and Hearing Auricles same color as facial skin, symmetrical and are aligned with outer canthus of eye Able to hear spoken words clearly Able to hear watch ticking in both ears Pinna is mobile, firm and not tender Pinna recoils after it is folded Presence of cerumen notedNose and Sinuses External nose has same color as facial skin except for same parts with smallpigments No discharges noted No tenderness and masses noted No sinusitis notedOropharynx (mouth and throat) Lips are pale and dry No swelling of the tongue noted

No palpable nodules Bad breath noted No bleeding and swelling of gums noted

Plaques on teeth noted No tonsillitis noted Gag Reflex notedNeck: Thyroid gland is not visible Patient can turn head left and right, up and down without pain No palpable nodulesThorax and Lungs No difficulty of breathing No abnormalities notedPosterior Thorax Normal curvature No tenderness upon palpation SymmetricAnterior Thorax Chest is symmetric Normal breath sounds noted No evidenced of any secretionsBreast and Axillae No discharges noted

Skin uniform in color, areola darken in color No evidence of enlargement of liver and spleen Audible bowel soundsMusculoskeletal System Limited movements in the lower extremities Weakness of his legs both right and left Tingling sensation, uncontrolled movements Numbness of the legs both right and left Patient didnt response to light touch Patient response to deep pressure only limited ability to perform gross/fine motor skills, difficulty turning his body slowed movement and uncoordinated movement postural instability, inability to maintain activity.Cardiovascular System No abnormalities noted Lub-dub sounds noted upon auscultation No edemaUrinary System Patient urinate 3x a day Patients urine is yellowish in color Gastrointestinal System

No vomiting No diarrhea No difficulty in swallowing Hard stool notedNeurologic SystemMental Status:Language Patient does not have any speech problems. He can understand and conversew e l l u s i n g B i s a y a d i a l e c t . H e u s e d n o n verbal communication such as eyem o v e m e n t s , g e s t u r e s a n d i n t e r a c t i o n w i t h t h e s u p p o r t p e r s o n . H e h a d a congruenc e of non-verbal and verbal expression.Orientation Patient is oriented to place, time and is able to answer our questions correctlyduring interview.Memory He has good memory and can recall what happened in the past.