WARD VISIT NUMBER: ___4___

GROUP NUMBER: ____5____

GROUP MEMBERS:
B3 FABITO
B7 DAGUIO
B31 LARA
DATE OF WARD VISIT: ______May 08, 2019____
DATE OF PATIENT’S ADMISSION TO THE HOSPITAL: ___ _April 30, 2019 __
DAYS/HOURS OF WARD STAY AT THE TIME OF HISTORY TAKING: ______ 8 days__________
I. CLINICAL HISTORY
A. General Data

Patient J.P.R. is an 8-day-old male infant, who was admitted for the first time at Gabriela Silang General Hospital
last April 30, 2019. He is a Roman Catholic, Filipino and currently resides at Cabaruan, Bantay, Ilocos Sur.

B. Source of Information and Reliability

Mother – 90%

C. Chief Complaint

Yellowish discoloration of skin

D. History of Present Illness

Patient was born term at 40 weeks gestation via normal spontaneous vaginal delivery after thirteen (13)
hours of labor to a 15yo G1P1 mother whose first prenatal visit was in the third month of her pregnancy. Patient
was meconium-stained upon delivery, but mother recalled hearing her baby cry. Patient’s weight was 3.5 kg and
seemed to be healthy until two days post-delivery when he started showing yellow discoloration of skin. Hence,
admission.

E. Past Personal History

i. Prenatal/Gestational History
Patient was born to a 15yo G1P1 (1001) mother, whose first prenatal check-up in the Rural Health
Center at Bantay, Ilocos Sur was in the third month of her unplanned pregnancy. Mother’s diet includes
vegetables, fish, meat, soft drinks (12 oz thrice a day) and junk foods. Mother’s prenatal screen was
unremarkable however her urinalysis revealed that she has Urinary Tract Infection (UTI) and was given
antibiotics (name unrecalled) taken thrice a day for seven days. She also took Ferrous Sulfate (dosage and
frequency unrecalled) and pampa-kapit (name, dosage and frequency unrecalled). She did not recall having
any other illnesses such as cough or colds. Mother denies exposure to radiation nor intake of teratogenic
agents.

ii. Perinatal/Natal/Birth history

Patient was born term at 40 weeks age of gestation via normal spontaneous vaginal delivery
(NVSD) after thirteen (13) hours of labor which was attended by Dr. Bautista. Mother remembered hearing
her child cry; birth weight was 3.5 kg.

iii.Postnatal/Neonatal history
Patient was born on April 30, 2019 at Gabriela Silang General Hospital. He was meconium-stained
upon delivery, but mother did not recall any resuscitative measures taken. Patient seemed healthy according
to the mother. No other congenital abnormalities or birth injuries noted.
 F. Feeding/Nutritional and Developmental History

Patient is breast-fed exclusively per demand up to present. He feeds around four (4) times a day every after
waking up. He is not taking any vitamins. Mother takes the main responsibility of care and feeding. Patient lies in
flexed position and turns head from side to side. Extremities are less flexed in supine position and arms are more
abducted.

G. Past Medical History

No past medical history to date. Mother denies any accidents or injuries, drug reactions and food or drug
sensitivities. This was the patient’s first admission after birth.

H. Immunization History

According to the mother, patient had not received any immunizations yet.

I. Family History

Father is Jerry Cordova, a 19yo mango vendor, healthy at present. Mother is Princess Diana Romero, a 15yo
Grade 9 student, also healthy at present. There is no history of consanguinity in the family. Paternal and maternal
grandfathers and grandmothers are all alive and healthy at present. There is no family history of diabetes,
hypertension, asthma, cancer, heart disease and tuberculosis.

J. Social, Economic and Environmental History

Patient lives with his unmarried father and mother in a house built on a rented land at Bantay, Ilocos Sur.
Mother stopped with her studies to take care of the patient. She is also not currently working outside of the home.
Patient’s father is a mango vendor at the market and the family depend solely on the father’s income. Water source
for drinking is distilled water and water for bathing and washing of clothes comes from poso. Their garbage is
collected weekly. There is a watermelon plantation near their house, but no environmental toxicants or occupational
hazards were noted.

K. Review of Systems

General: No fever, no recent weight change.

Skin: No rashes, lumps, sores or dryness. Skin peeling observed.
Head, Eyes, Ears, Nose, Throat (HEENT): Head: No history of head injury. Eyes: No excessive tearing. Nose: No colds,
nasal stuffiness or discharge. No history of epistaxis or nose bleeding. Throat: No history of bleeding gums.
Neck: No lumps or swollen glands. No stiffness of neck.
Respiratory: No cough or increased work of breathing. Mom notices patient sometimes breath fast then stops for a
few seconds, then breathes again. Never had a chest radiography (x-ray).
Cardiovascular: Never had an electrocardiogram (ECG).
Gastrointestinal: Frequency of bowel movement was unrecalled by mother.
Urinary: Patient uses 4-5 diapers a day.
Genital: No vaginal infections.
Neurologic: No seizures.
Hematologic: No easy bleeding or bruising.