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JOSE R.

REYES MEMORIAL MEDICAL CENTER


RizalAvenue, Sta. Cruz, Manila
____________________________________________________________________________
DEPARTMENT OF PEDIATRICS
CLINICAL HISTORY FORM

INFORMANT: Eleanor D. Beluang, Mother

GENERAL DATA
Name: Beluang Baby Girl Age/ Gender Newborn/F Nationality: Filipino
Religion: Roman Catholic Date of Birth: 10/12/2017 Place of Birth: JRRMMC
Present Address: Blk 106 Lot 24 Phase 4 Mabuhay City, Subdivision, Dasmarinas, Cavite
Number of Admission at JRRMMC: 2nd Admission Date of Admission: 10/12/2017

CHIEF COMPLIANT: Prematurity at 34 weeks

HISTORY OF PRESENT ILLNESS

The patient is a preterm baby girl, with BS of 34 week, AS 6,8,9 HC 28 cm, CC 24 cm, AC 30.5 cm,
BL 41 cm, BW 1260 g, SGA. Patient was , delivered via Low transverse Ceasarian Section seconary to Non-
reassuring Fetal Heart Tone to a 26 year old Gravida 3 Para 2 (1202) mother. Upon birth, the patient is
clearly stained with normal amniotic fluid amount, appearing with some flexion of the extremities, without
immediate cry andwith slow irregular breathing pattern, with good cardiac activity, patient appeared with
pink body and blue extremities. Patient had an APGAR score of 6 on the 1st minute, 8 on the 5th minute and 9
on the 10th minute hence admission for close monitoring.

The patients mother had regular prenatal check- ups, with more than 6 consults from De Lasalle
University Medical Center. Patient has a history of Gestational Hypertension which were diagnosed on her
1st and 2nd pregnancies. During her 1st trimester, patient was prescribed wit Multivitamins, Ferrous sulfate,
calcium carbonate, Methyldopa aspirin. Patient also had a history of vaginal bleeding during 2 nd trimester.
The patients mother sought consult at JRRMMC OB due to financial constraints.

Upon birth, the patient had poor to fair activity and cry, limp, and was acrocyanotic. Thorough
drying, continuous stimulation, and suctioning of secretions was done with the patient eventually presenting
with fair muscle tone and decreased retractions. Drying and stimulation was continued and patent was
hooked to O2 support via nasal cannula at 1- 2 lpm and the patient was then admitted.

FAMILY HISTORY
Maternal Age: 26 y/o Health status: (+) Hypertension maintained on Methyldopa

HEREDOFAMILIAL DISEASES
(+) hypertension paternal and maternal (-) Asthma (-) PTB
(-) Diabetes (-) Allergy

SOCIAL HISTORY
Mother: Single, college graduate, employed as a teacher, currently living in for 3 years with a 28 years old, auto
detailer

JRRMMC-F-PED-IIH-10 August 10, 2015 Revision No.: 0 Page 1 of 2


JOSE R. REYES MEMORIAL MEDICAL CENTER
RizalAvenue, Sta. Cruz, Manila
____________________________________________________________________________
DEPARTMENT OF PEDIATRICS
CLINICAL HISTORY FORM
PHYSICAL EXAMINATION
General Survey: Poor cry, poor activity, good cardiac activity
Vital signs:
HR: 140s O2 Sat: 95%
RR: 40cpm Temperature: 36.4 C
Anthropometric measurements
HC: 28 cm
CC: 24 cm
AC:30.5 cm
BL: 41 cm
BW: 1260 g
Skin
Pink, No lesions, No masses soft, warm to touch
(-) Jaundice, (-) pallor, (-) cyanosis
CRT: less than 2 seconds with good skin turgor

HEENT
Pink palpebral conjunctiva, Anicteric sclera, Both eyes are reactive to light. No nasal and aural
discharge, No alar flaring, No circumoral cyanosis. No cleft lip and no Cleft plate.

Chest and Lungs


Symmetrical chest expansion, (+) subcostal retractions, no crackles, Clear breath sounds

Heart
Dynamic precodium, Tachycardic with regular rhythm, (-) murmur

Abdomen
Globular, soft, non-tender, non- distended

Extremities
No deformities, no cyanosis, (-) edema, good muscle tone, good grasp

Genitals
Grossly female without vaginal discharge, patent anus

IMPRESSION: Newborn, preterm, live baby girl of Beluang, Eleanor, 29 1/7 weeks AOG by LMP, 34 weeks
by Ballard score, delivered via Low transverse Ceasarian Section seconary to Non-reassuring Fetal Heart
Tone to a 26 year old G3P3 (1202) mother with APGAR score 6,8,9 Head circumference 28 cm, Chest
circumference 28 cm, Abdominal circumference 24 cm, Birth length 41 cm, Birth weight 1260g, Small for
Gestational Age.

__________________________________ ________10/13/2017________
Resident In-Charge Date Accomplished

JRRMMC-F-PED-IIH-10 August 10, 2015 Revision No.: 0 Page 2 of 2