JOSE R.

REYES MEMORIAL MEDICAL CENTER

Rizal Avenue, Sta. Cruz, Manila
DEPARTMENT OF PEDIATRICS
CLINICAL HISTORY FORM

INFORMANT: Celine Lestujas 80 % RELIABILITY

GENERAL DATA
Name: Dwayne Villamor Age/ Gender: 24 days old, Male Nationality: Filipino
Religion: Roman Catholic Date of Birth: September 28, 2017 Place of Birth: Malabon
Number of Admission at JRRMMC: 2 Date of Admission: October 23, 2017

CHIEF COMPLAINT: Cough

HISTORY OF PRESENT ILLNESS:
10 days prior to admission, patient went to ER-JRRMMC due to cough, colds with associated difficulty of
breathing and was subsequently admitted. Patient was admitted at Pediatric ward for 1 week wherein patient
underwent antibiotic treatment (Ampicillin IV for 7 days) and nebulized with Salbutamol. Patient improved
and was later on discharged but still with cough with no other accompanying symptoms.
2 days prior to admission, still with cough, now with associated undocumented fever, and the mother
noticed gasping episodes of the patient. Patient medicated with Disudrin which provided temporary relief.
1 day prior to admission, still with above symptoms, now with accompanying retractions. Persistence of
the symptoms prompted the mother to sought consult at our institution and was later on admitted.

PAST MEDICAL HISTORY

Common Diseases (Indicate age at diagnosis)
(-)Measles (-)Chickenpox (-)Mumps (-)Roseola
(-)Rubella (-)Diarrhea- twice
Previously admitted at JRRMMC in October of the current year with the chief complaint of cough
Specific Allergies : none
Pulmonary Tuberculosis: none Chest Xray : (-) PPD: (-)
Drugs and duration of treatment: Ampicillin IV for 7 days (unrecalled brand and dosage)
Deworming (indicate age): none

FAMILY HISTORY
Paternal Age: 23 y/o Health Status: apparently well
Maternal Age: 18 y/o Health Status : apparently well
Siblings (in chronological order, indicate gender, age and health status): patient is the first-born child

Hereditary/ Familial Diseases (indicate relationship to parents)

(-) Allergy
(-) Tuberculosis
(-) Hypertension
(-) Diabetes Mellitus Paternal side
(-) Heart Disease
(-) Seizure Disorder

Father: Educational Attainment: High school graduate Occupation: Merchandiser

Mother: Educational Attainment: College undergraduate Occupation: Housewife
Residence and Community : well ventilated No. Of Occupants: 10
Source of Water for Drinking: Water refilling station Toilet Facility: Pour-flush type
Garbage Disposal: every 3 days disposal
Prevalent Disease in the Community: cough and colds
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 JOSE R. REYES MEMORIAL MEDICAL CENTER
Rizal Avenue, Sta. Cruz, Manila
DEPARTMENT OF PEDIATRICS
CLINICAL HISTORY FORM

PRENATAL HISTORY
Circumstances of Pregnancy: Wanted
Prenatal check ups: regular check-up at a local health center with whom/ where: Health center
Maternal illness : none
Medicines Taken: Ferrous sulfate
Exposure to Radiation/ Teratogens : (-)

BIRTH HISTORY
G1P1 (1001)
AOG: 39 weeks Manner of delivery: NSD Place of Birth: Malabon Lying-in
Who Assisted Delivery: Midwife Birth Weight: unrecalled APGAR Score: unknown

POSTNATAL HISTORY
Unusual signs/ symptoms : none
Medicines : none
Congenital Defects :none
FEEDING HISTORY
(+) On Demand
Breast feeding up to: present Bottle feeding started: 2 days post-delivery
Formula: Nestogen
Reasons for not breastfeeding : occasional unavailability of the mother
Solid foods started at : (-)
Current Food preferences: none
Vitamins/ mineral supplements: Tiki-Tiki taken every day

IMMUNIZATION HISTORY
Hepatitis B, BCG vaccine
Where were the vaccines administered? At the Barangay Health Center

REVIEW OF SYSTEMS
GENERAL: (-) chills (-)malaise
INTEGUMENTARY: (-)discoloration (-)lesions (-)pruritus
HEAD AND NECK: (-)lesions (-) diplopia (-)ear pain (-)sore throat (-)disturbance of taste
Respiratory System: (-) back pain (-)cough
Cardiovascular System: (-)PND (-)easy fatigability
Gastrointestinal Tract: (-)dysphagia (-)odynophagia (-)odynophagia (-)hematemesis
(-)hematochezia (-)hemoptysis
Genito-urinary Tract: (-)dysuria (-)anuria (-)polyuria (-)hematuria (-)incontinece
(-)discharges (-)flank/suprapubic pain (-)dribbling (-)urinary frequency
Hematologic: (-)easy bruisability
Endocrine: (-)polyuria (-)heat/cold intolerance
Neuropsychiatric: (-)syncope (-)paralysis (-)depression (-)loss of memory (-)delirium
(-)hallucinations (-)tremors
Neuromuscular System: (-) muscle pain (-) atropy (-) joint pain (-) back pains
(-)involuntary muscular movement

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 JOSE R. REYES MEMORIAL MEDICAL CENTER
Rizal Avenue, Sta. Cruz, Manila
DEPARTMENT OF PEDIATRICS
CLINICAL HISTORY FORM

PHYSICAL EXAMINATION
General Survey: asleep, not in cardiorespiratory distress
Vital signs: HR: 143 bpm RR: 35 bpm Temperature: 36.7 O2 sat: 98%
Anthropometric measurements
Actual weight: kg
Length/ height: 49 cm
HC: 48 cm, CC: 53 cm, AC: 46 cm
BMI: 9.8 kg/m2

HEENT
Head is normocephalic, anicteric sclera, pink palpebral conjunctiva, (-) nasoaural discharge, (-)
tonsillopharyngeal congestion, (-) cervicolymphadenopathy.

Chest and Lungs

No mass, no lesions, no visible subcutaneous vessels, no nodules, no hypo/hyperpigmentation,
symmetrical chest expansion, (-) lagging, (+) crackles

Heart
No mass, no lesions, no visible superficial veins, no nodules, adynamic precordium, apex beat at
5th left intercostals space midclavicular line, (-) murmur

Abdomen
Flat, normoactive bowel sounds, soft, non-tender

Extremities
No gross deformities, no edema, (-) for cyanosis, full equal pulses

IMPRESSION:

__________________________________ Francisco Gabbac III October 23, 2017

Resident In-Charge Clerk on Duty Date Accomplished

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