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3D JC Pediatrics Group 5
I. Information Data
%Reliability: 85%
Patient Y.C., a 9-day-old, male, Filipino, Roman Catholic, from Basak Pardo, Cebu City. Born
on October 17, 2018 in St. Anthony Hospital. Admitted for the first time in Vicente Sotto
Memorial Medical Center last October 20, 2018 at 2 pm.
The mother is 31 years old, G1P1001, last menstrual period was on February 2,
2018. Her first prenatal checkup was at 4 months and was given vitamins and was
vaccinated with tetanus toxoid. She had her CBC and urinalysis done but did not
have an ultrasound. Last prenatal visit was at 8 months. She denies history of
hypertension, diabetes, and use of any medications.
b. Birth:
Based on the mother LMP (2/2/18) the patient was delivered preterm at 36 weeks
5/7 age of gestation and was attended by a physician. The patient was 2.5 kg at
birth.
c. Neonatal History:
The patient was noted crying upon delivery. No jaundice, hemorrhage, birth
injuries were noted. Properly sucked but minimal milk was produced by the
mother.
d. Feeding history:
Parents are separated which the mother did not elaborate. The mother is 31 years old,
jobless, and receives financial support from the patient’s father and her parents. She denies being
hypertensive, diabetic, and other heredofamilial diseases.
Patient was conscious and displayed a symmetric posture with flexed extremities
with active movements and good muscle tone. No gross congenital abnormities
noted. IV access on dorsum of right hand.
b. Vital Signs:
Weight: 2.5 kg
c. Anthropometric measurements
Chest Circumference: 30 cm
d. Skin:
Reddish brown, leathery texture and with good turgor. No rashes, edema nor
jaundice noted. Lanugo not seen.
e. HEENT:
Fine black hair evenly distributed throughout the head, symmetric with no
molding noted. Anterior fontanel approx. 2x2 cm, posterior fontanel was barely
palpated, both are not bulging nor sunken. Lids are open and slightly icteric
sclerae. Ears are soft and pliable with some cartilage and instantly recoil. Pinna at
the level of outer canthi of eyes. Nasal septum midline, no alar flaring, no
discharges, no tenderness over paranasal sinuses. Mouth pink, moist gums, intact
soft and hard palate, uvula midline, tongue moves freely, symmetrical with short
frenulum. Neck is short, thick, able to flex and extend but cannot support full
weight of the head, creased with skin folds, trachea midline, and thyroid gland not
palpable, intact clavicle.
g. Heart:
h. Abdomen:
i. Genitalia:
j. Anus:
k. Extremities:
Flexed, full ROM, symmetric, clinched fist, and flat soles with minimal creases. No
extra fingers nor toes, creases only anterior 2/3 on palm and sole. Even gluteal
folds.
X. Neurologic System:
a. Neuromuscular Maturity:
Posture: Legs are flexed
b. Reflexes