JOSE R.

REYES MEMORIAL MEDICAL CENTER

Sta. Cruz, Manila
DEPARTMENT OF PEDIATRICS

CLINICAL HISTORY FORM

INFORMANT: Salmingo, Amy (Mother)

RELIABILITY: 90%

GENERAL DATA
This is a case of baby boy S.A. , newborn, full-term, Filipino, born on March 7, 2017 at
JRRMMC currently residing at Manila who was admitted for the first time in our institution on
March 11, 2017.

CHIEF COMPLIANT
Jaundice

HISTORY OF PRESENT ILLNESS

Patient is a term, live baby boy 32 3/7 weeks by LMP, 37 weeks by BS, delivered via
NSD to a 34 year old G5P5 (5005) mother who had 6 times prenatal check-up at a local
health center. Patients mother was prescribed with multivitamins, Ferrous sulphate, Calcium
as her prenatal medications with a good compliance. Patients mother denies any illnesses
during course of pregnancy. No diabetes, thyroid or heart disease or other heredofamilial
diseases. Few hours prior to admission patients mother experienced hypogastric pain with an
urgency of defecating and sensation of the babys head protruding out of the vagina, the
patient was delivered at home and within 1 hour patients mother was rushed to OB-GYNE ER
of JRRMMC where cord clamping and cutting was done.
Upon birth, patient was dried thoroughly, skin to skin contact and early breast feeding
was initiated. Patient is a Full Term live baby boy, with 32 3/7 weeks AOG by LMP and 37
weeks by BS, HC 31.5 cm, CC 31 cm, AC 27 cm, BL 50 cm, BW 2300 g. Patient had was
apparently well with a good cry, good activity and good suck until the 2 nd day of life when the
patients mother noticed yellowing of skin on the face and chest area which progressed up to
the ankles on the 4th day of life. Bilirubin profile was done which revealed elevated total
bilirubin (19.10 mg/dl) interpreted as high risk zone. Hence the patient was admitted to NICU
for further evaluation and management.

FAMILY HISTORY
Paternal age: 33 years old Highschool Graduate HEALTH STATUS:
Currently well
Maternal age: 34 years old Highschool under Graduate HEALTH STATUS:
Currently well

HEREDOFAMILIAL DISEASES
(-)Hypertension (-) Allergy (-) Goiter (+) Asthma
(-)Diabetes (-) PTB (-) Cardiac disease

PHYSICAL EXAMINATION
General Survey Good, not in cardio respiratory distress
Vital signs: HR 140 bpm RR 44cpm Temperature 36.9C

Anthropometric measurements
Actual weight: 2300g
Length: 50 cm
HC: 31.5 cm

February 1, 2015 JRRMMC-F-PED-IIH-10

Revision No: 0
 JOSE R. REYES MEMORIAL MEDICAL CENTER
Sta. Cruz, Manila
DEPARTMENT OF PEDIATRICS

CC: 31 cm
AC: 27 cm

HEENT
(-) Caput Succedaneum, Pink palpebral conjunctivae, anicteric sclera, PERRLA, pinkish
nasal turbinates, no alar flaring No aural discharge, no tonsillopharyngeal congestion,
no circumoral cyanosis, pinkish lips

Chest and Lungs

Symmetrical chest expansion, no retractions, no lagging, (-) crackles on both
lung fields, clear breath sounds

Heart
Adynamic precordium, normal rate, regular rhythm, no murmur

Abdomen
Globular abdomen, normoactive bowel sounds, non-tender to palpation, liver and
spleen non palpable, no shifting dullness

Extremities
Grossly normal extremities, no cyanosis, no edema, full and equal peripheral
pulses

Skin
Dry, cracked, wrinkled, (+) Jaundice up to ankles, no pallor no active lesions, CRT
<2 seconds, good skin turgor

IMPRESSION: New Born full term, Live baby boy, Non-institutional delivery 32 3/7
weeks AOG by LMP, 37 weeks AOG by BS, delivered via NSD at home to a 34 year
old G5P5(5005) mother with HC 31.5 cm, CC 31 cm, AC 27 cm, BL 50 cm, BW 2300
g, AGA ; Hyperbilirubinemia probably secondary to breastfeeding jaundice

_________________________________ March 12, 2017

Resident In-Charge Date Accomplished

February 1, 2015 JRRMMC-F-PED-IIH-10

Revision No: 0
 JOSE R. REYES MEMORIAL MEDICAL CENTER
Sta. Cruz, Manila
DEPARTMENT OF PEDIATRICS

February 1, 2015 JRRMMC-F-PED-IIH-10

Revision No: 0