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Date of Interview: July 29, 2016

Time of Interview: 8:30am


Informant: Mother
Reliability: 90%

General Data:
Our patient is Julie Anne Grepaldio, female, 48 hours old residing at #63 Sunflower Street, Brgy Batasan
Hills, Quezon City and a Roman Catholic. She was delivered in Quirino Memorial Medical Center on 27th of July
of 2016.

Chief Complaint:
Transferred from delivery room to rooming-in on July 27, 2016 for breastfeeding and new born screening
until the patient will be discharge.

History of Present Illness:


Birth History
The mother of the patient who is 38 weeks and 2 days AOG was referred by the Batasan Lying-in Center
to be admitted in Quirino Memorial Medical Center (QMMC) on July 27, 2016 at 11 o’clock in the morning with a
chief complaint of increased blood pressure of 140/110mmHg. Induction of labor was done. At 3:46pm, the
mother delivered a 3.5 kg well baby girl with good, strong cry and pink all over the body via normal spontaneous
delivery with no complications encountered. BCG and Hepa B were given upon birth. After birth, skin to skin
contact was immediately made. Within two hours, the patient was on her mother’s chest. Within one hour after
birth, initial breastfeeding was completed with good latching.

Prenatal History
The mother prenatal checkups were done once a month at Batasan Lying-in Center, seen by the resident
midwife. The following tests were done for the mother: CBC and urinalysis (March 2016) and ultrasound for three
times. The first vaginal ultrasound was last February 19, 2016; the second was abdominal ultrasound (unrecalled
when); and third ultrasound was last July 17, 2016. Tetanus toxoid vaccine was given to the mother. She took
ferrous sulphate as her supplement.

Maternal History
Mrs. Grepaldio, 27 years old is a G3P3 3003, married, plain housewife.
List of pregnancy Year Weight Outcome
st
1 child June 30, 2007 3.8 kg (8.4 lbs) NSD, home delivery
No complication
2nd child March 12, 2009 3.7 kg (8.2 lbs) NSD, delivered at lying in,
No complication
3rd child July 27, 2016 3.5 kg Premature

She is not smoking nor drinking during her pregnancy. She finished 3 boxes of maternal milk (Anmum).
Regular supplementation of ferrous sulfate was mentioned. From July 21, 2016, she started daily prenatal
checkups because of her increase blood pressure. No antihypertensive medication was given. There were no
exposures to any illnesses and teratogens during her pregnancy. Mother has positive attitude towards pregnancy
and the child upon giving birth.

Family History
Family history of hypertension, heart disease, diabetes and cancer of the breast, kidney and lung was
mentioned on the mother side. The patient’s father was known asthmatic.

Personal and Social History


The father of the patient is 29 years old who works as a security guard. The family composed of 5
members. They live in a two-storey house, first floor is concrete and second floor is made of wood, well-lit, well-
ventilated with two windows. Their drinking water source is from Maynilad. Their spiritual orientation is Roman
Catholic.
Review of Systems

Physical Examination

General Information:
Vital Signs
Weight: 3.5kg
Temperature: 36.5˚C
Pulse Rate: 138 beats/ mins
Respiratory Rate: 42 breaths/ min
Anthropometrics
Head Circumference: 36 cm
Chest circumference: 38 cm
Abdominal circumference: 35 cm
Length: 48 cm

General Inspection: Habitus appropriate for age, seated slouched at mother’s lap, calm, not in pain,
with spontaneous breathing,

Head: open anterior and posterior fontanel

Eyes : pupil equally reactive to light and accommodation, pink conjunctiva (-) for ptosis, (-) strabismus,
(-) paralysis, (-) corneal ulcers or opacities, anicteric sclera

Ears: (-) external canal for lesions or serous fluid

Nose: (-)nasal discharge, (-) foreign bodies, (-) purulent/ blood tinged drainage, (-) nasal flaring

Mouth: (-) pinkish mucous membranes, lips, gums and buccal area, (-) enanthema, uvula midline, (-)
enlarged tonsils, (-) exudates, (-) petechia, (-) vesicular or ulcerous lesions

Neck: (-) limitation of motion, (-) nuchal spasm or rigidity, trachea midline, (-) masses or swellings

Chest: shape and symmetry appropriate for age, symmetrical breast, areola follows skin contour of the
chest, symmetrical movement with respiration, (-) suprasternal, infrasternal or intercostal retractions

Lungs: vesicular on most of lung fields, (-) crackles, (-) wheezes, (-) rubs

Heart: regular rate S1, S2, (-) murmurs

Abdomen: abdomen flat, symmetrical, umbilical cord, normoactive bowel sounds, (-) palpable organs
or masses, (-) tenderness, (-) distension, (-) ascites, tymphanitic upon percussion

Genitalia:

Trunk and Spine: symmetrical, (-) spinal curvature

Extremities: (-) clubbing, (-) cyanosis, (-) venous engorgement, (-) nail abnormalities, (-) lesions of
skin, palms and soles, (-) edema, (-) haemorrhage, (-) contusion, full pulses, pink nailbeds, rapid
capillary refill

Skin:(+) rashes, good skin turgor, (-) edema, (-) erythema, (-) cyanosis, (-) pallor

Superficial Lymph Nodes: (-) lymphadenopathy

Neurological: intact cranial nerves, (-) clonus, (+) touch sensation, oriented to time, place and person,
full ROM, 5/5 motor strength, bilateral coordination of gait

Reflexes:
(+) Babinski reflex (both)
(+) Rooting reflex
(+) Suckling reflex
(+) Grasp reflex
(+) Moro reflex