PATIENT’S HISTORY

I. General Data
Sanchez, Qyra Levinn 2 years and a half female born on August 27, 2018 and a resident of
Guadalupe Baybay City, Leyte. A Roman Catholic. Patient was admitted in Baybay Western
Hospital at January 17, 2020 and was referred to Eastern Visayas Regional Medical Center on
January 27, 2020 because of febrile seizure. Spread of red raised spots is apparent all around the
patient’s body. Bilateral pneumonia was revealed on xray.
II. Chief Complaint
Patient has productive cough and cold with fever and reported the spread of small red raised
spots that had started on the lower extremities. Patient was admitted to Baybay Western Hospital
because of fever and was referred to EVRMC because of seizure.
III. History of Present Illness
Prior to admission, patient had recurrent fever and cold in a span of 2 months. Patient had
never been admitted in a hospital before.
IV. Prenatal / Birth History
Born to a 39 year old G2P via NSVD cephalic. Patient was born healthy. Mother is a non-
smoker, non-alcoholic and had monthly prenatal check up with multivitamins taken. She received
TT immunization. The mother had pregnancy induced hypertension.
V. Immunization
Patient was fully immunized.
VI. Family History
The mother had a history of hypertension rooting from her father side.
VII. Environmental History
Patient’s drinking water is obtained from spring water. Pets is comprised of a cat and
livestock of chicken. Patient is free to play with the neighbouring children. Patient lives in a cement
house with adequate ventilation and has toilet bowl with a close-system drainage bathroom.