CLINICAL HISTORY

CHIEF COMPLAINT: Blood-tinged urine

HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY:

● No history of Measles, German measles, Mumps, and Chicken Pox
● No history of bronchial asthma
● No history of primary pulmonary tuberculosis
● No allergies
● No history of seizure
● No history of glucose-6-phosphate dehydrogenase deficiency
● (+) History of fall s/p surgery last March 2021
● (+) Hyperbilirubinemia upon initiation of breastfeeding in the first 2 weeks of life

FAMILY HISTORY:

NUTRITIONAL HISTORY:

The patient was not exclusively breastfed since birth. Breastfeeding was initially
attempted, but was shifted to S26. Breastfeeding was continued after resolution of
hyperbilirubinemia. At present, she prefers to drink milk, one and a half cups of rice with viand
each meal, and eats 3 meals a day.

IMMUNIZATION HISTORY:

VACCINE DOSE PLACE GIVEN

BCG 1 dose Health Center

Hepa B 3 doses Health Center

Hib 3 doses Health Center

OPV 3 doses Health Center

MMR 1 dose Health Center

Pneumococcal conjugate 1 dose Health Center

vaccine (PCV)

Varicella 1 dose Health Center

PERSONAL AND SOCIAL HISTORY:

The patient lives with her parents, both fully vaccinated with COVID vaccine. Patient has
no known COVID exposure and no other sick household members. They live in a well-lit, well
ventilated home. Garbage is segregated and collected thrice a week. Supply drinking water is
from Maynilad.Patient sleeps for more than 8 hours per day with noonday naps of 1 and half
hours per day. The patient has occupational therapy sessions twice a week and speech therapy
sessions once a week.

PHYSICAL EXAMINATION UPON ADMISSION:

General Survey: Awake, active, not in cardiorespiratory distress, with no signs of dehydration
Vital signs: BP: 90/60 mmhg HR: 103 bpm RR: 21 cpm T: 36.6 °C O2 sat: 98%
Anthropometric measurements: Weight: 11 kg Height: 92 cm (Z-score: +2 length for age)
BMI: 13 kg/m2 BMI for age: Underweight IBW: 16 kg
HEENT: Symmetrical facial features, no palpable mass, with 1cm healed linear scar on the
forehead. Hair is color black with normal distribution. Pink palpebral conjunctiva, white sclera,
pink turbinates, moist lips, moist buccal mucosa, pink pharyngeal walls

NECK: Supple, no palpable lymph nodes

CHEST/LUNGS: Symmetrical chest expansion, clear breath sounds, no retractions, good air
entry
HEART: Adynamic precordium, tachycardic, regular rhythm, no murmur
ABDOMEN: Slightly globular, soft, nontender, no mass, no organomegaly, with normoactive
bowel sounds
EXTREMITIES: full and equal pulses, CRT <2 seconds, with keratosis pilaris, dry rough skin.

NEUROLOGIC EXAMINATION
Cerebrum: Conscious, coherent, GCS 15/15
Cranial nerves:
I: Not assessed
II: 2-3 mm pupil equally reactive to light
III, IV, VI: Intact extraocular muscles
V: able to clench jaw
VII: No facial asymmetry
VIII: intact gross hearing
IX & X: uvula at midline
XI: able to elevate shoulders, can shrug both shoulders equally
XII: tongue at midline
Cerebellum: No nystagmus
Signs of meningeal irritation: (-) nuchal rigidity, (-) Kernig’s sign, (-) Brudzinski sign
Reflex: (-) Babinski reflex

Motor Function Sensory Function Deep Tendon Reflexes

5/5 5/5 100% 100% +2 +2

5/5 5/5 100% 100% +2 +2