Republic of the Philippines Form Code FM-MED-GEN-01

Department of Health
BICOL REGIONAL TRAINING AND TEACHING HOSPITAL Effectivity September 30, 2013
Legazpi City
Revision 0

ADMITTING HISTORY

SURNAME: MARTILLAN AGE: NEWBORN HOSPITAL NO.: 665521

GIVEN NAME: BABY BOY SEX: MALE WARD: NICU
EXTENSION
MIDDLE NAME: VERDEFLOR CS: - BED NO.: -

GENERAL CONDITION OF THE PATIENT

The patient is comfortable and not in cardiorespiratory distress

BRIEF HISTORY

The patient was born to a 24-year-old G1P0 mother with 10 prenatal checkups at 3 different health facilities
(Valenzuela, JBDAPH, San Vicente Health Station-Jovellar). During the course of pregnancy, the mother had Ferrous
Sulfate and Tetanus Toxoid Vaccine. No UTI and other maternal illnesses and infections were confirmed nor any exposure
to teratogens and radiation. 5 days prior to parturition, the mother was admitted at the OB department due to headache and
uncontrolled elevated BP. Upon admission, the mother tested positive for Hepatitis B infection. The mother was given
dexamethasone (4 doses), methyldopa, nifedipine, MgSO 4, paracetamol, CaCO3, FeSO4 and multivitamins. The mother’s
BP and condition was monitored as well as the patient’s fetal heart rate. 2 days prior to parturition, the mother cleared for
discharge and was advised for an induction of labor on August 11.
The patient was born preterm, 33 weeks by Ballard Score, with a birthweight of 1. 595 kg AGA, cephalic delivered
via normal spontaneous vaginal delivery with an Apgar score of 8,9. Aside from prematurity, the patient was noted with
shallow subcostal retractions hence admission to NICU extension for management.

PERTINENT PHYSICAL EXAMINATION

BW: 1.595 kg BL: 44 cm HC: 24 cm CC: 26 cm AC: 25 cm MAC: 8 cm

Cardiac rate: 140 bpm Respiratory rate: 49 breathes/min Temperature: 36.8 °C

The patient was noted with good cry and good activity. The patient has a normocephalic head with equally distributed hair.
No caput succedaneum and cephalhematoma was noted. There was symmetrical features (symmetrical nose, midline
septum, equal size and shape nares) and no deformities observed in the face of the patient. No eye, nose and ear discharge.
Abundant lanugo was present. No cervical lymphadenopathy and palpable mass on the neck. Shallow subcostal retractions
were noted. Clear breath sounds. No murmur. No fractures. No edema. Positive reflexes assessed were rooting, palmar and
plantar grasp, Moro and Babinski reflex.

ADMITTING DIAGNOSIS

Preterm, 33 weeks by BS, 1.595 kg BW, AGA, cephalic delivered via NSD, live baby boy, AS 8,9.