PEDIATRIC HISTORY & PHYSICAL EXAM

General Data:
J.C. a 2 days old premature neonate, male, Filipino, born in Camp Phillips Memorial
Hospital, currently residing in Barangay Lingion, Manolo Fortich, was admitted for the first
time at Northern Mindanao Medical Center on the evening of July 30, 2023.

Source of information is mother with 98% reliability

Chief Complaint:
“ Hospital transfer due to unavailable incubator from previous hospital”

History of Present Illness:

J.C. a 2 days old preterm infant was born at 36 weeks gestational age which was small for
gestational age with body weight of 1.49 kg, with an Apgar score of 9,10 was born to G1
mother via NSD, cephalad in Camp Phillips Memorial Hospital. The infant has been with his
parents since birth and has been doing well. The patient was referred to Northern Mindanao
Medical Center due to lack of an incubator in the previous hospital. Upon admission, the
patient was given IV fluids with 5% dextrose in 0.3% NaCl solution.

Past Medical History:

No past medical history to date.

Family History:
No history of paternal and maternal grandparents. Father is 31 years old and has a history of
tuberculosis. Mother is 33 years old and has a history of hypertension, stroke, diabetes and
arthritis. One brother, age 4 years old. Mother doesn’t smoke.

Birth History:
J.C. was born at 36 weeks gestation via normal spontaneous vaginal delivery to a 33 years
old mother G1P1.

Maternal History:
Mother was hypertensive during pregnancy and spotting was noted. The mother was given
dexamethasone during pregnancy and is also taking euthyrox 150 mg, amlodipine 10 mg
and methyldopa 250 mg.

Gestational Age:
Baby born at 36 weeks.

Feeding history:
J.C. was breast fed and was advised to breastfeed every 2 hours about 5 ml

Immunisation History:
At the time of birth, the patient was given;
● Vit. k
● Hep B
● BCG
Growth and development history:
Mother has bonded with her son taking the main responsibility of care and feeding.

Socioeconomic and Environmental History:

Lives with his mother and father and his 1 sibling in a one story house with 1 room and 1
CR. The father works as a pastor and the mother works as an auditor. Both have been
vaccinated with SINOVAC vaccine with both 1st and 2nd dose against COVID. Both parents
don't have booster shots. They are exposed to poultry.
Physical Examination:
General Data:
● Examined awake, not in respiratory distress, irritable, ill looking, lying in bed. The
baby is alert and responsive

Vital Signs:
● BP: not taken
● HR: not taken
● RR: 42 bpm
● T: 34.7 C
● O2 stat: not taken

Anthropometric Data:
● Wt.: 1.4 kg
● Length: 38.5 cm
● Head Circumference: 28 cm
● Abdominal circumference: 30 cm
● Z scores: -7.6

Skin:
● The skin is pinkish and slightly yellow in colour representing jaundiced, no visible
lesions but presence of slight rashes in face and arms. Skin is warm in touch, with
good turgor.

HEENT:
● Head: microcephalic, atraumatic, anterior fontanel and posterior fontanel slightly
depressed.
● Eyes: Pupils equal, round and reactive to light. Extraocular muscles appear intact but
the patient is too young to cooperate with the exam. No discharge, conjunctivitis or
scleral icterus. No ptosis. Patient focuses briefly on the face.
● Ears: clear external auditory canals. Pinnae are normal in shape and contour. No
preauricular pits or skin tags. No erythema or bulging.
● Nose: Normal pink mucosa. No discharge or blood visible, nasal flaring. Normal
midline septum
● Mouth and Throat: Moist mucous membranes but without lesions. Gums appear
healthy. No evidence of a cleft or any abnormalities. No signs of inflammation or
infection in throat. Lymph nodes in the neck are not enlarged.

Neck:
● Grossly non-swollen. No tracheal deviation. No decrease in range of motion. No
lymphadenopathy, goitre or masses detected.

Chest & Lungs:

● Inspection:
○ The chest is symmetrical and without deformity. No lesions, lumps and
masses were noted.
● Palpation:
 ○ The chest is soft and nontender. There are no masses or tenderness. The
chest expands equally on both sides when the baby breathes in.
● Percussion:
○ Not taken
● Auscultation:
○ Normal findings with lungs resonant bilaterally. There are no wheezing,
crackles, or other abnormal breath sounds.

Cardiovascular:
● Inspection:
○ The chest is symmetrical and without deformity. Normal findings.
● Palpation:
○ There are no palpable masses or thrills
● Auscultation:
○ The heart sounds are clear and regular. There are no murmurs, gallops, or
rubs.
● Percussion:
○ Not taken

Abdomen:
● Inspection:
○ The skin is warm in touch, no any bruises, erythema or contours but noted to
be jaundiced. No discharge or foul smell.
● Auscultation:
○ Bowel signs are present and active and normal. There are no bruits or other
abnormal sounds.
● Percussion:
○ Not taken
● Palpation:
○ Soft, non tender and non distended. No palpable masses.

Genitalia:
● Unable to check the genitalia
Back:
● Straight, no lordosis, no kyphosis. No sacral dimple and no hair tuft.

Extremities:
● Warm, no clubbing, cyanosis or edema. No gross deformities. Good skin turgor.

Neurological:
● Mental status:
○ Patient was asleep, but easily arousable, and irritable.
○ Moves all extremities symmetrically, appropriate tone
● Motor:
○ No spasticity and flaccidity. All reflexes were normal and . Normal su
● Cranial nerves:
○ CN I not taken
○ CN II can focus on face briefly
○ CN III, IV, VII unable to tell if eyes move in all directions
○ CN V corneal reflex deferred
○ CN VII symmetrical facial expression, closes eyes forcefully
○ CN VIII startles to clap
○ CN VII, IX, X, XII not taken
○ CN XI deferred