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Neonate PE and HX

Date post: 17-Aug-2015
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Historian: Rikki Kent D. Ba-aco Medicine IIA | SGD 1 I. GENERAL DATA Informant: Hermilyn Joy Bernal, 23 Relationship to Patient: Mother Reliability: 99% Name of Patient: Rhayen Bernal Age: 6 days old Sex: F Civil Status: New Born Date of Birth: July 9, 2015 Time of Birth: 6:51 pm Birthplace: WVSU Medical Center Address: Oñate, Mandurriao, Iloiolo Religion: Roman Catholic Nationality: Filipino Ward: Step-Down NICU Historian: MED 2A, Group 1 Date History Taken: July 14, 2015 II. CHIEF COMPLAINT Fever III. HISTORY OF PRESENT ILLNESS Prenatal This is the mother’s second pregnancy having an OB score of G2P1 (1001)prior to delivery. She discovered that she was already pregnant when it was about 2 months through a positive pregnancy test. However, after 2 weeks of delayed menstrual period, she already experienced fatigue, nausea and vomiting that lasted until 3 rd month AOG. She had her first prenatal checkup at 3rd month AOG at their barangay health center. The succeeding checkups were conducted once every month until the 7th month, and twice starting at the 8 th month at WVSU Medical Center. She had 8 prenatal checkups prior to delivery.
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Historian: Rikki Kent D. Ba-acoMedicine IIA | SGD 1I. GENERAL DATAInformant: Hermilyn oy Bernal! "#Relations$i% to &atient: Mot$erRelia'ility: (()*ame of &atient: R$ayen BernalA+e: , days oldSe-: ./i0il Stat1s: *e2 BornDate of Birt$: 1ly (! "3145ime of Birt$: ,:41 %mBirt$%lace: 67S8 Medical /enterAddress: 9:ate! Mand1rriao! IloioloReli+ion: Roman /at$olic*ationality: .ili%ino6ard: Ste%-Do2n *I/8Historian: M;D "A! Gro1% 1Date History 5aken: 1ly 11331?%rior to deli0ery.S$edisco0eredt$ats$e2asalready%re+nant2$enit2asa'o1t"mont$st$ro1+$a%ositi0e%re+nancytest. Ho2e0er! after "2eeksofdelayedmenstr1al%eriod! s$ealready e-%erienced fati+1e!na1seaand0omitin+t$at lasted1ntil #rdmont$A9G. S$e$ad$er @rst %renatalc$eck1% at #rd mont$ A9G at t$eir 'aran+ay $ealt$ center. 5$es1cceedin+c$eck1%s2erecond1ctedoncee0erymont$1ntil t$eAt$mont$! and t2ice startin+ at t$e Bt$mont$ at 67S8 Medical /enter. S$e$ad B %renatal c$eck1%s %rior to deli0ery. D1rin+ t$e "33"?.IV. FAMILY HISTORY5$is is t$e mot$er=s second %re+nancy. S$e $ad $er @rst %re+nancy


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