COMPLETE HEALTH HISTORY/PHYSICAL EXAM

Biographical Data
Initial: Y.V.P

Age: 5 weeeks

Gender:_Female

Race/Ethnicity: Hispanic
Living situation: Living with biological parents and maternal grand mom, safe physical
environment, no pets at home, dad is employed, mom is un-employed, stay home mom to care
for pt.
Informant & Reliability: Information provided by biological mom and medical records from
Johns Hopkins NICU.
The reason for the visits (CC): H&P and f/u NICU discharge
PMH- mom was late in starting prenatal care, born at 39 weeks and 5 days to a 41 yr old gravida
2 para1001, admitted to Johns Hopkins NICU for respiratory support and cleft lip and palate
evaluation. Poor Apgars;1, 6 at one and five minutes. CPAP was started at about 4 minutes of
life for respiratory support.
Screenings; Blood type B+, antiboby neg, Direct Coombs neg, PKU screening x4 in the NICU
Birth wt; 3500gms, head circ; 36cms, Length; 50cms.
HPI: Elevated BP with a dx of hypertension, bilateral hydronephrosis, urogenital fistula with
urethra reflux (requires straight catheterization 2x/day), unilateral Cleft lip and palate, requires
specialized nipple for feeding due to cleft lip/palate.
Drugs/Medication:
Currently on 1. Amoxicillin 125mg/5ml, 2ml by mouth daily for prophylaxis,
2. Amlodipine0.18mg by mouth QHS
Allergies: NKA

Family hx/Genogram
Maternal grandparents:
MGM: Alive
MGF:Alive
Paternal grandparents: expired
Mother: Alive, was late n seeking prenatal care
Father: Alive
Siblings: 1 boy, age 3
Diabetes: no

Anemia: no

Heart Disease: yes

Allergies: no

High BP: MGM

High Cholesterol: MGF

Asthma: no

Headaches: no

Cancer: no

Kidney disease: no

Seizures/ Epilepsy: no

Arthritis: no

Tuberculosis: no

Mental Health Problems:no

Alcoholism: Dad

Thyroid:no

Overweight: Mom

Other problems not mentioned: no

Stroke: PGF

Review of system
V/S BP=102/66, P= 140, RR=40, T=37.2 C, wt= 3.8kg, head circ=36cm, length= 51cm
GA: Dressed appropriately for the weather, clean
Skin: smooth, clear, warm, moist, elastic with immediate recoil, no lesion, no edema, hair is
smooth, shiny, evenly distributed, no infestation; nails smooth, pink, cap refill< 3 secs
H normacephalic, anterior & posterior fontanel open/soft, no depression, no bulginess, poor head
control,
E: PERRL, positive red reflex
E: auricles aligned &symmetrical, TM pearly gray bilaterally
N: unilateral cleft lip and palate, no nasal septum, no lesions
T: deformed rt sided gum due to cleft palate, poor swallowing reflex, requires special nipple for
feeding

Neck/Lymph: supple, trachea midline, no nodes, thyroid not palpable

Respiratory: good air exchange, bilateral lung sounds clear, irregular pattern
Cardiovascular: RRR, S1S2, no murmurs
Gastrointestinal Tract: Abd soft, round, non-distended, positive bowels sounds, no
organomegaly, peri
Urinaryl/Renal: requires straight catheterization BID due grade 1 ureteral reflux / leakage of
urine from bladder to the vagina according to Hopkins VCUG report. (Dx of Bilateral
hydronephrosis/hydroureter)
No visible external vaginal abnormality noted.
Musculoskeletal/Joints/Extremities: bilateral equal muscle strength, spine aligned, no
deformities, unremarkable
Neurological: within normal limit (crying, moving extremities appropriately)
Upcoming F/U: follows up with Johns Hopkins for special child care
Cleft lip and palate repair with plastic surgeon in 3 months,
Urology f/u for urogenital fistula repair