Informant:  Patient  Mother  Father  Other: _____________ KYLE CHRISTOPHER SIA CIM-III SY 2014-2015

% reliability: __________

PATIENT’S PROFILE
 Patient’s name ______________________________________________  Number of times admitted ____________________________________
 Age ______________  Hospital __________________________________________________
 Sex  Male  Female  Date admitted ______________________________________________
 Nationality  Filipino  Other: ______________________________________  Chief complaint _____________________________________________
 Religion  Catholic  Jehovah’s  Other: ______________________
 Birthdate _____________________________________________ Ex. Q.Z. a 2 year old female Filipina catholic born on 1/1/1, currently residing in Ramos, was
admitted for the 2nd time in CVGH on 1/2/3 due to high fever.
 Address _____________________________________________

PAST MEDICAL HISTORY

Prenatal History
Mother’s age during pregnancy: _____ Immunization / vaccination received during pregnancy:
OB score during pregnancy: G___T___P___A___L___  Previous CS TT vaccine status:
Blood type: A B  AB O RH: + / – Doses: _________________________
1st prenatal checkup… When: ______________________________ When given: ____________________
 Health Center  Private Clinic Others: _______________________________________________
 Regular /  Infrequent ______________________________________________________
Ex. Mother was 35 years old with an OB score of G8P7 5116 at time of pregnancy with no
 Monthly/ _________________
previous CS. Blood type is O+. Her first prenatal checkup at 5 months AoG and had regular
monthly check up there after. Received 1 dose of TT during 1 st PNC. …

Vitamins / supplements [Rearrange in chronologic order]

Starting when? Dose Duration/ Compliance
 NONE
wk AoG/ mo AoG / Trimester Tab/cap/mL/ OD/BID PO Until when? Good Poor
 Folic acid
 Iron
 Multivitamins


…At 5 months AoG, during 1st PNC, mother started taking iron supplement 1 tab OD every day until delivery with good compliance…
General condition of the mother during or since before pregnancy [Rearrange in chronologic order]
Dose Compliance /*Note if relevant*/
 NONE Since when diagnosed? Any medication?
Amt/Vehicle/freq per day/route Good Bad
Highest: _____ Usual: _____
 Hypertension  Controlled? Other s/s?
Labs during PNC? ---------------------
Highest: _____ Usual: _____
 Diabetes  Controlled? Other s/s?
Labs during PNC? ---------------------
 Asthma Freq of attack? : __________

…Mother has hypertension, since diagnosed on 2000, but was controlled throughout pregnancy by taking captopril of unrecalled dose with good compliance. Highest BP was 130/90mmHg…
Previous hospitalizations / surgeries during pregnancy NOTES ---
Date Diagnosis Duration Compliance
Treatment
Month/Trimester of admission Good Poor

…On 1999 mother had an ectopic pregnancy which resulted in the removal of her right fallopian tube. She was hospitalized for 1 week and discharged in good condition. No take home meds were given…
Previous illnesses/infections [toxemias] during pregnancy
[Rearrange in chronologic order]
When? Dose Duration/ Compliance
 NONE Any medication?
wk AoG/ mo AoG / Trimester Amt/Vehicle/freq per day/route until when? Good Poor
 UTI

 Fever

 Cough/coryza

 Rashes


…At 8 months AoG, upon PNC, it was found out that she had asymptomatic bacteriuria. She was prescribed with unrecalled antibiotic but took it for 7 days with good compliance. Condition improved…
 NON Alcoholic / how much and often: _____________________________  Bleeding  Threatened abortion  Exposure to X-ray
 NON Smoker / how much and often: ______________________________
…mother is a non-alcoholic and a non-smoker. No history of bleeding during pregnancy.
Natal History
Age of gestation: ____ weeks  full term  preterm  post term Resuscitation  No  Yes Ex. Q.Z. was delivered term [38weeks] via NSVD with no
induction done at CCMC assisted by an OB after 2 hours of
Pallor/Blue  No  Yes labor. Had good cry and no immediate complications. Birth
Type of delivery:  NVD  pCS  rCS  VBD Meconium staining  No  Yes weight was 4kg. eye ointment, vit K, hepB, and BCG were all
Cord coil  No  Yes given. Birth rank is 7/7.
With [no] induction [of]  PGE1  Oxy Convulsions  No  Yes
With [no] augmentation [of]  Amnio  Oxy  Forceps Congenital defects  No  Yes
Notes:
Setting:  Home delivery  Health Center  Specify: Birth weight: __________
 Lying-in clinic  Hospital delivery ___________ Birth Height: __________

Assisted by:  OB  Nurse  Midwife  TBA Eye ointment  YES  NO

Vitamin K  YES  NO
After [duration of labor] __________ HepB  YES  NO
BCG  YES  NO
APGAR score _____ or Good cry  YES  NO
Jaundice  No  <24 hours Birth rank

Postnatal History
Duration of stay in hospital: __________ days/hours
Newborn screen:  YES  NO Results:  Pending  Normal  Abnormal: _______________
Blood type: A B  AB O RH: + / –
Jaundice  No  more than 24 hours  Phototherapy  Discharge with outcome good
Ex. Q.Z. stayed in the hospital for 2 days. Newborn screening was done and came out negative. Blood type is O+. Was not jaundiced after 24 hours…
Exclusive Breastfeed / until when / Water / Weaned / Introduce solid / Mixed feed / Dilution / Vitamins / Supplements

…Q.Z. was exclusively breastfed up to 6 months of age. Solid foods, starting with Cerelac, were introduced at 6 months. She was weaned off from breast milk at 1 year of age. No multivitamins were given…
Immunizations

…Mother claims full immunization coverage for 1 year of age was given at local health center… OR …Immunization status are as follows: BCG, HepB3, IPV3, DTaP3, MMR2, HiB3, Rota1 etc….
Allergies or other health conditions / diagnosed when / Maintenance medication – dose

…She is allergic to shrimps, oysters, crabs, and other crustaceans…She is also asthmatic, was diagnosed at 1 year of age, and is currently managing it using ICS during bouts of attack…
Developmental milestones
Gross Fine Language Social Cognitive
Rolls back to stomach Reaches for object Babble Smile Stare at own hands
Sits without support Transfer objects from hand to hand Mama dada Laughs Uncovers
Stand alone Turn pages of book Points to object Respond to name Pretend play
Walks alone Scribbles 1st real word Bye-bye
Runs Write alphabet 2 word sentence
…At 6 months of age she was able to sit without support, at 8 months of age she was able to say mama, at 1 year old she was able to walk, at 1 ½ years she was able to run, and recently she is able to…
Childhood illnesses / Hospitalizations / Other medical conditions
Chicken pox Measles Mumps Rubella Dengue Dog bites
Recurrent sore throat Infected wounds
Fractures Concussion Contusion Falls
…She recently had chicken pox 3 weeks ago. No other childhood illnesses experienced…
[Rearrange in chronologic order following format]
5/7
1 3 Treatment during 8
Date 2 Duration of stay 4 Compliance 6
Hospital Diagnosis admission/Take home meds Outcome
Year-Month-Date Days/Weeks
Dose & Duration Good Poor

…She was hospitalized on Jun 2001 in CVGH for 1 week due to PCAP C, was discharged in good condition, and take-home-medications of unrecalled classes and doses were taken with good compliance…
NOTES
PERSONAL-SOCIAL HISTORY
Number of people in house? ______________
Anyone ill? __________________________
Symptoms: __________________________
Close contact to animals?  No  Yes
What animals/pets? __________________
Primary care provider? __________________
Who prepares the food? _________________
Water source? _________________________
_____________________________________
_____________________________________
FAMILY HISTORY
Parents & Siblings
[Age / Job / Health / Maintenance medication]
Heredofamilial diseases:
Ex. She lives with 7 other people in the house, all apparently well.
Mother the primary care giver and the one who prepares food. She
is 37 years old, hypertensive and no longer managed with
maintenance medication. Father died due to cardiac arrest at 51
years of age. Eldest brother is…Youngest sister is…HFD are
hypertension [paternal and maternal], asthma [maternal], and
diabetes [paternal]
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HPI
 C – characteristic [5 senses; dyspnea in or out? pain during or after or…]  S – severity [scale for pain and dyspnea]
 O – onset [when, gradual, abrupt, insidious, indolent]  P – pattern [intermittent, sustained, waxing and waning]
 L – location & radiation  A – associated symptoms
 D – duration & frequency  M – management [medications taken / consult done / relief]
 S – setting it occur [if applicable]

NO PHYSICAL EXAMINATION [refer to comprehensive PE for focused] Extremities: full range of motion, no lesions, pink nail beds, strong peripheral
General survey: [conscious, sleeping,] pulses
[active, playful, crying], Neurologic:
[carried by mother, standing, sitting, lying on bed] Cerebral: [conscious, asleep]; [playful, irritable]
afebrile, not in respiratory distress, Cerebellar: well-coordinated movements, normal gait
with the following vital signs: Cranial Nerves
T: HC: weight: 1: able to distinguish smell
P: CC: height: 2: bilateral blinking of eye
R: AC: BMI: 3, 4, 6: conjugate eye movement
Skin: [brown, fair] complexion, good mobility and turgor. No rashes or lesions 5: [good suck, able to feel well]
HEENT: 7: symmetric facial expressions
Head: normocephalic 8: turns to source of sound
Face: no dysmorphic features 9, 10: able to swallow
Eyes: symmetrical, white sclera, pink palpebral conjunctiva, 11: symmetric shoulders
normal EOM 12: tongue at midline
Ears: normal pinna, no discharges, no impacted cerumen, Sensory: able to sense heat pain and vibration
tympanic membrane – no alteration in cone of light Motor: good tone on both sides, no atrophy
Nose: patent nares, no discharges, pink mucosa, septum midline Primitive Reflexes:
Mouth and Throat: pink buccal mucosa, no gingivitis, no
pharyngeal erythema or exudates, # of teeth, dental carries,
tongue at midline
Neck: supple, trachea at midline, no lymphadenopathy
C/L: symmetric chest expansion, no deformities, clear vesicular breath
sounds, no rales, tachypnea, dyspnea
Heart: adynamic precordium, PMI, CAD within normal limits, HR, distinct s1
and s2, regular rhythm, no murmur
Abdomen: [globular, flat], normoactive bowel sounds, no organomegally, no
tenderness, no masses
GUT: grossly male, no external genitalia anomalies, no discharges
Anus and Rectum: patent anus
Back: straight, no spinal dimple