PATIENTS PROFILE AND HEALTH HISTORY Name of Patient: Lawrence Cordere Yboa Age: 6 years old Date of Birth:

November 1, 2005 Place of Birth: Catbalogan Samar Address: Brgy. Salug, Catbalogan Samar Date of Admission: January 22, 2012 Date discharged: February 9, 2012 Name of Mother: Cresencia Yboa Name of Father: Primo Yboa CHIEF COMPLAINT A. Source of Information/Informant Mother B. History of Present Illness 1 month prior to admission, patient had on and off low-moderate grade fever and was given Paracetamol tablet three times a day and was temporarily relieved. 27 days prior to admission, they consulted to a private medical doctor and laboratory work-ups such as CBC and U/A was done. Managed as a case of urinary tract infection and was given/prescribed by the doctor with Cotrimoxazole with unrecalled dose for 7 days which offered no relief; still with on and off fever. 20 days prior to admission, had consulted again to the private medical doctor due to no relief to on and off fever this time already associated with abdominal pain. Patient was again prescribed with unrecalled medication. 15 days prior to admission, patient was brought to Samar District Hospital; was admitted and managed as a case of urinary tract infection given with Cefuroxime IV for 3 days then was discharged with improved condition. 9 days prior to admission, recurrence of abdominal pain was noted with purpuric rash on both lower extremities and was re-admitted again at Samar District Hospital and was managed as a case of Henoch-schonlein purpura/HSP. While admitted, patient was given with Furosemide 15 mg, Hydrocortisone 60 mg and Ranitidine 15 mg IV. 6 days prior to admission, still at SPH, patient noted to have black, tarry stools twice. Given Ceftriaxone IV with unrecalled dose. 1 day prior to admission, patient was then referred at the center due to persistent appearance of hematuria hence admission.

C. Past Medical History 1. Pre-Natal History Patient was born to a 29 year old Gravida 1 Para 1 mother, who had her pre-natal check-ups at rural health unit or RHU at Catbalogan Samar. She received 2 doses of TT Tetanus Toxoid injections and with intake of Ferrous Sulfate one tab once daily. She is a non-smoker, non-alcoholic beverage drinker and denies any exposure to radiation or infections during the entire course of pregnancy. She had no history of bleeding, undue labor pains and severe vomiting. 2. Birth History Patient was delivered full term, via normal spontaneous vaginal delivery at home, assisted by a traditional birth aide/hilot. At birth, patient was active, pinkish and had good cry. There was no cyanosis, no dyspnea, no convulsions nor jaundice noted. 3. Neonatal History Patient passed first urine and meconium within the first 24 hours of life. Umbilical stump was cleaned with cotton with alcohol and sloughed off at 6 days of life, without redness and discharges.

D. Developmental History 1. Nutrition Birth 6 months patient was exclusively breastfed per demand

6 months can already eat porridge 8 months porridge and fish 11 months rice and fish 24 hour diet recall Breakfast: 1 cup of rice with fish and 1 glass of milk Lunch: 1 cup of rice with fish and vegetables Dinner: cup of rice with fish

2. Growth and Development 1 month raised head, eye follows object midline, throaty sound, can smile 2 months head control at 45 degree angle, laughs, responsive 3 months head control at 90 degree angle, hands together, moves head toward sound, plays rattle 4 months rolls over, grasp object, moves head toward sound 5 months good head, reach objects, turns to sound 6 months no head lag, chews 7 months sits with support, rakes object, ma when crying, feeds self 8 months sits without support, transfer object, plays peek-a-boo 9 months stands with support, holds bottle, imitate sounds, waves bye-bye 10 months pulls self to stand, thumb finger grasp, understand gestures, and do nursery games 11 months walks with support, bangs object together, utter 2 words like ma/pa, helps dress 12 months stands alone, throws objects, obeys command, attempts to use spoon, other words than ma/pa 18 months sits by self, indicates needs, uses spoon 2 years old runs well up and downstairs, imitates circular stroke, points to one body part, toilet trained by day 2 years old jumps, imitates circles, follows directions 3 yrs old throws ball, tells stories, dry by night 3 yrs old stands with one foot per step, gives full name and sex, dresses with supervision, counts to 3 or more 4 yrs old downstairs with one foot per step, , imitates cross, recognizes colors, tells long tales 4 yrs old catches ball well, draws man, recognizes 3 or more color, dresses by self 5 yrs old heel to toe walk, skips both feet, copies square, writes alphabet, counts to 10, writes name, can use knife

6 yrs old walk heel to toe and backward, draws complete person with dress, writes fairly well, adds and or subtracts, dresses well, distinguishes L or R Kinder 1 Pupil attentive, cooperative 3. Past Illnesses Mother denies exposure of her child to measles, mumps, chickenpox, streptococcal infections, and allergies to food and drug. Occasionally, they visit RHU for cough and colds. Recently they went to a private MD for his on and off fever. 4. Immunization Patient had complete vaccination at RHU. No complications or side effects noted. E. Family History Mother is a 35 year old housewife, apparently well. Father is a 38 year old farmer, apparently well. Siblings: 2, apparently well. History of Family Disease No history of tuberculosis, allergy, blood dyscrasias, mental or nervous diseases, diabetes, cardiovascular diseases, kidney disease, rheumatic fever, neoplastic diseases, congenital abnormalities, cancer, convulsive disorders, others. F. Psychosocial History Patient was born on November 5, 2005 and was raised in Catbalogan Samar. Aside from his family, patient lives with his grandmother and grandfather in a household made up of light materials. Water source is from deep well not boiled prior to drinking. Garbage disposed by burning. They use charcoal for cooking. Father works as a farmer.