JOSE R.

REYES MEMORIAL MEDICAL CENTER

Rizal Avenue, Sta. Cruz, Manila
DEPARTMENT OF PEDIATRICS

CLINICAL HISTORY FORM

INFORMANT: Gabuya, Wilmarie RELIABILITY: 85%
GENERAL DATA:
Name: Gabuya, BB “A” Wilmarie Religion: Roman Catholic
Age/Sex: Newborn/Male Nationality: Filipino
Birthdate: November 02, 2018 Date of Admission: 11/02/18
Birthplace: Manila Number of Admission at JRRMMC: 1
Address: Tondo, Manila

This is the case of Gabuya, BB “A” Wilmarie, newborn, Filipino, born on November 02, 2018 in Manila,
currently residing at Tondo, Manila.

CHIEF COMPLAINT: Prematurity

HISTORY OF PRESENT ILLNESS:

Patient was born preterm, live baby boy of Gabuya, BB “A” Wilmarie with 35 3/7 weeks of age of
gestation by USG, 36 weeks by Ballard Score, delivered via normal delivery to a 24 years old G2P0 (0010)
mother with AS 8(2 Heart rate, 2 Respiratory rate, 2 Muscle tone, 1 Reflex, 1 Color) 9(2 Heart rate, 2
Respiratory rate, 2 Muscle tone, 2 Reflex, 1 Color) Head Circumference: 33cm; Chest Circumference:
30cm; Abdominal Circumference: 28cm; Birth Length: 50cm Birth weight: 2,625gms, appropriate for
Gestational Age.

Patient’s mother had 7 pre-natal check-up done at Cortez-Pineda Clinic and prenatal medications
taken, Multivitamins, Folic Acid, Isoxiprine. There was no exposure to teratogen and radiation. During the
second trimester of patient’s mother, his mother noted a good fetal movement and continued her
prenatal check-up and medications. His mother had Gestational Hypertension. During the third trimester
of his mother, his mother noted a good fetal movement, continued her prenatal check-up and medications
with good compliance.

At birth, patient was responsive, with spontaneous breathing and activity with an Apgar score of
8, 9 for 1st and 5th minute of life, respectively. Patient was born preterm at 36 weeks by Ballard Scoring.
Hence, subsequently admitted at the Neonatal Intensive Care Unit at JRRMMC.

FAMILY HISTORY:

Hereditary/Familial Disease
(+) Hypertension (-) Seizure Disorder
(-) Diabetes Mellitus (-) Malignancy
(-) Bronchial Asthma (-) Psychiatric Disorder
(-) Pneumonia (+) Pulmonary Tuberculosis
(-) Typhoid Disease (-) Liver Disease
(-) Heart and renal disease

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 JOSE R. REYES MEMORIAL MEDICAL CENTER
Rizal Avenue, Sta. Cruz, Manila
DEPARTMENT OF PEDIATRICS

CLINICAL HISTORY FORM

CLINICAL HISTORY FORM

BIRTH HISTORY

G2P0 (0010) Manner of Delivery: NSD Place of Birth: JRRMMC

AOG: 35 3/7 weeks Birth Weight: 2,625 gms. APGAR Score: 8,9
Who assisted delivery: Obstetrician

PHYSICAL EXAMINATION

General Survey
Patient is awake, conscious and alert.

HR: 134 bpm RR: 37 cpm T: 36.5 C O2 sat: 98%

Anthropometric measurement

BW: 2625 gms. BL: 50 cm AC: 28 cm HC: 33cm

CC: 30 cm

Skin:
Pink in color, no jaundice from face to trunk, no motting, no cyanosis, no lesions, no blanching,
warm to touch.

HEENT:
Normocephalic, no bulging fontanelle, anicteric sclera, pink palpebral conjunctiva, (-) cleft
palate/lip, patent nose, patent ears.

Chest and Lungs:

Symmetrical chest expansion, no lagging, no retractions, clear breath sounds.

Heart:
Adynamic precodium, normal rate, regular rhythm, no murmur.

Abdomen:
Soft, nondistended, normoactive bowel sounds, no palpable mass, no guarding, umbilicus has two
arteries and one vein, patent anus

Genitourinary:
Grossly male

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 JOSE R. REYES MEMORIAL MEDICAL CENTER
Rizal Avenue, Sta. Cruz, Manila
DEPARTMENT OF PEDIATRICS

CLINICAL HISTORY FORM

Extremities:
Grossly normal extremities, no edema, capillary refill time of less than 2 seconds both upper and
lower (right and left) extremities.

Neurologic Examination:

General:
Patient is awake, conscious and alert.

Cranial Nerves:
CN I- not assessed
CN II- equally reactive to light
CN III, IV and VI- not assessed
CN V- reacts to touch on face
CN VII- no facial asymmetry
CN VIII- startles to sound
CN IX, X- not assessed
CN XI- not assessed
CN XII- not assessed

Reflexes
(+) Babinski (+) Grasp (+) Suckling

Motor:
Spontaneous movements

Sensory:
Responds to touch

Meningeal Signs:
(-) Brudzinski and Kernig’s sign

IMPRESSION:

NB, PT, LBB of Gabuya, Wilmarie with 35 3/7 weeks of age of gestation by USG, 36 weeks by
Ballard Score, delivered via normal delivery to a 24 years old G2P0 (0010) mother with AS 8, 9, Head
Circumference: 33cm; Chest Circumference: 30cm; Abdominal Circumference: 28cm; Birth Length: 50cm
Birth weight: 2,625gms, appropriate for Gestational Age.

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 JOSE R. REYES MEMORIAL MEDICAL CENTER
Rizal Avenue, Sta. Cruz, Manila
DEPARTMENT OF PEDIATRICS

CLINICAL HISTORY FORM

________________ Maranan, Ana Carmela A. November 2, 2018

Resident-in-charge Junior Intern on Duty Date Accomplished

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