Historian: Charles Jebb B.

Juanitas
Date & time of Interview: July 29, 2015; 1:00PM
I.

General Data
Informant: Carolina
Donque (maternal
grandmother of the
patient)
Patients name:
Jyle Christoph Donque
Nationality: Filipino

II.

Date of birth:
November 29, 2013
(1 year, 8 months, 0
days)
Address: Quintin Salas,
Jaro, Iloilo City
No. of Admissions: 1

Sex:
Male
Birthplace:
Mandurriao, Iloilo City

Chief complaint:
nag convulsion kag hilanat (upward rolling of eyeballs)
III.

History of present illness

4-5 days PTA, the patient had cough but was reported to be alert, not
showing signs of weakness. His cough was described as ga sagrak with
phlegm that cannot be expressed by the patient. The color of the phlegm was not
identified.
3 hours PTA, the patient was reported to be feverish by his grandfather.
The informant was not present. The patient was still having coughs at this time.
2 hours PTA, the patient started having convulsions lasting no longer than
2 minutes and was seemingly not breathing. He was wiped down with a damp
cloth and was taken to WVSU Medical Center. He was reported to be breathing
upon admission. His temperature was recorded as 42C. Thus this admission.

IV.

Past personal history

a. Prenatal
The patients mother started prenatal checkups at the health center in
Quintin Salas at 4 months AOG as reported by the informant. She took ferrous
sulfate, multivitamins and folic acid supplements during her pregnancy. She had
episodes of cough and nasal catarrh and sought treatment but no medications
were recalled by the informant.
No alcoholic beverages were consumed during the pregnancy as reported
by the informant. There was also no radiation exposure as claimed.
b. Natal
The mothers OB score at birth of the patient is G1P1 (1001). She was 23
years old at the time of the patients birth. The patient was delivered at Western
Visayas Medical Center in Mandurriao by normal spontaneous vaginal delivery

after 6-7 hours of labor as reported. He was full term with a birth weight reported
at 3 kg. His length was claimed by the informant as taas.
JCD was given BCG, hepatitis B vaccine and vitamin K shortly after birth.
No APGAR score was given by the informant but the baby was reported to be
vigorously crying. No jaundice, head trauma, seizures, infections or other
complications were reported.
c. Neonatal
JCD patient was reported to pass meconium and urinate within 24 hours
after birth. He undergone Newborn Screening after birth and no significant results
were reported. His blood type was tested though unrecalled by the informant.
d. Feeding
JCD was breastfed for three weeks after birth. The mothers necessity to
go back to work was pointed out by CD as a factor for discontinuing exclusive
breastfeeding. He was given Formula milk (Nestogen) after the breastfeeding
period.
Complementary food was given at 5 months of age. He was fed with soup,
vegetables and su-am, and occasionally was given chocolates by his mother.
e. Developmental/behavioral history
The following milestones were achieved at ages reported by the informant:
Gross Motor
Head control 2 months
Prone 3 months
Sat alone 3 months
Stand with support 6 months
Walked Alone 9 months
Ran 20 months
Fine Motor
Fixated newborn
Reached 5 months
Held bottle 7 months
Scribbled 20 months
Personal/Social
Smiled responsively - <1 month
Waved goodbye/clapped 12
months
Command with gesture 15 months
Command without gesture 20
months

Receptive Language
Responded to sound newborn
Turned to sound 6 months
Responded to name 9 months
Understood no 12 months
Command with gesture 15
months
Command without gesture -20
months
Expressive Language
Vocalized 2 months
Laughed/squealed 6 months
Babbled 4 months
Mama/dada 4 months
Jargon 18 months

f. Past illnesses
JCD had a previous hospitalization at 8 months of age due to fever and
convulsion. The patient also had cough 2 months ago (18 months of age) which
the informant claimed to have resolved after treatment with a homemade
concoction of Atis leaves. The patient was not brought to a health center for his
cough and no medications were given.
V.

Immunization history
Immunization is complete as claimed by the informant. BCG, hepatitis B
vaccine and vitamin K administered at birth.

VI.

Family history
The patients maternal grandmother is hypertensive and has a family
history of asthma and TB. There was no history of cancer or diabetes reported,
but the patients maternal grandmother has not been tested for diabetes. The
patients grandfather was reported to also have febrile seizures but the patients
mother and her siblings do not. The patients mother is an occasional drinker. No
allergy to food or drugs was reported.
No information was given about the patients father.

VII.

Socioeconomic and Environmental History

There are seven members in the household: The patients maternal
grandparents, his mother and her three siblings and JCD. The patients mother is
currently not staying at home because she is processing her application in Manila
to work as an OFW to Kuwait.
The grandfather works as a caretaker of the Lopez Property ( private
cemetery at Quintin Salas) and earns about P6,000 every month. He has
PhilHealth coverage which does not extend to the patient. The grandmother is a
full-time housewife.
The house is described as a two-story house in a grassy area with lots of
trees near the cemetery and with few neighbors. The informant reported
exposure to mosquitoes. They have a cat, a dog, and a number of chickens,
which stay outside the house. The water source is through a deep well, and
drinking water is purified water.
The family is Roman Catholic but has irregular attendance in church.

VIII.

Physical examination

a. General survey
Patient awake, active and conscious to surroundings, ambulatory, walking
near bed with grandmother at side, face, extremities moves symmetrically; No
gross deformity noted. Heplock at right wrist.
b. Vital signs
Temperature 36.5 C
Heart Rate 92 bpm
Respiratory Rate 37 bpm
Blood Pressure 80/50
%O2 Saturation 99
c. Anthropometrics
Head circumference 49.5 cm
Chest circumference 52 cm
Abdominal circumference 50 cm
Height / Length 82 cm
Weight 13 kg
d. Skin
Skin is soft, smooth, reddish to light brown, darker in sun exposed areas.
Scratches on face and scars from mosquito bites on extremities noted; Finger
and toe nails untrimmed and dirty. No redness or bruising noted. Good skin
turgor noted.
e. Head, face, eyes, ears, nose, mouth and throat, neck
Head is normocephalic, anterior and posterior fontanels, closed; Face
symmetrical, with few scratches on the bridge of the nose. Eyes are in place,
patient blinks and follows faces and able to fix gaze on objects, no abnormal
findings noted; Sclera bluish-white, conjunctiva pink; Ears normal in shape and
position, cerumen present, no abnormal findings noted; Nasal septum at midline,
nares patent; Mouth is pinkish and moist, no lesions or bleeding noted, milk teeth
present, yellowish in color with few dental carries; Throat midline, No lesions and
tenderness noted.
f. Chest and Lungs
Chest is symmetrical with nipples measuring 1 cm each. Breathing
irregular, patient coughs from time to time. Tactile fremitus is noted when the
patient is crying and there is symmetry in transmitted vibrations. Crackles heard
on both lungs.
g. Heart and Blood Vessels

No cyanosis was noted; the point of maximal impulse was noted at the left
4th intercostal space; Distinct heart sounds were noted. There is normal S1 and
S2 heart sounds, HR = 92 beats per minute. Blood vessels not distended
peripheral pulses normal in rate and rhythm.
h. Abdomen
Abdomen is globular and soft with umbilicus protruding out; No distention,
tenderness or masses were noted; Bowel sounds present 10-15 cycles per
minutes
i. Anus and rectum
Anus and rectum both patent; no redness noted on perianal area.
j. Extremities
Good muscle tone, hands are clenched. The digits are normal. There is no
discrepancy in leg length. Able to ambulate alone in the ward.
k. Spine
There are no pigmented spots, hairy patches or deep pits.
l. Lymph nodes
Lymph node non-tender, non-palpable.
m. Hips
There are no signs of dislocation. No clicking sounds were noted upon
flexion and extension, and abduction.
n. Primitive reflexes
Babinski Reflex
Palmar Grasp Reflex
Rooting Reflex
Moro / Startle Reflex
Asymmetric Tonic Neck Reflex
Trunk Incurvation / Galants Reflex
Positive Support Reflex
Placing and Stepping Reflexes

Presen
t
Absent
Absent
Absent
Absent
Absent
Absent
Absent