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FAR EASTERN UNIVERSITY

DR. NICANOR REYES MEDICAL FOUNDATION MEDICAL CENTER


Regalado Ave., Corner Dahlia Street, West Fairview Quezon City 1118
Telephone Number: 427-02-13
DEPARTMENT OF CHILD HEALTH
May 18, 2016

Reliability: 70%
Informant: Mother

GENERAL DATA:
Celestino, Anica M., 1 year old, female, Filipino, Roman Catholic, born on May 2, 2015
at Fabella Hospital, presently residing at 185 Saint Anthony. Brgy. Holy Spirit, Quezon City,
admitted for the 1st time to FEU-NRMF Medical Center on May 18, 2016.
CC: upward rolling of eyeball and twitching of upper and lower extremities
BIRTH HISTORY
Live, born, term, 37 weeks, single, female, delivered via Emergency Cesarean
Section, with a birthweight of 2500 grams,
NEONATAL HISTORY
Patient was born to a 31-year old G2P1 (4004), Maternal blood type is B+. Paternal
blood type is unknown. HBsAg screening was non-reactive. Mother had irregular prenatal
check-up and took multivitamins, ferrous sulfate, folic acid and calcium starting 3 rd month of
pregnancy. Non-asthmatic and non hypertensive. No history of allergy to medication.
MATERNAL HISTORY
First Trimester
The mother experienced the usual signs and symptoms of early pregnancy such as,
nausea, vomiting and breast tenderness. Consult was done on the 1 st month of missed
menses on their local Health Center No medications were taken. No associated signs and
symptoms such as hypogastric pain, vaginal bleeding watery vaginal discharge, spotting,
bloody show. Mother had UTI on her 3 rd month of preganancy and was given unrecalled
antibiotics for 7 days and was completed. She started taking multivitamins, ferrous sulfate,
folic acid and Calcium on her 3 rd month of pregnancy. She denies any history of accidents,
trauma, illness or any exposure to radiation or toxic chemicals.
Second Trimester
Quickening was felt on the 4th month of pregnancy. Regular pre-natal check-up and
intake of multivitamins No associated signs and symptoms such as hypogastric pain, vaginal
bleeding watery vaginal discharge, spotting, bloody show. She denies any history of
accidents, trauma, illnesses, or any exposure to radiation of toxic chemicals.
Third Trimester
Subsequent prenatal check-ups at this time were regular as well as intake of
Multivitamins 1 tablet once a day, Ferrous Sulfate 1 tablet to be taken once per day, and
Calcium 1 tablet twice a day. No other subjective complaints such as abnormal vaginal
discharge, vaginal spotting, dysuria and fever. She denies any history of accidents, trauma,
major illnesses and any exposure to radiation or toxic chemicals.
Patient was apparently well until 3 days prior to consult when patent had cold, with
watery nasal discharge. No fever, no cough, no vomiting, no loose stooling with good
appetite (breastfeeds for 15-30 minutes on each breast every 4 hours with 5 tablespoons of

rice with viand per meak with snacks in between) and good activity (described by mother as
playful and active.
Few hours priot to consult, while patient was on her walker, patient was out of
balance described as tumaob ung walker kasama si baby on her right side. Baby was carried
by mother and was noted to be weak lookin, awake but prefrerred to be lying down. There
was upward rolling of eyeballs with twitching of upper and lower extremities, with circumoral
cyanoisi, no drooling of salive lasting for 10 seconds. There was no loss of consciousness. No
consultation was done. N medications .
PAST MEDICAL HISTORY:
Patient had her 1st seizure episode on February 2016 described as upward rolling of
eyeballs with twitching of her upper and lower extremities lasting for 30 seconds , with fever
of 39 C, no drooling of saliva, no loss of consciousness,. They south consult to a private
clinic where CBC was done and revealed normal results. No medications were given. Folloup was done and patient was well and wa subsequently went home.
On May 3, 2016- clinic, for EEG and ultrasound cranial
On May 4, 2016 consulted at PMC and was scheduled for EEG on May 24 but
wasnt able to come back.
FAMILY HISTORY:
Mother is 31 years old housewife, with history of seizures with fever on childhood.
Last seizure was on her childhood. No history of hypertension, diabetes, or asthma
Father is 34 years old and works as a construction worker, apparently healthy with
family history of Diabetes.
Patient is the youngest among 4 siblings, eldest is 16 years old female, 2 nd is 4
years old, female, 3rd is 3 years old, , all apparently healthy
IMMUNIZATION HISTORY:
VACCINE
Hepatitis B
MMR
BCG

DOSE
1st dose (at birth) 5/4/15
1st dose 5/4/16
At birth- 5/4/15

PLACE
Health Center
Health Center

Newborn Screening: Done on 5/14/16 at FEU-NRMF


Otoacoustic Test: Done on 5/15/16 at FEU-NRMF
DEVELOPMENTAL MILESTONES:

NUTRITIONAL HISTORY:
Patient is breasfed from birth to present for 15-30 minutes each breast
every 4 hours. She strated complementary feeding at 6months with____. She
consumes 5 tablespons of rice with viand every meal with snacks in between.
PHYSICAL EXAMINATION
General Survey: awake, active, with good cry and reflexes, febrile, hydrated, not in
cardiorespiratory distress with the following vital signs:
CR:
RR:
Temp: 37.7C BW: 1670 grams (z score = -3 (stunted, wasted))
HC:
CC: 2 AC: 24 cm
BL: 37 cm

HEENT: pink palpebral conjunctiva, white sclera, bilateral, well-formed pinna, with skin tag
on left tragal area, patent ear canals, patent nostrils, intact lips and palate
Neck: supple, no palpable masses, no lymph nodes, no crepitations, no limitation of
movement
Chest: thin chest wall, symmetrical chest expansion, no retractions, clear breath sounds
with good air entry
Heart: adynamic precordium, tachycardic, regular rhythm, no murmur
Abdomen: Slightly globular, dry intact umbilical stump, no discharge, non erythematous,
non foul smelling; soft, normoactive bowel sounds, no organomegaly, no masses
Spine: straight, midline, no tufts of hair
Genitalia: normal looking female external genitalia
Rectum: patent anal orifice, no perianal rashes
Extremities: no gross deformities, full and equal pulses, CRT<2 seconds
Skin: with intertrigo and rashes on on lumbar area
Reflex: (+) Palmar, (+) Plantar, (+) Moro, (+) Rooting, (+) Babinski
Meningeal Irritation: No nuchal rigidity, no Kernig sign, No Bruzinski

NEUROLOGIC EXAMNINATION:
Cerebrum: awake, active, with good cry and reflexes
Cerebellum: no nystagmus
CN I : turns head to the smell of milk
II : 1-2 mm pupils equally reactive to light
III, IV, VI: intact extraocular muscles
V: good suck, positive corneal blink reflex
VII: no facial asymmetry
VIII: intact gross hearing, turns eyes to sounds
IX,X: positive gag reflex
XI: moves head from side to side
XII: tongue at midline
ASSESSMENT:
T/C Neonatal Sepsis, Early Onset
PLAN:
Please admit to Service Ward under the service of Dr. Dacula/Genuino/Aquino/Angeles
Secure consent for admission and management.
Continue breastfeeding.
Insert heplock.
For Complete Blood Count with Platelet Count.
For urinalysis.
For chest x-ray ,Anterior Posterior-Lateral View.
For referral to Neonatology Service.
Start Ampicillin 75 mg TSIV every 12 hours (TD: 100mg/kg/day).
Start Cefotaxime 75mg TSIV every 12 hours (TD: 100 mg/kg/day).
Weigh patient now then daily and record.
Monitor intake and output every shift and record.
Monitor vital signs every 4 hours and record.
Refer accordingly.

Dr.Dacula/Genuino/Pangilinan/Aquino/Angeles/
JIIC De luna/ Co-JIIC Sulit/ CoJIIC Salvador