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General Data

General Data. Name: JS Age: 14 months old Gender: Female Date of Birth: August 12, 2009 Religion: Roman Catholic Informant: Mother Reliability: Good. Chief Complaint. generalized seizures. Review of Systems. General: (-) weight loss, (-) diminished activity, (-) delayed growth

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General Data

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  1. General Data • Name: JS • Age: 14 months old • Gender: Female • Date of Birth: August 12, 2009 • Religion: Roman Catholic • Informant: Mother • Reliability: Good

  2. Chief Complaint • generalized seizures

  3. Review of Systems • General: (-) weight loss, (-) diminished activity, (-) delayed growth • Cutaneous: (-) rash, (-) pigmentation, (-) hair loss • HEENT: (-) headache, (-) dizziness, (-) visual difficulties, (-) excessive lacrimation, (-) hearing difficulties, (-) aural discharge, (-) nasal discharge, (-) toothache, (-) sore throat • Cardiovascular: (-) easy fatigability, (-) cyanosis, (-) fainting spells

  4. Review of Systems • Gastrointestinal: (-) constipation, (-) diarrhea, (-) abdominal pain, (-) jaundice, (-) pica • Genitourinary: (-) dysuria, (-) edema, (-) discharge • Endocrine: (-) heat/cold intolerance, (-) polyuria, (-) polydipsia, (-) polyphagia • Musculoskeletal: (-) joint pain, (-) limitation of motion • Hematopoietic: (-) pallor, (-) easy bruisability

  5. Personal History Gestational History • Patient was born to a 23-year old G1P0 housewife married to a 24-year old driver. • Patient’s mother had regular prenatal check-up at USTH with an OB-GYN. She was given unrecalled medication. • She denied illicit drug use, alcoholic intake, exposure to viral exanthems, teratogenic drugs, cigarette smoke and radiation.

  6. Personal History Birth, Neonatal History • Mother denied any illnesses during the pregnancy. No maternal fever, no pruritis and no discharge before labor. • Patient was born live, term (39-40 weeks), singleton, female, via NSD at USTH. • The patient weighed 3 kg upon delivery.

  7. Personal History Feeding history • Patient was exclusively breastfed during the first three months. • she was then shifted to Bonamil on the 4th month and then Nido fortified milk on his 1st year. • Complementary food was introduced at 6 months. • The patient has good appetite and is not a picky eater. He likes to eat biscuits, cookies, and milk.

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