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Comprehensive Health Assessment of a 14-Month-Old Female with Generalized Seizures

This report provides a detailed health assessment of a 14-month-old female child presenting with generalized seizures. Key findings indicate no significant weight loss, diminished activity, or delayed growth. The mother reported no notable dermatological, HEENT, cardiovascular, gastrointestinal, genitourinary, endocrine, musculoskeletal, or hematopoietic issues. The child's prenatal and neonatal history appears stable, with a good appetite and normal feeding patterns. The assessment highlights the need for continued monitoring and evaluation of the child's neurological condition.

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Comprehensive Health Assessment of a 14-Month-Old Female with Generalized Seizures

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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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