1 / 8

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

oria
Download Presentation

General Data

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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.

More Related