GENERAL DATA

This is the case of PB, 1 year and 8 months old, Female, Roman Catholic, and
currently residing at Mallig, Isabela.
Source of Information: Mother, Father
Reliability: 95%
CHIEF COMPLAINT: Dry cough
HISTORY OF PRESENT ILLNESS
1 day PTA, the patient experienced dry cough accompanied by fever, bluish
discoloration of lips, soft palate and nails. She was brought to CVMC for a check up
and was advised for admission.
PAST MEDICAL HISTORY
The patient was 2 weeks old when she was diagnosed of Congenital Heart
Disease. Since then, she had been taking maintenance medications (Propanolol).
Due to her condition, her parents would immediately bring her to the
hospital everytime she gets sick to prevent worsening of symptoms.
When the patient was 3 months old, she was brought to Philippine Heart
Center for surgery but was deferred.
She has no known food and drug allergies.
PRENATAL HISTORY
The patient's mother has a maternal history of G4P4, she was 40 years old
when she conceived the patient. She claimed that she was 3 months pregnant when
she learned about the pregnancy. She claimed having regular check ups and denied
taking any medications throughout the pregnancy. She also denied acquiring any
diseases during pregnancy. Despite being pregnant, she continued working at the
farm. She is neither smoking nor drinking alcoholic beverages.
NATAL HISTORY
The patient was delivered via NSD at a government hospital in Roxas,
Isabela. The mother reported that she delivered 15 days earlier from the expected
date. The mother did not experience any difficulty in labor and delivery. Loud cry,
normal respiration and pinkish skin color of the baby were noted.
POSTNATAL HISTORY

The child's birthweight was 1.8kg. She was given Hepatitis B vaccine at birth.
The patient was subjected to Newborn Screening, results were normal.
IMMUNIZATION HISTORY ????

NUTRITIONAL HISTORY
The patient is able to tolerate solid foods. She drinks 5-6 glasses of milk a
day. She takes Vitamin C and appetite enhancer everyday.
GROWTH AND DEVELOPMENT
MOTOR:
FINE: Able to hold milk bottle
GROSS: Sits with support, Not able to walk
LANGUAGE:
EXPRESSIVE: Says mama non-specifically
RECEPTIVES: Responds to name
COGNITIVE: Unable to assess
PERSONAL: Holds bottle, finger-feeds
SOCIAL: Solitary play
FAMILY HISTORY
She has a family history of Congenital Heart Disease and Hypertension from
her fathers side and asthma from her mother's side. No family history of cancer,
and Diabetes Mellitus.
SOCIAL AND PERSONAL HISTORY
The patient is the 4th child of the family. Her mother is 42 years old and a
farmer while her father is 43 years old and works as a body guard. Her siblings are
18, 15 and 10 years old respectively. They live in Mallig, Isabela.