Date and Time: 10/__/2017 at 0900h

Source and Reliability: Grandmother (100%)

General Data:

K.A., 12 years old, male, Filipino, child, Roman Catholic, born on December 02, 2004 in Mandaue
City, currently residing in Minglanilla, Cebu, was admitted for the second time in CDUH on 10/__/2017.

Chief Complaint: Burn Injury

History of Present Illness:

NOI: hot water

TOI: 12:00 pm

DOI: August 15, 2017

POI: Mandaue City (residence)

1 hour prior to admission

Prenatal History:

Patient’s mother was 21 years old at time of pregnancy, with an OB score of G1P0. Mother’s
first prenatal check-up was at 16 weeks AOG, and had regular visits thereafter. Mother is a non-smoker,
non-alcoholic, and denies illicit drug use. Mother had no maternal illness throughout pregnancy.

Natal History:

Patient was delivered full term at 38 weeks AOG with a birth rank of 1/1 via NSD attended by an
Obstetrician at CHH. Patient had a good cry, and was acyanotic at birth. Birth weight was 7.3 lbs. Patient
had meconium aspiration during delivery, and stayed in the nursery for 3 days.

Post-Natal History:

Feeding History:

Patient was breastfed from birth up to 2 months old, and was formula fed thereafter.
Semisolids where given at 6 months old, and solids where given at 1 year old.

Growth and Development:

 Social smile – 3 mos

 Rolls over – 5 mos
 Sits without support/crawls – 6mos
 Says, “mama/papa” – 8 mos
 Stands alone – 9 mos
 Walks alone – 12 mos
 Run – 18 mos
 Talks in sentences – 2 years
  Draws circle/ pedals tricycle – 3 years
 Draws cross/ hops – 4 years
 Draws square – 5 years
 Draws triangle – 6 years

Immunization History:

Patient is a completely immunized child. BCG was given at birth, 3 doses of Hep B, DPT,
OPV, and HiB were given at 2, 4 and 6 months, respectively, AMV was given at 9 months old,
and MMR was given at 1 year old.

Past Medical History:

Patient is a known allergic to crustaceans, and has no known drug allergies. No history of prior
surgeries, injuries nor accidents. Previous hospitalizations includes:

1. 2007 – fever and cough, stayed for 7 hospital days in CDUH

2. 2012 – asthma, stayed for 7 hospital days in Cortes Memorial Hospital
3. 2015 – Dengue fever, stayed for 7 hospital days in South General Hospital

Family History:
Heredofamilial diseases includes Hypertension on maternal side, and Asthma on paternal side.

HPN

asthma

Personal and Social History:

Patient is a grade 7 student at USJR Minglanilla. Patient’s hobbies includes playing computer
games and watching the television.

Patient’s parents are separated for eight years. Patient lives with his father in a 3 storey house
made of mixed materials, with 4 bedrooms and 3 bathrooms, well ventilated and with proper and
regular garbage disposal. Patient’s mother works abroad. Patient, together with his family goes to
church every Sunday.