PAST MEDICAL HISTORY

MENDEZ, NEBATO
V. Personal History
a. Gestational History
The mother is a G1P1 (1-0-0-1) and was 22 y/o when she was pregnant with the
patient, the first baby of the family. During the course of her pregnancy, she was well
and healthy, eats three times a day which usually consists of rice, vegetables, fish and
fruits. Her exercise routine includes walking early in the morning and late in the
afternoon for at least 30 minutes a day. No infections experienced. No intake of other
drugs except Ferrous Sulfate taken every after lunch. No X-ray exposure claimed. She
had her prenatal check-up in their health centre which consists of 4 visits. UTZ was
done during the 6th month of pregnancy to reveal the gender of the baby. The pregnancy
lasted for 9 months.
b. Birth
Baby A.M. was delivered last April 19, 2017, 8:40 in the morning, term via NSVD
at a district hospital in Guimbal, Iloilo. She has a weight of 2.21 grams. At birth, newborn
screening was done with the first dose of Hepatitis B (intramuscular) and BCG
(intradermal) given. It was attended by her husband and mother.
c. Neonatal History
She was active at birth with a pulse approximately over 100 bpm, with prompt
response to stimulation. She had a pink body and blue extremities as claimed by the
mother accompanied with a vigorous cry. The APGAR score was interpreted as 9/10 for
the first minute. She appeared pinkish after 5 minutes, thus an APGAR of 10/10 after 5
minutes. There were no problems, and injuries noted.
d. Feeding History
I. Type of feeding
The mother was exclusively Breastfeeding the patient from birth up to 6 months
per demand and would usually take an hour per breast to finish the feeding or until the
patient is asleep. The baby was 6 months old when they decided to introduced Mixed
type feeding. The primary reason for this shift was that the mother felt that her
breastmilk was not enough to provide the nutritional needs of her baby, primarily driven
by her goal of making her baby gain some weight. The milk is Nestogen, and the
dilution is 2 scoops of milk in 30 ml of water, given once a day. The mother noticed that
her child can only consume at east 2 tablespoons of the bottled milk. She also added
that her daughter prefers her breastmilk over the formula per observation.
Simultaneously they introduced water and sometimes juice in the feeding.
 II. Complementary foods
The baby was 6-months-old when complementary feeding was introduced.
Cerelac (banana flavor) was the first food given with an average of 4 – 7 tablespoons
consumed per meal . Mashed squash, egg yolk, egg white, and rice mixed with
vegetable soup or sometimes arozcaldo were introduced chronologically, with 1 day
interval per food.
Fruits were introduced at 1 year old. Apple was the first one then orange,
banana, and mango. She can usually consume half of the fruit served.

III. Usual food intake for breakfast, lunch, dinner and snacks
The feeding pattern of the child follows that of the family, hence, would usually
have breakfast at 8 am, lunch at 1 am, and dinner at 5 pm. The usual food is composed
of rice mixed in a vegetable soup and sometimes with fish, taken three times a day. She
could consume approximately ¼ of the standard plate. For her snacks she usually
consumes 1 biscuit and 1 dutchmill or yakult at 3 pm.

IV. Food intolerance

None

VI. Multivitamins and Supplements

Tiki-tiki and Celine since 6-month-old were given at ½ tablespoon, once a day
taken after bath.

VII. Caregiver
Primary care and needs were given by the mother and father. No issues as to
performance of caregiver roles noted within the family.
e. Development/Behavioral History
I. Developmental Milestone

Domain Skill Age-achieved

Gross Motor Head control at 3rd-4th months
Prone 6 months
Stand with support 9 months
Stand alone at 10-12 months
Fine Motor Reached at 5th- 6th months
Held bottle at 7th-8th months
Personal/Social Smile responsively 2 months
Wave bye2/clapped at 1 year old
Receptive language Turned to sound at 6th-7th months
Respond to name 6 months
Understood “no” unrecalled
Command with gesture 1 year and 2 months
(mother’s estimate)
Expressive language Vocalized 3 months
Laughed/squeled 5th-6th months
Bubbled 7th-8th months
Mama/Papa 1 year old (Papa was the
first word)
Behavioral Bedwetting unrecalled
Fecal soiling unrecalled

II. Dental Eruption and Practices

First Oral Check-up at the Municipal Health Center in Oton was last May 2, 2018.
The first teeth (central incisors) erupted when she was 6 months old. Likewise, oral
hygiene (toothbrushing) commenced on her 6 months with a baby toothbrush and a
toothpaste for Kids (Colgate), usually every after her morning bath.
III. No behavioral problems noted.
f. Past Illness
Pneumonia- June 2018, diagnosed in a hospital but not admitted, given
Amoxicillin 3 times a day for 7 days.

VI. Immunization History and Tuberculin Test (c/o Glecyl)

VII. Family History

Parents:
The father is 26 y/o, construction worker, doesn’t smoke, physically fit and
healthy.
The mother is 24 y/o, housewife, physically fit and healthy.
Familial Illness or Anomalies:
Father’s Side:
Father: Died of a Liver Disease
Sibling: 3rd: Hypertension
Mother’s Side:
Father: Diagnosed with a Heart condition
Siblings:
3rd: Food Allergy (crustaceans)
4th: Diagnosed with Pulmonary Tubercolosis at the age of 17

(managed and treated as claimed)

Family Venogram (refer below)
VIII. Socioeconomic History
The family lives in a rural area, in a mixed type concrete and wooden house, with
one room, dining room, living room and a separate dirty kitchen. There are 4 of them in
the house: the father, the mother, the patient and with the 6 y/o nephew of the mother.
The father is the one who works and provides for the family with the income of
approximately 4,000/month that is usually spent for their food. The mother is a pure
housewife who primarily attends to the daily needs of the baby and the demands of the
household.

IX. Environmental History

Exposure to cigarette smoke from their neighbor was a primary concern for the
family. They throw their garbage in a sack and is collected every Sunday. They have a
flush-type of toilet. The distance of the toilet from the deep well is approximately 40 m
(interpreted as safe base on the set guidelines) The water used for household chores
are primarily from the deep well while they purchase a separate purified water for
drinking (especially for the baby). No pets inside the household.