Patient Name: AL

Sex:
Male
Age:
24 days old
Date of Birth: Dec. 18, 2016
Address: Balingain, Tugbok District, Davao City

Date and Time of Admission:

January 10, 2017, 4:00 PM

Date and Time of Interview:

January 11, 2017, 4:00 PM

Informant :

Mother

Reliability:

95%

CHIEF COMPLAINT: Jaundice

HISTORY OF PRESENT ILLNESS

Twenty-four days prior to admission, after NVSD, patient AL was

immediately transferred to NICU for work up for possible sepsis attributed to
maternal urinary tract infection. He was prescribed with ampicillin (165mg)
BID every 12 hours and gentamicin (17mg) OD every 24 hours both injected
intramuscularly. Within the same day, father claimed to have noticed a
generalized yellow discoloration on the patients skin. No medications were
given for the yellow discoloration of the patient as it was reassured that the
said discoloration was a physiologic process and was only advised to expose
the baby to sunlight.
Twenty days prior to admission, patient AL was discharged since blood
culture result was said to be negative. However he was still to continue the
said medications for the next three days at the ER as an outpatient. Upon
discharged, it was again reiterated that patient AL should be exposed to
sufficient sunlight since he was still yellowish.
The following days, mother noticed that the baby was still yellowish
with slight progression in color intensity. She said that patient AL was not
sufficiently exposed to sunlight due to the persistent rainy weather. No
associated symptoms was noticed such as fever, chill, rashes,
cephalhematoma, vomiting, diarrhea, constipation, dyspnea, feeding
difficulties and irritability. Urine was yellowish. Stool was also yellowish but
brown at times. Mother claimed that she changes the diaper 10 or more

times a day. Baby was exclusively breastfed 8 times a day every 3 hours
and defecates after.
Seven days prior to admission, due to the persistence of yellow
discoloration that never did subside, mother sought medical consultation in
a private clinic and had the baby checked. Patient was prescribed with
phenobarbital (5mg/kilo) for 10 days and instructed to have a follow-up
check-up at the third day, which the mother failed to comply.
One day prior to admission, patient was still yellowish with no
improvement or changes in skin color despite medications taken. The
persistence of the yellow discoloration for almost a month with no
improvement at all prompted the mother to admit the patient the day after.

PAST MEDICAL HISTORY

Upon delivery, patient was admitted to NICU to consider sepsis as the
diagnosis. He was prescribed with ampicillin (165mg) BID every 12 hours
and gentamicin (17mg) OD every 24 hours both injected intramuscularly for
seven days.

No surgical procedures done.

FAMILY HISTORY
Mother had tuberculosis (2012). Grandfather on the paternal side had
arthritis. Grandmother on the paternal side had asthma. No family history of
hepatitis, diabetes, jaundice, liver diseases, cancer, obesity, metabolic
syndrome, thyroid diseases, and mental illnesses.
SOCIAL HISTORY
Socioeconomic:
Patient was the second born. His father is 30 years old and currently
working as a secretary. His mother, 27 years old, works as a government
employee. Both of them provides the financial support. His biological
parents are married for three years now.
Environmental:
The area is well-ventilated and with good supply of electricity and clean,
portable water (Davao City Water District). The patient lives with his mother,
father and big sister. No smoker in the family. Garbage disposal is scheduled
once a week. No significant exposures to pollution, dusts, and radiation
noted.