CLINICAL HISTORY

CLINICAL HISTORY
By: Intern Sonny Cyrus Bata

General Data:
M.L., 5-day-old male, from Muntinlupa City, admitted on November 22, 2001 for yellowish discoloration of the skin.

History of Present Illness:
The Pt was born full term, via spontaneous vaginal delivery to a 29-year-old G3P2 (2002) at home c/o a midwife. Weight=8.2 lbs. No significant maternal illnesses/infection during present pregnancy, no maternal drug intake during the pregnancy, (+) regular prenatal check-ups, and no perinatal complications. Minimal blood loss during the delivery. (-) cephalhematoma, (?) Vitamin K, (+) good cry, good activity, no cyanosis, good suck at birth. (+) UO, BM
Pt was apparently well until 1 day PTA, there was note of icteric sclerae and jaundice of the whole body. (-) fever, (-) seizures, (-) feeding problems. Pt was noted to be awake with good suck and activity.
12 hours PTA, note of upward rolling of eyeballs associated with stiffening of the extremities which lasted for less tha...