Historian: Rikki Kent D. Ba-aco Medicine IIA | SGD 1 I. GENERAL DATA Informant: Hermilyn Joy Bernal, 23 Relationship to Patient: Mother Reliability: 99% Name of Patient: Rhayen Bernal Age: 6 days old Sex: F Civil Status: New Born Date of Birth: July 9, 2015 Time of Birth: 6:51 pm Birthplace: WVSU Medical Center Address: Oñate, Mandurriao, Iloiolo Religion: Roman Catholic Nationality: Filipino Ward: Step-Down NICU Historian: MED 2A, Group 1 Date History Taken: July 14, 2015 II. CHIEF COMPLAINT Fever III. HISTORY OF PRESENT ILLNESS Prenatal This is the mother’s second pregnancy having an OB score of G2P1 (1001)prior to delivery. She discovered that she was already pregnant when it was about 2 months through a positive pregnancy test. However, after 2 weeks of delayed menstrual period, she already experienced fatigue, nausea and vomiting that lasted until 3 rd month AOG. She had her first prenatal checkup at 3rd month AOG at their barangay health center. The succeeding checkups were conducted once every month until the 7th month, and twice starting at the 8 th month at WVSU Medical Center. She had 8 prenatal checkups prior to delivery.