Pediatric History and Physical Examination

Informant: R.B. Date: January 22, 2017

Relation to Patient: Mother Time: 10:45 PM
Reliability: 98%

General Data

Name: R.Z.B. Date of Admission: January 16, 2018; 8 PM

Age: 7 mos Number of Admission: 1
Sex: Male Blood Type:
Address: Jalandoni Estate, Lapuz, Iloilo
Birthplace: St. Paul’s Hopsital Iloilo Father: A+
Nationality: Filipino Mother: A+
Religion: Roman Catholic Baby: B+

Ward: Pedia Ward

Chief Complaint: Cough for one week

History of Present Illness:

(3 months prior to admission

(+) cough after immunization of Pneumococcal Vaccine (1st dose)
No remedies done at home

1 week after Pneumococcal Vaccine Immunization

Still with persistent cough
Consultation at St. Paul’s Hospital Iloilo- OPD Department done
Antibiotic Prescribed:
• Amoxicillin (unrecalled dose and brand name) for 7 days
• No relief from treatment
Follow up check up done under Dr. C.’s care
• Change of antibiotic (unrecalled dose and brand name) for 7 days
• Treatment regimen not completed. Above mentioned antibiotic only given for 2 days (2/7).
• Consultation made due to persistence of cough
Consultation at SPICE under Dr. R.’s care
• Shifted to Clarithromycin and Cefixime (Tergecef). Relief noted.

2 weeks prior to admission

Exposed to cigarette smoke at home.
(+) clearing of throat by mother
(+) cough (occurrence frequently noted in the morning)

1 day prior to admission

(+) one episode of vomiting on waking up (whitish, milky,, sticky approximately 2 ml)
(+) shallow breathing noted
(+) Fever (Temperature: 37.8)
• Paracetamol drops 0.5 ml every 4 hours given (given only twice, Temperature within normal
limits after 2 doses given)
On admission
(+) vomiting (whitish, milky,, sticky approximately 2 ml)
Chest X-Ray, CBC
• No significant fishings
Physical Assessment Findings:
• (+) rales (decsribed by the mother as “Daw gacrack daw hambal ni Doc”
Repeat Chest X-Ray and CBC done:
• CBC: (+) elevated WBCs
• Pending X-Ray result
Antibiotic via heplock started
• Cefuroxime Sodium 750 mg IV

Family History

No. of Siblings: 3 No. of Males: 2 No. of Females: 1

Age of Siblings and Illnesses:
• R.J.B
7y.o.
G6PD

• R.G.B
5 y.o.
Well and Alive

• R.Z.B.
7 mos
Pediatric Community Acquired Pneumonia

History of the Parents:

MATERNAL SIDE PATERNAL SIDE

(+) Allergies: Shrimp (-) Allergies
(-)Asthma (-)Asthma
(-) Tuberculosis (-) Tuberculosis
(-) Seizure (-) Seizure
(-) Hypertension (-) Hypertension
(-) Diabetes (-) Diabetes
(-) Thyroid Disorder (-) Thyroid Disorder
(-) Malignancies (-) Malignancies
Others: Others:
Personal and Social History

Sleeping Habits
Morning: 2 hours
PM: 3 hours
Night:
usual sleeping time: 8PM
usual waking period: 7AM

Toilet Habits
• Twice a day via diaper
• Stool decried as yellowish, sticky

Games and Play

• Tranfers toys from one hand to another
• Fond of rolling over

Gestational History

Maternal Status
• Prenatal Check-up schedules religiously followed as claimed
• Iron and Folic Acid supplements taken
• G3P3 (T3P0A0L3)
• Planned Pregnancy
• Duration of Gestation: 38 weeks AOG
• No history of maternal infections on three pregnancies

Birth and Neonatal History

• Term
• NSVD
• Child breathe spontaneously but attached to Oxygen after delivery but removed thereafter
• Vigorous cry at birth
• Discharged 2 days after delivery
• No cord coil
• Birth Weight: 3.7. kg
• Birth Length: 49 cm
• Newborn Screening result: (+) G6PD
• Appraised by Physician to avoid Antibiotics (Cotrimoxazole) and Soya-based foods
• Immunisation Staus
• 3rd dose of Pneumococcal Vaccine given
• Vaccines given at SPH-I

Feeding History:
Exclusive Breastfeeding for 2 months after birth
Current Milk Feeding:
• Morning: Bottle Feeding ( Similac 2 scoops :240 mL)
- Drinks 8oz, 3x/day
• Afternoon to Evening: Breastfeeding
• Cerelac given at regular intervals
• Mamon (2x/day)
• Vitamins:
Nutrition
Celin
0.5 mL

Others:
Extended Type of Family
Water Source:
• Drinking: Purified Water
• Daily Household Use: Tap Water
Housing:
• Mixed Type