MARTIN FEDERIC M.

PALCO
Medicine II PEDIATRICS


I. General Data

Patient GKYE, 3 years old, born on March 14, 2011, Male, Child, from Villa, Iloilo
City. Newly admitted at June 24, 2014 for shortness of breath and paleness of nail
beds and lips. Informant is the mother of the child, Mrs MCY with 95% credibility

II. History of Present Illness

2 days prior to admission, upon awakening in the morning, the informant noticed
the patient having nasal cathar with yellowish secretion. Broncophen 1 teaspoon
administered orally as claimed with no relief. Still with nasal cathar, on the evening,
patient started to have non-productive cough with no associated difficulty of
breathing as claimed. Ambroxol 1 teaspoon administered orally. With no medical
consultation made, informant administered Cefalexin 1 teaspoon orally as claimed.

A day prior to admission, nasal cathar was gradually resolving as claimed.
Patient was continued to be given Cefalexin 1 teaspoon and Ambroxol 1 teaspoon
orally by the informant. Still with non productive cough, informant noticed the patient
having difficulty of breathing as manifested by nasal flaring and shortness of breath.
Still with no medical consultation made, Hivent nebulization was administered with
slight relief as claimed. On the evening, patient reported abdominal pain associated
with cough and difficulty of breathing as claimed.

On the day of admission, upon awakening in the morning, informant noticed the
patient to feel warm. Temperature taken per axilla and was noted to be 37.7 degrees
Celsius as claimed. Calpol 2 teaspoon administered orally. Fever was resolved as
claimed. Still with cough and difficulty of breathing, informant noted paleness of the
nailbeds and lips. Thus, the admission.


III. PAST MEDICAL HISTORY
With no history of admission as claimed. Incidence of skin asthma and sought
medical advise. No known allergies to medications and food as claimed.

IV. FAMILY HISTORY

Parents lives separately and independently. Patient lives with the informant, with the
father providing financial support. Parents are generally healthy as claimed. With one
siblings aged 9 months old. With no known familial and hereditary illnesses within the
family.
V. PERSONAL HISTORY

Informant was generally healthy during pregnancy. At around 7
th
week of gestation,
unknowing to be pregnant as claimed, informant had an intake of 1 bottle of beer as
claimed. She does not smoke and stopped intake of alcoholic drinks when she knew
that she was pregnant. Prenatal visit was done with an OB-gYNE.
The child is the eldest. Informant was g1 p0 in the time of the delivery. Labor not
progressed until 5 cm cervical dilatation, patient was induced to labor. The patient was
delivered via Caesarean section as per request. Birth weight was at 7.4 pounds as
claimed. With an APgAR Score of 9-10, with no significant birth complications as
claimed.
Patient had slight jaundice and was placed under the bililight and gradually resolved.
Patient was exclusively breastfed for 3 days and was mixed fed with Enfalac A+
thereafter. Patient started intake of solid foods at around 4 months still being
complemented by a formula milk up to the present.
Patient started to crawl and held head at around 5-6 months as claimed. At around
9-10 monhts, was able to walk with support. Walked alone at around 1 year old. First
tooth erupted at around 5 months old started with upper central incisors. First word was
Mama at around 4 months of age. Patient was not potty-trained up to the present.
Patient appears to be at track with his developmental age as noted, with good
performance in school as claimed. Sleeps at around 11:00 PM and wakes up at around
8:00 AM during non school days. On school days, sleeps at around 9:00 PM and wakes
up at around 6:00 AM.


VI. SOCIOECONOMIC/ ENVIRONMENTAL

The family with the patient lives in a generally healthy environment as claimed. Being
unmarried, the father provides financial support for the patient, with the informant as the
main caregiver of the patient. Father, 32 years of age, works as an agent in a Business
Process Outsourcing company. The patient together with his sibling lives with the
informant

VII. PHYSICAL EXAMINATION

Vital signs noted as follows: temperature of 36,7 degrees Celsius taken per axilla,
cardiac rate of 119 beats per munite, synchronous with the pulse, regular in rate and
rhythm. Respiratory rate at 30 breaths per minutes, with no use of accessory muscles in
breathing and no nasal flaring. Blood pressure of 80/60 mmHg. Height is 98 cm and
weight of 14.7 kilograms.