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Pediatric Assessment

Name of Patient: __C. D. G.______ Date of Birth: __February 26, 2009___Sex: __Male__

I. Prenatal History (of mother) Maternal Age _26 years old__ Obstetric Score G 1 T 1P 0 A 0 L 1 M 0 Prenatal Check-up: Regular __Irregular __ none Done by: Obstetrician Nurse __ Hilot Place: Hospital __ Clinic __ RHU __ Home Maternal Illness: None __ Fever __ Rash __ GDM __ Asthma __ Rash __ UTI __ TB __ Hepatitis __ Allergy __ Hyperemesis __ PIH Medications (mother) ____Multivitamins___________________

II. Natal History Date of Birth February 26, 2009 Place of Delivery Hospital Attendant __ Midwife Gestation Full term Mode of Delivery __NSVD Presenting Part Cephalic Medications

Birth Rank 1 Apgar score 10 __ Home __ Lying-in __ Hilot __Others (Doctor) __ Preterm __ Post term __Forceps C/S (indication C.P.D) __ Face __ Breech __ Transverse Vit. K Hep. B

Eye Prophylaxis

III. Post-Natal History Feeding __ Breast milk Medical Problems __None Sepsis

Milk Formula __ Respiratory __ Seizure

__Mixed __ Cyanosis __ Jaundice

IV. Immunizations BCG DPT OPV HiB Hep B Pneumococcal Rotavirus Flu Varicella AMV MMR Others: Typhoid Hep. A Meningococcal HPV 1st dose

__ No 2nd dose

Yes at: __Center 3rd dose 1st booster

Private 2nd booster

__ both None

V. Feeding History 0 6 months Breastfeed Milk formula __Mixed 6 12 months __ Breastfeed Milk formula __ Mixed Age semisolid started _____7 months old______ Type ___cerelac_____ Food preference: ______none_______ Allergies __none___ Food dislikes: ________ none _____ Vitamin Supplements: Type ___none ___ When started ___none __ Amount _none___ Duration ___ none_____
VI. Past Medical / Surgical History Unremarkable __ Remarkable If Remarkable: ______________________ Date Diagnosis N/A N/A Hospitalization (including operation) Date Hospital N/A N/A

Intervention N/A Diagnosis N/A

VII. Family History __ No significant FH

Significant FH __Asthma __ Kidney Disease __ Cancer __ Stroke __ Mental Disorder __ Heart Disease

HPN __ Diabetes __ Blood Disorder __ Allergy TB __ Seizure Others: ____________________________

VIII. Growth and Development First raised head N/A Rolled Over N/A Sat Alone N/A Pulled up N/A Walked with help N/A Walked alone N/A Talked N/A Urinary continence: Day N/A Night N/A Control of Feces N/A Comparison of development with that of other siblings N/A School Grade N/A Quality of Work N/A

IX. Behavioral History A. Does the child manifest behavior like thumb sucking N/A Masturbation N/A Temper tantrums N/A Negativism N/A B. Does the child have sleep disturbances? __ Yes No C. Phobias N/A D. Pica (ingestion of substances other than foods) N/A E. Abnormal bowel habits (stool holding) N/A F. Bedwetting N/A

X. Family History (Genogram) Fathers Side Mothers Side

8 0

7 2

HPN ASTHMA

HEART DSE

4 0

36

15 y.o

9 y.o

2 y.o

Healthy Legend: Grand Father

Healthy

Healthy

Sepsis secondary to PCAP

- Grand Mother Patient!

Father Male Sibling

- Mother - Female Sibling

Patients mother denies of having a family history of Cancer, thyroid disease, kidney disease, blood dyscrasias.

XI. Review of Systems A. Skin: Texture: smooth Color: Fair B. Eyes: Have the childs eyes ever been cross eyed? Any foreign body? Any infection? C. Ears / Nose and Throat: __ Frequent colds __ Sore throat Sneezing __ Stuffy nose __ Discharges __ Post-nasal drip __ Mouth breathing __ Snoring __ Otitis Media __ Hearing Problem D. Teeth: Age of eruption of deciduous teeth N/A Age of eruption of permanent teeth N/A E. Cardio-respiratory: __ Dyspnea __ Chest pain Cough Sputum Wheeze __ Expectoration __ Wheeze __ Expectoration __Cyanosis __ Edema __ Syncope Tachycardia F. Gastrointestinal: __ Vomiting __ Diarrhea __ Constipation __ Abdominal pain / discomfort __ Jaundice Type of stools: sticky and yellowish G. Genitourinary: __ Enuresis __ Dysuria __ Frequency __ Polyuria __ Pyuria __ Hematuria __ Vaginal Discharge __ Abnormal penis / testes Character of stream (urine): clear Bladder control: N/A H. Neuromuscular: __ Headache __ Nervousness __ Dizziness __ Tingling Sensation __ Convulsions __ Spasm __ Ataxia __ Muscle or joint tolerance __ Postural Deformities __ Exercise tolerance I. Endocrine __ Disturbance of Growth __ Excessive fluid intake __ Polyphagia __ Goiter J. General __ Unusual weight loss __ fatigue __ Temperature sensitivity

XI. Chief Complaints (History of Present Illness) 5 days prior to admission, Patient had intermittent moderate high grade fever partially relieved by paracetamol. 3 days prior to admission, fever was now associated with non productive cough. 2 days prior to admission, parents sought consult with AP and was given Cefaklor for cough. The morning prior to admission, noted tachypnea, no consult done, feeding was continued by the mother despite patient having fast breathing. 4 hours prior to admission, tachypnea was persistent so, parents decided to rush patient to the hospital.

Pediatric Physical Examination 1. Vital Signs BP: 100 / 60 mmHg Wt: 9 kg 2. General observation: Patient was seen lying on bed, sleeping, with continuous positive airway pressure attached. Patient had an ongoing IV # 2 D5IMB @ 25 30 cc / hour. Patient had a good skin color and was tachypneic. Patient was irritable especially when CPAP was dislodged. 3. Skin Color: Normal Texture: Normal Turgor: Good Lesions: None HR: 220 bpm Ht: 52 cm RR: 145cpm Temp: 38.3 C

__ Cyanotic __ Pale __ Dry __ Oily __ Poor __ Rashes __ Burns __ Punctured Wound Comments: _________________ 4. Head / Ears / Neck / Throat

__ Icteric

__ Flushed

__ Ashen

__ Abrasions __ Scars

__ Lacerations __ Decubitus

Head circumference: 36 cm ( up to 2 years & if significant) Shape: Round Scalp: Normal __ Ovoid __ Pustule __ Irregular __ Seborrhea __ Flat __ Flat

__ Scales __ Sunken __ Sunken R

__ Lice __ Bulging __ Bulging L

Fontanels: Anterior: __ Close Posterior: Close 5. Eyes Eyelids Normal Laceration Inflamed Mass Puffy Drooping Sclerae Normal Icteric Red Discharges R

Open __ Open L

none

none

Eyeballs Normal Sunken Bulging Pupils Reactive Unreactive Equal Unequal Vision Normal Blurred Contact Lens
With Correctional glasses

Not assessed

Not assessed

6. Ears Pinna Normal Anomalies Symmetrical Tympanic Membrane Intact Perforated Discharge Mastoid Tenderness Swelling

R R

L L

External Canal No Problem Discharge Pain Hearing Normal Deaf With hearing aid

Not assessed

Not assessed

Normal

Normal

Comments: ____________________ 7. Nose / Neck / Thyroid Nares No Problem Nasal Flaring Discharge Epistaxis Turbinates Normal Inflamed / congested Neck Normal Torticollis Opistothonus Inability to support head Lymph Nodes Swelling Tender Sternocleidomastoid Swelling Shortening Thyroid Size Contour Bruits Nodules Tenderness Enlarged Not Appreciated

8. Mouth / Throat Lips: Pink __ Red __ Pale __ Cyanotic Dry __ Moist __ Swelling __ Thin __ Down turning __ Fissures __ Cleft Teeth: __ Temporary __ Permanent No teeth __ No Problem __ Braces __ Mottling __ Discoloration __ Notching __ Malocclusion / malalignment Gums: Normal __ Inflamed __ Number Tongue: Pink __ Coated __ Furrows __ Strawberry red Mucosa: Normal __ Thrush __ Discharge __ Ulcers __ Bleeding Tonsils: Normal __ Inflamed __ Exudates Smell: __ Normal __ Foul Not assessed Voice: __ Hoarseness __ Stridor __ Grunting Type of Cry: Sharp, shrill Type of Speech: ________________ Comments: __________________________ 9. Respiratory / Thorax Upper Airways: Normal __ Stridor Chest / Upper Trunk: Normal __ Scars Expansion: Equal Retractions: __ Absent Lungs: __ Hoarseness __ Drooling of Secretions __ Scoliosis __ Rash __ Mass

__ Kyphosis __ Abrasions __ Unequal Present

Breast:

Normal __ Tenderness Resonant __ Tympanic __ Clear Breath Sounds __ Ronchi __ Wheeze Normal for age __ Assymetrical

__ Crepitations __ Dullness __ Flatness Rales __ Symmetrical __ Lumps / masses

Comments:_______________________ 10. Cardiovascular Apical impulse: Location: 5th intercostals space midclavicular line __ Precordial Bulging __ Heaves Pulse: __ Strong Regualar __ Weak __ Irregular Heart Sound: Normal __ Splitting __ Murmurs Rate: Regular __ Irregular Normal __ Bradycardia __ Tachycardia Capillary Refill Time: < 2 seconds Comments: __________________________

11. Gastrointestinal Abdomen: Inspection: Percussion: Palpation Tenderness: Bowel Sounds:

__ Flat __ Scaphoid __ Distended Globular Tympanic __ Dull __ Fluid wave Normal __ Splenomegaly __ Mass Location: _________ __ Direct __ Indirect Normal __ Hyperactive __ Hypoactive

Rectal Exam: Not Done Comments: ___________________ 12. Genitourinary Normal Genitals: __ Mass Normal __ Tenderness (Location) ___________ __ Discharges __ Anomaly __ No Tanner Score: ________

Males: Circumcised: __Yes Tanner Staging:

Females: Menses started: ________ Length of Cycle: _______ Tanner Staging:

Not Applicable __ Regular Tanner Score: 1

__Irregular

13. Neurologic A. Pediatric Glasgow Coma Scale (Teasdale and Bennett) Eye Opening Open eyes spontaneously Opens eyes in response to speech Opens eyes in response to painful stimuli Does not open eyes Verbal Response Smiles, oriented to sound, follow object, interacts Confused, consolable crying, inappropriate actions Inappropriate, persistently irritable, vocal sound, moaning Incomprehensible, restless, agitated, cries No verbal response Motor Response Obeys, infant moves spontaneously or purposefully Localizes pain, oriented, follow infant withdraws from touch Infant withdraws from pain, consolable crying, interact
Abnormal flexion to pain in infants (decorticate response), inconsistently consolable crying

Score 4 3 2 1 5 4 3 2 1 6 5 4
3

3
9

Extension to pain (decerebrate response), inconsolable, irritable, restless 2 No motor response 1 Aggregate Score (Normal) 0-6 months = 9 6-12 months = 11 (E4 V2 M3) (E4 V3 M3) 1-2 years = 12 (E4 V4 M4) 2-5 years = 13 5 years = 14 (E4 V4 M5) (E4 V5 M5)

B. Mental Status: __ Awake __ Stupurous __ Disoriented __ Conscious __ Coma Drowsy __ Oriented

C. Cranial Nerves CN I (Olfactory) __ Intact __ Anosmia __ Hyperosmia Not Done CN II (Optic) __ Intact __ Blindess __ Scotoma Not Done CN III, IV, XI (Occulomotor, Trochlear. Abducens) Pupils: Reactive __ Non-reactive Equal __ Non-equal ROM: Full ROM __ Palsy __ Ptosis CN V (Trigeminal) __ Trismus __ Paresthesia Intact Corneal Reflex Present __ absent __ Right __ Left CN VII (Facial) Facial Symmetry: Symmetric __ Asymmetric Tongue (sensory) Intact __ Absent Facial Muscle Strong __ Weak CN VIII (Vestibulo-cochlear) Hearing: Normal __ Deafness Balance: Normal __ Disequilibrium CN IX, X (Glossopharyngeal) Gag Reflex: Present __ Absent __ Able to swallow __ Not done CN XI (Spinal accessory) Shrug Shoulder: __ Able __ Not Able Not done CN XII (Hypoglossal) Tongue at rest: midline __ Deviated __ R __ L D. Cerebellar FTNT: APST: Rombergs: E. Sensory Light Touch Intact Pain Intact Temperature Intact F. Motor R Upper Extremity Proximal Distal Lower Extremity Proximal Distal 5 5 5 5 L 5 5 5 5 Manual Scoring 5 Normal 4 can raise against slight resistance 3 can raise against gravity 2 gross movements but not against gravity 1 flicker movements 0 No movements __ Absent __ Absent __ Absent __ Not done __ Not done __ Not done Well-coordinated Well coordinated __ Ataxia __ Positive __ Not-coordinated __ Not-coordinated __ Nystagmus __ Negative __ Not done __ Not done Not done

14. Reflexes Deep Tendon Reflex: + 4 = Very brisk, hyperactive + 3 = Brisker than average + 2 = Average; normal +1 = Somewhat diminished 0 = No Response < (-) Babinski >(+) Babinski Meningeal Signs: Primitive Reflex: Moro Rooting Sucking Grasp Present Absent __ __ __ __ Tonic Neck Babinski Ankle Clonus Present __ __ Absent __ None __ Nuchal Rigidity __ Kernigs __ Brudzinkis 2 Deep Tendon Reflexes

15. Musculoskeletal Normal __ Fractures __ Deformities __ Tenderness __ Swelling

Comments: _____________________________