STUDENT: SOSTENES PAUL J. GLER PRECEPTOR: DRA.

SALINAS
DATE AND TIME OF HISTORY: August 8, 2013
DATE AND TIME OF ADMISSION: August 5, 2013 at around 10am.
SOURCE OF HISTORY: MOTHER and FATHER
REFERRAL: NONe
RELIABILITY: 90%

IDENTIFYING DATA:
JM, 5months old, infant, female, Filipino, Born Again, residing at Brgy. Banayon, Dagami, Leyte
was admitted for the first time in EVRMC on August 5, 2013 at around 10 am.

CHIEF COMPLAINT: DIARRHEA

HISTORY OF PRESENT ILLNESS:

The patient was apparently well until 2 weeks PTA, the she experienced cough and colds with a
whitish secretions. This was not associated with irritability and change in her feeding pattern. These
persisted for 2 weeks. The mother decided to bring her to a private clinic. She was given co-amoxiclav
2ml drops 3 times a day for 7 days for relief of the symptoms mentioned above.
2 days PTA, she passed out greenish watery stool with a whitish secretions every 5 minutes. This
was not associated with irritability, abnormal sleepiness, sunken eyeballs and decrease in feeding habit.
The mother brought her to a private clinic for consultation. She was given oral hydrating solution diluted
in a 200ml water and Bacillus clausii (Erceflora) 2billion/5ml for relief of diarrhea.
1 Day PTA, she still passed out greenish watery stool with mucous secretions for 15 times a day.
Sunken eyeballs and weakness were noted by the mother. The mother decided to bring her to EVRMC
for the first on August 5, 2013 hence admission.

PERSONAL HISTORY:
l. Prenatal: Patient was born to a 31 years old G4 P3(3003) mother who doesn’t smoke and drink
any alcoholic beverage during the course of her pregnancy. Prenatal consultation started from 5 months
to 9 months AOG at Leyte Provincial Hospital conducted by a physician. She has already received 5 doses
of tetanus toxoid. Vitamins, ferrous sulfate were taken3 months. She was apparently well throughout
the pregnancy. No history of x-ray exposure, abortion, pain and bleeding.
ll. Birth: The patient was delivered pre-term, 36 weeks AOG via NSVD assisted by a doctor at Leyte
Provincial Hospital. She was in cephalic presentation with 5 hours of labor. Umbilical cord was cut by
using a pair of scissors that was sterilized. Umbilical cord sloughed off after a week. There were no
complications observed such as erythema and discharges.
lll. Neonatal: Pinkish in color with good cry and vigorous movements. No jaundice, dyspnea, no
convulsions, no hemorrhage.
IV. Feeding Pattern
Breastfeeding started after 2 days because of insufficient breast milk production. She is
exclusively breastfed. She was given ascorbic acid at 4 months age which lasted for a month.

24-HOUR DIET RECALL:

BEFORE THE ILLNESS:
Exclusive breastfeeding every hour with a total of 20 minutes duration on both breast.
DURING THE ILLNESS:
 Exclusive breastfeeding every hour with a total of 20 minutes duration on both breast.

GROWTH AND DEVELOPMENT:

AGE Gross Motor Adaptive fine Language Personal Social

motor
Newborn: Tonic Neck reflex Crying

Startles ( moro
reflex)
1 month: Raises head Eyes follows Throaty gurgling smiles
slightly from prone object at midline sound
(<45 degree)
2 months: Head control 45 Eyes follow object Laugh Responsive when
degrees in prone past midline Vocalizes talked to
Hands no longer
fisted
3 months: Head control 90 Hands together Regards hands
degrees in prone
4 months: Rolls over Grasp object Moves head Plays with rattle in
Chest up with arm placed in hand towards sound hand
support
5 months Good head control Reaches for object Turns t sound

BEHAVIOR:
She is quiet, not irritable, and friendly. Sleeping habits are from 8pm – 4m and 10 am – 12 pm.
Thumb sucking was also noted.

IMMUNIZATION:
At birth: BCG at R deltoid; hepa1 IM at R vastus lateralis
2months: Hepa 2, DPT1, OPV1

PAST MEDICAL HISTORY

She doesn’t have chickenpox, rubella, mumps, measles. She had occasional cough and colds;
and fever. She has no allergy to food and drugs. She hasn’t receive blood transfusion to date.

FAMILY HISTORY:
Father is 34 years old, works as a farmer. He is apparently well. Mother is 31 years old, a
housewife and also apparently well. 3 siblings as follows:
7 years old, male – with hole in the heart. Undergo medication for 2 years. Lanoxin and captopril
5 years old, female – apparently well
3 years old, female – apparently well

PSYCHOSOCIAL HISTORY:
Patient was born at LPH and raised in Brgy. Banayon, Dagami, Leyte. Her father works as a
farmer earning P200 per day. Her mother is a housewife, taking care of patients needs like taking a
bath, preparing her meals. They have close family ties. Their house is made of wood, roof made of
galvanized iron. CR and kitchen is located 3 meters away form the house. Source of water supply is from
NAWASA. They have their own electricity. They practice composting as a source of garbage disposal.
They are not part of any religious and civic groups.

REVIEW OF SYSTEM:
GENERAL:
(-) weight loss, fever, weakness, fatigue
SKIN:
(-) jaundice
No itchiness, sores, active lesion, pallor
HEAD:
No headache, lightheadedness, dizziness
EYES
No pain, redness, blurring of vision, excessive tearing
EARS
No tinnitus, vertigo, itchiness, earaches, discharges
NOSE AND SINUSES
no nasal stuffiness, no nasal discharge, no itching, no epistaxis

Mouth & Throat:

no sore throat
Neck:
no pain, no lumps
Respiratory:
no dyspnea, no orthopnea, no hemoptysis
Cardiovascular:
NO chest pain, no palpitations, no dyspnea, no orthopnea
GIT:
NO nausea, vomiting, constipation
defecates with a watery greenish stool
GUT:
No dysuria, frequency and urgency, urinates frequently with a characteristic yellow colored
urine.
Genital:
With no pain, discharges and itchness
Peripheral Vascular:
NO bipedal edema
no leg cramps
Musculo Skeletal:
no muscle pains, no joint pains, no backache, no weakness
Neurologic:
with weakness, irritable
NO fainting, no seizures, no involuntary movements
Hematologic:
no easy bruising or bleeding tendencies
Endocrine:
 no excessive thirst/hunger, no heat/cold intolerance
Psychiatric:
no nervousness, no tension, no memory loss, no tantrum

PHYSICAL EXAMINATION:

General Survey: The patient was examined awake, well-groomed, in respiratory distress, afebrile, and
well-developed body, with the following vital signs:

MEASUREMENTS RESULT NORMAL VALUE PERCENTILE RANK Z SCORE

BP NOT TAKEN 70/50 – 90/65
mmHg
RR 49 CPM 30-45cpm
HR 130 BPM 90-120 bpm
TEMPERATURE 370C 36.5-37.50C
HC 41 CM 41cm P50 0
CC 45 CM 42cm P75 +1
MUAC 16 CM 12.5cm >P95 +3
WEIGHT 6.7 KG 6.5 kg > P50 0
HEIGHT 55 CM 63cm <P5 -3

WATERLOW CLASSIFICATION OF WATERLOW CLASSIFICATION OF

WASTING: stunting:
= actual weight/ ideal weight = actual height/ ideal height for
for age x 100 age x 100
= 6.7/6.5x100
=55/63x100
=103 % ( no wasting)
= 87% ( moderate stunting)

SKIN:
(-) jaundice
fair complexion, no rashes, no active lesions, no scars, no hypo/hyperpigmentation, no central
and peripheral cyanosis, no clubbing of nails,
Head:
Hair – long, straight,fine black in color, evenly distributed, without nits and lice
Scalp – no lumps, no scars, no engorged veins
Skull – normocephalic, temples not depressed; anterior fontanel not depressed; closed posterior
fontanel
Eyes:
Eyebrows – symmetrical, fine, black, intact
Eyelashes – fine, black, oriented outwards
Eyelids – no edema, no ptosis, no lidlag
Conjunctiva – pale palpebral conjunctiva, no hemorrhage
 Sclera – icteric, no hemorrhage
Cornea – no ulcerations, no scars
Pupils – symmetrical, with a 1mm diameter pupillary constriction, and briskly reactive to direct light
and consensual light reflex
EOM – eyes able to move at the side, up, and down
Ears: symmetrical, no discharges, no impacted cerumen
Nose: no discharges, nasal septum at midline, pale mucosa, no nasal flaring
Mouth and Throat:
Lips – no angular deviations,
Mucous membrane – pale,moist, no bleeding
Gums – pale, no bleeding
Teeth – none
Tongue – pinkish, no ulceration; no tremors on protrusion
Throat: uvula at midline, no tenderness
Neck: trachea at midline, no engorged veins, no tenderness, thyroid gland not palpable, not palpable
cervical lymph nodes
Breasts: symmetrical, no nipple discharge
Chest and Lungs:
- Inspection: truncal in shape, symmetrical lung expansion, no retraction of intercostals and
subcostal muscle
- Palpation : confirmed lung expansion
- Percussion: resonant in all lung fields
- Auscultation : bronchovesicular breath sounds over all lung fields

Heart:
- Inspection: PMI not visible, no visible pulsations, no precordial bulging
- Palpation : PMI palpable @ 4th ICS left MCL, no thrills, no heaves
- Auscultation: heart rate is 130 bpm, regular rhythm, synchronous with pulse, no murmurs,
no pericardial friction rub
Abdomen:
- Inspection: globular, no visible pulsation, no venous engorgement, with flank bulging, no
areas of hypo/hyperpigmentation, no petechial rashes
- Palpation: smooth, palpable liver at subcostal right mid-clavicular line and 8cm, spleen
- Percussion: tympanitic in all quadrants
- Auscultation: normoactive bowel sounds (10), no venous hum, no bruit, (-) fluid wave test

EXTRIMITIES:
NO deformities, no tenderness

Back and Spine

- Inspection: no abnormal deviation, no retraction, no bulging,
- Palpation: no paravertebral tenderness
Genitalia: grossly female, no lesions
ANUS: no ulceration, patent

Neurologic Exam:
MSE – quiet, and alert
Cerebellar – no nystagmus
Cranial Nerves:
I – Not tested
II – pupils constrict to 1mm in diameter, pupils briskly reactive to light with direct and consensual
eye reflex
III, IV, VI – eyes able to move upward, laterally and downward, medially
V – intact corneal reflex
VII – able to cry, frown and smile without asymmetry, pout
VIII- able to follow sound
IX, X – able to swallow
XI – able to turn head side by side
XII – no L/R deviation on protrusion
Motor Function
- no atrophy of muscles, no involuntary movements, no spasticity, no rigidity, and no flaccidity
Sensory
-sensitive to pain, touch and pressure on right and left upper and lower extremities, seen as arousal,
withdrawal of tested extremity to pain, and change in facial expression
Muscle Strength
-passive movements – able to extend both wrists; grip both hands; abduct and adduct fingers; flex,
extend, and laterally bend trunk; flex and extend knees, plantar flexes and dorsiflexes ankles.

Deep Tendon Reflexes

Not tested
Pathologic Reflexes
(-) Babinski reflex
(-) Ankle clonus
Meningeal Signs:
(-) Nuchal rigidity
(-) Brudzinki’s sign
(-) Kernig’s sign
Autonomics
No bowel and urinary incontinence, no excessive sweating
Impression: acute gastro enteritis