Karl Lloyd P.

Licup MD 1 Date and time of interview: December 27, 2012 9:15am Place of interview: German Hospital

General data: Patient TJS is a 6 year old preschooler male, roman catholic, currently living at Lapasan, CDOC Mother TS is the source of information with 95% reliability. Chief complaint:: Gahubaka akong anak ug taas ang hilanat as verbalized by the mother of the patient History of present illness: 5 days prior to consultation, the mother noticed that her son TJS was manifesting signs of incoming cough such as verbal complaints of throat discomfort and frequent spitting. The mother was not able to provide interventions to relieve the discomfort but rather had close observation of her son. Day after the onset of the aforementioned clinical manifestations, the mother noted worsening of her sons condition as evidenced by productive cough expectorating with viscous, greenish sputum in moderate amount. Fever (the mother was not able to provide accurate temperature), skin warmth and

flushing, lethargy, body weakness, lack of appetite, and lack of interest to mingle with playmates were also noted. This time, the mother provided paracetamol and tepid sponge bath, forced fluids to loosen the cough, and oil liniment (Efficascent) applied on the back. There was temporary relief of fever but would tend to recur 5-6hrs following ingestion of antipyretics. 2 days prior to consultation, manifestations still persisted thus prompting the mother of the patient to seek medical consultation at German Hospital.

Past medical history: The patient was born via normal spontaneous vaginal delivery at Northern Mindanao Medical Center last July 18, 2006. The mother immediately introduced breast feeding right after birth. For the growth and development, the patient started to smile at 2 months, started to roll over at 3 months, started to creep and sit at 6 months, started to utter his first word mama at 10 months, started to walk and speak papa at 1 year old, started to enjoy playing with others at 2 years old, started to enjoy imitating super heroes such as Batman at 3 years old, started to love drawing at 4 years old, started to enjoy games intended for boys such as mini basketball at 5 years old, started to go schooling at 6 years as preschooler.

The mother verbalized that her son hadnt experienced serious illness except for diarrhea when he was 1 year old that lasted for approximately 4-5 days but was then relieved after proper medical intervention. Before the onset of symptoms and discomforts, the patient was alert, very mobile, usually enjoy going out to neighborhood to play and had a very good appetite. Gestational History: The mother carried her son at the age of 29. She got pregnant thrice and was able to deliver them normally and at term (Gravida=3 Para=3 Term=3 Aborted=0 Multiple=0 Living=3). When she was pregnant with her son, she frequently went to Barangay Health Center every month for check-up which was usually done by the midwife. The mother had free vitamins (folic acid) intended for pregnant as provided by the health center. She preferred eating vegetables with some meats such as fish and pork all throughout her pregnancy. She would tend to refrain from eating junk foods and from drinking too much of carbonated beverages. No history of smoking and alcohol consumption all throughout the pregnancy. No history of substance abuse and radiation exposure as well. The mother had no serious discomforts during her pregnancy of her son. Mild nausea and mild edema at lower extremities were noted but were bearable. Back pain was her major concern but as she said, as her pregnancy progressed, she had gotten used to it. The usual stressor to her was financial difficulty as her family is not well-off

and her husband is only a construction worker. She also verbalized that as much as she wanted to buy milk and other vitamins for pregnant women she couldnt due to financial constraints. She likewise verbalized that she had some problems with her neighborhood especially during her resting nights since some people were fond of karaoke and shouting in the middle of the night. Birth history: The patient was delivered via normal spontaneous vaginal delivery at Northern Mindanao Medical Center (NMMC). The mother mentioned that by the time her son was delivered, she heard the loud cry but she could not provide further details in order to determine the APGAR score. The patient was delivered after 9 months, no corresponding number of weeks was given by the mother. She also verbalized that she started to experienced true signs of labor 5-6 hours before the birth of her son as evidenced by nibuto akong tubigan ug gasugod na sakit akong tiyan nga murag gakumuton busa nidiretso nami provincial Feeding history: Right after birth, introduction of breast milk was done. It was continued up to 2 years and started to wean to powdered milk (Bear Brand). She started to provide soft food (lugaw) at 6 months. Solid food (cooked rice, vegetable, fish/pork) was given at 1 year old. The mother verbalized that she was not able to provide vitamins for her son due to financial difficulty.

Prior to the onset of illness, her son had a good appetite and could consume 1 cup of rice. Her son loves to eat fried fish, porkchop, omelet, mechado in can and hotdogs but hates vegetables such as ampalaya, talong and malunggay. The patient usually eats 3 times a day with snacks (biscuits, champorado, etc.) every afternoon after siesta. No feeding difficulty was noted except when served with food he hates to eat. Childhood illness: As mentioned above, no serious illness except when the patient had diarrhea when he was 1 year old which lasted for approximately 4-5 days after proper interventions. The patient usually experiences cough and colds especially during rainy seasons, but this does not warrant as an alarming situation as mentioned by the mother as she would just provide neozeop and haplas on the back with the use of oil liniments. The child does not have any allergy to food and medication. Immunization: The mother mentioned that her son was fully immunized, although specific dates and vaccines given couldnt be remembered. Immunizations were given at Lapasan Barangay Health Center by the nurse-on-duty. The mother could attest that her son was fully immunized by saying nakompleto ug fill-up ug pirma iyang gamay nga papel para immunization. No untoward reactions to vaccines were noted. Environmental History:

The patient is residing at Lapasan, CDOC squatters area. The mother described the area as congested, garbage placed everywhere, and with loud people. The mother didnt have any idea if they have a neighborhood with history of TB and other highly infectious diseases. They have been in the said area for more than 10 years as they were originally from Surigao CIty but decided to move here due to job opportunities. The family is composed of 5 members: 3 children (3 males, the patient as the youngest), and the couple.

Family history: Heart disease: None Cancer: None Stroke: Mother and father side Diabetes Mellitus: Mother side Substance abuse: Father side Hypertension: Father side Asthma: Father side Bronchitis: None Psychiatric problems: None