I.

PEDIATRIC ASSESSMENT

BIOGRAPHIC DATA Childs Name: Age: Sex: Date of Birth: Address: Ward: Bed no.: Medical diagnosis: Mothers Name: Age: Occupation: Fathers Name: Age: Occupation: Client JM 6 y.o Male March 5, 2005 Navotas City Pediatric 509 Enteric Fever Mrs. MM 41 Sari-Sari Store Mr. LM 36 None

I. Parental view of presenting problem/ medical diagnosis A. Direct qoute of problem Pabalik-balik kasi yung lagnat niya. Siguro mga isang linggong ganun, tapos yung sumunod nagtatae na siya na maberde ang kulay. B. Description of duration and symptoms/precipitation factors. 7days prior to admission the client experienced step ladder fever. Then 6 days prior to admission the client experienced stomach pain. He also experienced diarrhea which is greenish, mucoid, non-bloody stool. II. General Observations A. Appearance and behavior The client was observed to have happy disposition, he is jolly and happy all the time, and he answers cheerfully when being asked. He is friendly and easy to get along with. B. Parent-child interaction The client has a very good relationship on both of his parents, he seems to be very close to them, and his father was the one who takes care of him when her mother is not around and vice versa.

C. Home environment/living quarters

The clients family lives in a bungalow made out of cement and wood. According to the father, The space of their home is adequate for their family. III. Significant past medical history A. Family history The client belongs to an extended family. The clients mother have history of asthma while on his father side have history of hypertension. They have no familial disease of diabetes, cancer, or hypertension. B. Prenatal 1. Mrs. MM had 5 pregnancies. She was 35 when she got pregnant to the client who is her 4th child; 2. Obstetrical/ gynecological history According to the clients father his wife was in good health during her pregnancy and did not encounter any problem aside from nausea which is a normal symptom; she had regular prenatal check-up at the health center. A. Birth history Client JM was delivered via normal spontaneous delivery in one of the hospital in Navotas; he was full term (cannot recall how many weeks). He was their fourth child. B. Neonatal No history of Congenital Disease. E. Infancy and Childhood Client JM has been breast fed for up to 2 years of age. He has started to take complementary foods about 6 months of age. During childhood he is taking TIKI TIKI as his vitamins. He does not have any feeding problems. IV. Early developmental milestones A. Mr. LM, can no longer remember the developmental milestone of client JM, but he stated that at about 8 months of age she can already crawl, and at 9 months can now walk with less supervision. In less than a year the client can start to talk with little words. By 1 year and half of age, client JM feeds himself using a spoon with minimal spill has been described. Near two years of age, the client already has a bladder and bowel control. B. Early behavior patterns None.

C. Relationship with the siblings

The client has a good relationship with his siblings, the father said that the client sister usually teaches him and helps him with his studies and also plays with him, though like other typical sibling they do have conflicts but not so often and they were able to solve it easily. A. Relationship with peers ``` The client does not have many friends because he prefers to watch cartoons than play outside of the house. IV. Eating/ drinking patterns Prior to admission the client used to eat 3 times a day, his usual breakfast was hotdog, , while his lunch was composed of rice and chicken or fish or pork or vegetable the same with his dinner. The client is not choosy when it comes to food but his usual favorites were fish and vegetables aside from ampalaya. He doesnt have known allergies in food and do not have any problem in nutrition, He doesnt take any dietary supplements. VI. Elimination patterns The client dont have problem with bowel elimination. VII. Sleeping pattern The client usually takes a nap at 10 am or 12 pm prior and during hospitalization and sleeps around 8-9 in the evening and wakes up at 6 am, he doesnt have particular sleeping rituals or any special rituals and do not have any sleeping problems or difficulties. VIII.Temperaments The client is not moody and always on happy or good mood but according to the clients father when his son got irritated he usually has temper tantrums. IX. Play The client loves playing with his siblings they usually play hide and seek. play with his toy cars. X. Discipline It is both her father and mother who discipline him in all his acts; he is often scolded and is given advices and words of wisdom to guide him. The client loves to

XI. School history

He started to attend school at the age of four. He is currently at kindergarten but he stopped studying for almost a month because of his hospitalization, According to the father his son is a consistent honor student and doesnt have problem with regards to study and school. XII. Present medical history A. Review of system

System Neurological Status Respiratory System Integumentary System Gastrointestinal System Musculoskeletal System Genito-urinary System

Deviations GCS: 15 Client is alert and awake. Clients respiratory rate is Skin is dark brown in color. Client has healed scars on leg. Bowel movement every 2 days No body weakness The client does no experience any pain while urination.

B. Immunization The client has complete immunization such as BCG, OPV 1-3, DPT 1-3, Hepa B 1-3 and measles though the father cannot recall the date it was given.